Fig. 32.1
ERCP via gastric remnant
There have been a number of described approaches for access to the gastric remnant for the purpose of either ERCP or endoscopic ultrasound to evaluate the pancreas and biliary tree. Placement of a G-tube can be performed as a temporary measure for the procedure and a G-tube can be left in place to facilitate access for stents, repeated biliary dilatations, or surveillance for bleeding. Our approach is to use four sutures at the greater curvature of the stomach close to the antrum. Sutures are used to fix the stomach to the anterior abdominal wall. This can be accomplished by placing a long (>30 cm) absorbable suture through the seromuscular layer of the stomach at the greater curvature to create a box. These sutures can be retrieved and secured at the abdominal wall in four quadrants leaving space for placement of a 15 mm trocar that will facilitate placement of the ERCP scope. Short gastric vessels do need to be divided in order to facilitate mobility to the anterior abdominal wall of the gastric remnant. Additionally, adhesions between the lesser curvature of the stomach and the liver need to be mobilized in order to have adequate mobility of the stomach. In some cases, the upper short gastric vessels are divided to create a tongue of stomach that can be tethered to the anterior abdominal wall. It is a routine observation that these G-tubes can be quite painful.
The recommendation is that the gastroenterologist/surgeon performing the ERCP or other intervention utilizes carbon dioxide gas as this becomes less painful for the patient and decompresses more quickly than by using regular air. If stents are used, it is recommended to leave a G-tube for the completion of the case. We will often use a large diameter malecot tube that can easily be passed through the 15 mm port and left in place and secured at the level of the skin. These tubes are typically left for up to 4 weeks and then can be removed at the bedside and during this time can be a valuable access point for nutrition and medications as needed.
For those patients with short Roux and biliary pancreatic limbs, single-balloon or double-balloon enteroscopy has been utilized to access the gastric remnant. These procedures can be quite cumbersome and while access to the stomach can be obtained, it may not be ideal for performing an ERCP procedure. This form of enteroscopy may, however, be quite useful if only surveillance of the gastric remnant is needed. These modalities can be quite expensive and their accessibility is quite institutionally dependent.
An additional modality to access the gastric remnant is the Endo-Ease™ (Spirus Medical Inc, Stoughton, MA) that uses a novel over-tube with a corkscrew-like device to plicate the small bowel. In patients with shorter Roux lengths, less than 100 cm, and a biliary pancreatic limb less than 25 cm, it can be quite reliable to access the gastric remnant using this technique. However, for the longer Roux limb lengths where the length to traverse is over 200 cm, this can be unreliable and thus we rely on our technique of gastric access to facilitate access to the stomach.
In those patients who have undergone previous BPD/DS, access is even more of a challenge and consideration of earlier cholecystectomy in these patients due to the risk of complicated biliary tract disease and technical difficulties in accessing to the bile duct. Here, percutaneous transhepatic cholangiography can be particularly useful depending on the skill and availability of the radiographers. Alternatively, access to the biliary pancreatic limb using a laparoscopic approach facilitates access by a retrograde ERCP through a 15 mm trocar to facilitate a definitive therapeutic endoscopy. Leaving a stent in this circumstance can be quite tricky if it needs to be retrieved. The option always exists in these patients for retrieval of stones via a transcystic approach or to perform a laparoscopic or open formal common duct exploration, but all of these have their respective downsides.
An alternative solution might be to limit the length of the intestinal bypass. Spurred by potential of increased weight loss and reduced alkaline reflux, many surgeons advocate lengthy Roux and biliopancreatic limbs. Another unsubstantiated advantage is that following development of internal hernias, it is often either the BP limb or the Roux limb that might individually be involved in the internal hernia. Though this is not always the case, we have frequently observed this. Longer-term data now suggests that with the exception of the distal bypass, modest elongations of intestinal length are of limited benefit [34]. Shorter limbs may facilitate direct endoscopic access to the gastric remnant.
Conclusion
In summary, management of the gallbladder at the time of RYGB remains controversial. The incidence of stones after bariatric surgery can be reduced using pharmaceutical therapy. However, this may not reduce the incidence of symptomatic disease. The challenge of access to the biliary tree magnifies the potential risk of choledocholithiasis and cholangitis. Despite the number of ways used to access the biliary tree via the gastric remnant or directly using endoscopy, it can still be quite cumbersome. Routine cholecystectomy in asymptomatic patients without stones would be a relatively straightforward solution but carries a higher morbidity at the time of surgery. The use of ursodeoxycholic acid adds cost and may not reduce the incidence of symptomatic disease. In patients with cholelithiasis, the need for cholecystectomy is higher. This may be ameliorated through the use of ursodeoxycholic acid, but cost and compliance with a 6-month course remains an issue. Thus, more information is required long term following the RYGB to clearly understand the beneficial clinical pathway. The BPD/DS operation adds an additional layer of complexity because no reliable conduit for sphincter of Oddi access is available. Unfortunately, preoperative characteristics of patients, including higher BMI and metabolic disease, who will undergo BPD/DS tend to put them at the highest risk for preoperative morbidity at the time of their initial bariatric procedure.
Question Section
Questions
1.
Only surgical rapid weight loss increases gallstone formation. True or False?
2.
Administration of Actigall postop decreases risk of gallstone formation from 33 to 2 %. True or False?
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