Laparoscopic Transgastric Endoscopy after Roux-en-Y GB
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: Laparoscopic transgastric endoscopy is a safe and minimally-invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en-Y gastric bypass.
Source: Ceppa FA, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3:21-24.
Background: Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en-Y gastric bypass. Ceppa and colleagues propose a minimally-invasive technique to access the bypassed stomach for endoscopic diagnosis and treatment after Roux-en-Y gastric bypass.
Technique: A carbon dioxide pneumoperitoneum was established to a pressure of 12-15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears, and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler.
Results: Ten patients have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathology findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because of stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration, and the third had negative endoscopic findings. Two patients evaluated for chronic abdominal pain had negative endoscopic findings. No complications developed following this technique.
Conclusions: Ceppa et al conclude that laparoscopic transgastric endoscopy is a safe and minimally-invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en-Y gastric bypass.
Access to the gastric remnant is important following Roux-en-Y gastric bypass. There are 2 big indications: biliary problems (more specifically, stones in the common bile duct) and peptic ulcer disease and its complications.
Some surgeons, in that effect, have proposed a systematic analysis of the Helicobacter status of perioperative patients with an upper GI endoscopy to rule out an active peptic ulcer; although this is not widely done.
Some have proposed the use of a pediatric colonoscope, but the technique is difficult, as it has to pass several segments of bypassed GI tract. The success rate is 68%.
The technique described here is straightforward. It is considered safe, as no complications were reported and it allowed the performance of all ERCPs, with a success rate of 80%, which is quite high. Three patients had an upper GI bleed, with a negative endoscopy. A cause was found in 2 of the 3 (bleeding ulcer and a bleeding tumor) patients. The technique, therefore, is effective but requires reoperation and general anesthesia.
In my opinion, it should be reserved for non-biliary problems, in situations where conservative measures to stop the bleeding failed.In common bile duct stone disease, a magnetic resonance cholangiopancreatography should precede any decision, as many stones pass on their own, and only patients with cholangitis should be considered for an urgent laparoscopic transgastric Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgeon should make provisions to reoperate the patient through traditional open methods, should the ERCP fail in the same setting.