Gallbladder and Biliary Disease in Bariatric Surgery Patients

Fig. 1.

A gastrostomy is created and a 15 mm trocar is then inserted in the left upper quadrant and advanced into the gastrostomy. The enteroscope is advanced through the gastrostomy and used as in standard ERCP procedures.

Fig. 2.

The distribution and sizes of the trocars used in a standard laparoscopic ERCP.

Retrograde Endoscopy

In order to reach the ampulla of Vater in patients who underwent a Roux-en-Y gastric bypass, the endoscope must travel the length of the alimentary limb which is 100–150 cm and then travels retrograde through the biliopancreatic (BP) limb. The angulation between the BP limb and the anastomosis can be difficult to negotiate. The technical challenges of this procedure are mainly related to the length of the bypassed segment and the angulation at the Roux-en-Y anastomosis. The use of side-viewing scopes that are utilized for ERCP is difficult due to their short lengths. Therefore, a traditional push enteroscopy is used, and more recently single- and double-balloon enteroscopy has been reported. This comes at the cost of losing the side view which makes cannulation of the ampulla more difficult. Choi et al. [27] summarize the limitations of double-balloon enteroscopy which has the potential to be the most successful endoscopic technique due to the length of the scope. These limitations are (1) the lack of an elevator, (2) the absence of the side view, (3) the long time of the procedure and the fact that it is time-consuming (40–180 min), (4) the limited accessories for therapeutic maneuvers, and (5) the presence of a learning curve. In their study, Choi et al. examined the indications and outcomes of ERCP via laparoscopy and double-balloon enteroscopy. They included 72 patients with a prior RYGB; 44 of these patients underwent an open or laparoscopic-assisted ERCP via a gastrostomy (GERCP), while 28 patients had a double-balloon enteroscopy-assisted ERCP (DERCP). The most common indication for cholangiography in the GERCP group was sphincter of Oddi dysfunction (77 %), while for the DERCP group (57 %) common bile duct stones were suspected. In the GERCP group ERCP was performed at 4–6 weeks once the gastrostomy tract is matured. The mean total duration of GERCP was 45.9 ± 26.6 min. The mean endoscopic procedure time in the DERCP group was 101.2 ± 36.8 min; this was statistically significantly longer than the GERCP group. The diagnostic and interventional success for the GERCP technique was 100 %. In the DERCP group the ampulla was reached in 78 % of cases, and cannulation was achieved in 63 % of cases with successful intervention in only 56 % of cases.

The complication rate was higher in the GERCP group (14.5 %) when compared to the DERCP group (3.1 %).

In a study from Virginia Mason [28], 56 patients who had a Roux-en-Y gastric bypass underwent assisted ERCP. Twenty-four patients underwent laparoscopic-assisted ERCP, while 32 patients had balloon enteroscopy-assisted ERCP. Despite reaching the major papilla in 72 % of cases of balloon enteroscopy, the therapeutic success of balloon enteroscopy-assisted ERCP was 59 %, while the therapeutic success of laparoscopic-assisted ERCP was 100 %. Laparoscopic-assisted ERCP following a failed balloon enteroscopy saved $1,015 when compared with laparoscopic-assisted ERCP. The only factor associated with successful balloon enteroscopy-assisted ERCP was a Roux limb less than 150 cm in length.

In conclusion, gallstone disease is prevalent in the bariatric population when compared to the general population. The trend in the United States is to perform a cholecystectomy only if patients are symptomatic at the time of the bariatric operation. Prevention of gallstones formation can be achieved using ursodiol, but compliance may be an issue. Surgically assisted ERCP is the most effective technique in managing diseases of the CBD in patients who have a bypass operation.

Questions

Obesity is associated with formation of gallstones because:

(a)

Supersaturation of buying with cholesterol leading to enhanced nucleation and crystallization.

(b)

Increased secretion of Mason General due to inflammatory state.

(c)

Alteration in gallbladder motility.

(d)

All of the above

True or false

(a)

The incidence of normal gallbladder in morbidly obese patient undergoing bariatric surgery is 50 %.

(b)

The most frequent abnormality in the gallbladder of morbidly obese patient is cholesterolosis (37 %).

(c)

Gallbladder contractility is increased and is highly sensitive to cholecystokinin after bariatric surgery.

(d)

The most cost-effective strategy for gallstones is to perform LRYGB without preoperative ultrasound and without simultaneous cholecystectomy followed by postoperative ursodiol.

(e)

The only factor associated with successful balloon enteroscopy-assisted ERCP is Roux limb less than 150 cm in length.

In the multicenter randomized trial by Sugerman et al., the most effective dose to prevent formation of gallstones was:

(a)

300 mg of ursodiol daily.

(b)

600 mg of ursodiol daily.

(c)

1,200 mg of ursodiol daily.

Which of the following is not true:

(a)

The indication for accessing the biliary tree post-bariatric surgery includes sphincter of Oddi dysfunction, biliary pancreatitis, choledocholithiasis, pancreatic mass evaluation, and treatment of by a leak postcholecystectomy.

(b)

The side-viewing scopes (traditional ERCP) are effective for both laparoscopic-assisted ERCP technique and retrograde endoscopy to access the biliary tree.

(c)

Although double-balloon enteroscopy has the potential to be a successful endoscopic technique due to the length of the scope, it has several limitations.

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