Dapri G, Himpens J, Buset M, Vasilikostas G, Ntounda R, Cadière G B
Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.
Surg Endosc. 2009 Jul;23(7):1646-8. doi: 10.1007/s00464-009-0417-3. Epub 2009 Apr 3.
Rapid weight loss after Roux-en-Y gastric bypass (RYGBP) often is associated with gallstones formation, which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the gastric remnant for an endoscopic retrograde cholangiopancreatography (ERCP).
A 40-year-old woman with a BMI of 48 kg/m(2), was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. In April 2007, she was admitted for upper right side abdominal pain, vomiting episodes, fever, and jaundice; the BMI at the time was 24 kg/m(2). Hepatic ultrasound showed lithiasis of the common bile duct with intra- and extrahepatic bile duct dilation, as well as gallbladder lithiasis. The patient was taken to the operating room for laparoscopic evaluation. A pursestring suture was performed on the greater curvature of the gastric remnant. After the opening of the stomach, an 18-mm trocar was inserted into the lumen and the endoscope was directly passed through the port into the duodenum. An ERCP was performed under fluoroscopic guidance, and as a result of sphincterotomy the stone was retrieved. After removing the endoscope, the gastrotomy was closed by tying the pursestring. Cholecystectomy was performed as well.
The procedure lasted 98 min. Liver function tests returned normal on postoperative day 2, and the patient was discharged on postoperative day 4. After 9 months, the patient was well and asymptomatic.
Patients previously submitted to RYGBP and presenting choledocholithiasis can benefit from an ERCP through the gastric remnant.
Roux-en-Y胃旁路术（RYGBP）后快速体重减轻常与胆结石形成相关，这可能导致胆囊炎和/或胆总管结石。RYGBP术后的一个缺点是难以进入胆道。我们报告一种用于内镜逆行胰胆管造影（ERCP）的腹腔镜经胃进入胃残端的有用技术。
一名40岁女性，体重指数（BMI）为48kg/m²，于2003年12月接受腹腔镜RYGBP手术。当时腹部超声检查胆囊结石为阴性。2007年4月，她因右上腹疼痛、呕吐、发热和黄疸入院；当时BMI为24kg/m²。肝脏超声显示胆总管结石伴肝内和肝外胆管扩张，以及胆囊结石。患者被送往手术室进行腹腔镜评估。在胃残端的大弯处进行荷包缝合。打开胃后，将一个18mm的套管针插入腔内，然后将内镜直接通过该端口进入十二指肠。在荧光透视引导下进行ERCP，通过括约肌切开术取出结石。取出内镜后，通过系紧荷包缝合关闭胃切开术。同时进行了胆囊切除术。
手术持续98分钟。术后第2天肝功能检查恢复正常，患者于术后第4天出院。9个月后，患者情况良好，无任何症状。
先前接受RYGBP手术并出现胆总管结石的患者可通过胃残端进行ERCP而获益。
