Endoscopic Retrograde Cholangiopancreatography and Gastroduodenoscopy after Roux-en-Y GB

Abstract & Commentary

By Richard Peterson, MD, MPH, Clinical Instructor of Surgery, Department of Surgery, USC. Dr. Peterson reports no financial relationship relevant to this field of study.

Synopsis: The transgastrostomy endoscopic route ensures access to the excluded stomach and proximal small bowel after RYGB.

Source: Martinez J, et al. Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass. Surg Endosc. 2006;20:1548-1550.

The use of roux-en-y gastric bypass (RYGB) for morbid obesity has raised concern that subsequent endoscopic evaluation of the gastric remnant and duodenum is difficult. By gaining percutaneous access to the gastric remnant, however, both gastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) can be performed easily. This report describes the results of a novel technique for performing transgastrostomy gastroduodenoscopy and ERCP.

Methods: Six patients with a RYGB for morbid obesity underwent transgastric remnant endoscopic evaluations. If a gastric remnant tube had not been placed prior to surgery, one was placed percutaneously by an interventional radiologist. The tube tract then was dilated to either 20- or 24-Fr. At the time of endoscopy, the gastrostomy tube was removed and the skin anesthetized. Then either a pediatric duodenoscope (outer diameter, 7.5-mm) or a slim gastroscope (outer diameter, 5.9-mm) was inserted through the gastrostomy tube tract.

Results: Percutaneous gastroduodenoscopy was successfully performed for all 6 patients. The findings included 2 patients with prepyloric ulcers identified and assessed with a biopsy, one patient with intestinal metaplasia and a benign gastric polyp, and 3 patients with a normal gastric remnant and duodenum. A nonstructured enteroenterostomy was noted in one of the 3 patients with a normal endoscopic evaluation. Percutaneous transgastrostomy ERCP was performed for 3 of the 6 patients who underwent gastroduodenoscopy. The findings included one patient who had papillary fibrosis treated with a sphincterotomy, a second patient with a normal biliary tree, and a third patient with a normal pancreatic duct. Selective cannulation of the common bile duct was not successful in the third patient.

Commentary

The transgastrostomy endoscopic route ensures access to the excluded stomach and proximal small bowel after RYGB. This route is safe and effective, allowing the use of a duodenoscope to improve the cannulation success rate for ERCPs in this patient population.

Martinez and colleagues present a very interesting paper with a novel technique. With the ever growing popularity of obesity surgery and the need for it rising, we are presented with an interesting problem. Laparoscopic Roux-en-Y gastric bypass is the gold standard in treatment of morbid obesity. This procedure consequently divides the stomach into a neo-pouch and a remnant stomach. This means a segment of the population are going to be left without a means of evaluating a portion of their gastrointestinal tract by conventional methods. Martinez et al identified several disorders that can affect a bypassed stomach.

  • Intestinal metaplasia
  • Bleeding ulcers
  • Anastomotic strictures
  • Intestinal polyps
  • Gastric cancer
  • Biliary/pancreatic abnormalities

Martinez et al developed a new approach to accessing the bypassed segment of the gastrointestinal tract. This new approach relies on a gastrostomy tube and healed gastrotomy tract. The initial access is obtained by interventional radiology via a CT-guided approach to access the gastric remnant. After insufflation of the stomach under fluoroscopy a 14-Fr gastrostomy tube is placed and upsized to a 20-Fr for a duodenoscope, or 24-Fr for ERCP scope over the next 2-3 weeks. Martinez et al present their approach in 6 patients. They reported successful evaluation of all of the patients. In 5 of the 6 patients, they performed procedures ranging from biopsies to ERCP.

There are other less invasive approaches to evaluation of the excluded segment of bowel, including virtual gastroduodenoscopy and percutaneous contrast approaches. Many will agree that these are useful diagnostic tools, but the disadvantage is that they are limited by their nontherapeutic potential.

While this approach does offer reasonable access to the excluded GI tract, it seems clear that the time delay may pose potential problems. There was no specific mention of time for each patient, but it appears that the earliest a patient was evaluated with this method was about 4 weeks later. This approach does have advantages, but in some of the more acute patient evaluations the time delay will be problematic. Martinez et al have laid the groundwork for a solid approach; the next step is to fine tune and improve the turn-around time to the procedure itself.