Gonzalez-Urquijo Mauricio, Baca-Arzaga Adrian A, Flores-Villalba Eduardo, Rodarte-Shade Mario
Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Dr. Ignacio Morones Prieto O 3000, Monterrey, 64710, Mexico.
Tecnologico de Monterrey. Escuela Nacional de Ingeniería. Departamento de Ciencias Clinicas. Hospital Zambrano Hellion, Batallon de San Patricio 112, Col. Real de San Agustin, Monterrey, 66278, Mexico.
Ann Med Surg (Lond). 2019 Jun 14;44:46-50. doi: 10.1016/j.amsu.2019.06.008. eCollection 2019 Aug.
Exclusion of the stomach after Roux-en-Y gastric bypass (RYGB) makes access to the biliary tree very challenging for the surgeon or the endoscopist. Different techniques have been described to overcome this downside, including laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP), which is an outstanding method to access the remnant stomach in order to reach the duodenal papilla. The use of this technique is associated with a high success rate.
Here we present the case of a 57-year-old patient with altered RYGB anatomy. The patient underwent laparoscopic cholecystectomy. Intraoperative cholangiography revealed the presence of a stone in the common bile duct. A laparoscopy-assisted transgastric ERCP was performed successfully. During the procedure, the duodenoscope was introduced through a gastrostomy, obviating the need for an intragastric trocar. The patient evolved favorably and was discharged on second postoperative day without any complications.
Transgastric laparoscopy-assisted ERCP represents an effective approach for the management of biliary complications after RYGB, even if there is a long interval between the two interventions, as occurred in the present case. Other methods described for accessing the biliary tree in patients with altered RYGB anatomy are double-balloon ERCP and endoscopic ultrasound-directed transgastric ERCP. We elected to perform the laparoscopy-assisted approach because choledocholithiasis was diagnosed transoperatively, thus, avoiding the need for secondary procedures or interventions.
Transgastric laparoscopy-assisted ERCP is a feasible procedure with low complication rates and is used in treating patients with altered RYGB anatomy who present with biliary tract disorders. The use of transgastric laparoscopy-assisted ERCP allows endoscopic treatment and cholecystectomy to be performed in a single setting.
在Roux-en-Y胃旁路术（RYGB）后，胃被排除在外，这使得外科医生或内镜医师进入胆管树极具挑战性。已经描述了不同的技术来克服这一缺点，包括腹腔镜辅助经胃内镜逆行胰胆管造影术（ERCP），这是一种进入残胃以到达十二指肠乳头的出色方法。该技术的使用成功率很高。
在此，我们报告一例57岁RYGB解剖结构改变的患者。该患者接受了腹腔镜胆囊切除术。术中胆管造影显示胆总管有结石。成功进行了腹腔镜辅助经胃ERCP。在手术过程中，十二指肠镜通过胃造口术插入，无需胃内套管针。患者恢复良好，术后第二天出院，无任何并发症。
经胃腹腔镜辅助ERCP是处理RYGB术后胆道并发症的有效方法，即使两次干预之间间隔时间较长，如本病例所示。对于RYGB解剖结构改变的患者，其他进入胆管树的方法包括双气囊ERCP和内镜超声引导下经胃ERCP。我们选择进行腹腔镜辅助方法是因为术中诊断出胆总管结石，从而避免了二次手术或干预的需要。
经胃腹腔镜辅助ERCP是一种可行的手术，并发症发生率低，用于治疗RYGB解剖结构改变且出现胆道疾病的患者。使用经胃腹腔镜辅助ERCP可在单一环境中进行内镜治疗和胆囊切除术。
