Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery.
BACKGROUND
Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones.


METHODS
We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up.


CONCLUSIONS
Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively.


CONCLUSIONS
Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.
Department of Surgery, United Kingdom.
Marialessia
M
Milella
Department of Surgery, United Kingdom.
Maryam
M
Alfa-Wali
Department of Surgery, United Kingdom.
Luca
L
Leuratti
Department of Radiology, United Kingdom.
James
J
McCall
Department of Surgery, United Kingdom. Electronic address: Gianluca.Bonanomi@chelwest.nhs.uk.
Gianluca
G
Bonanomi
Bariatric; Choledocholithiasis; Gastric bypass; Laparoscopy; PTC