From the Guidelines
Patients with cholelithiasis and a prior Roux-en-Y gastric bypass should be referred to specialized centers for advanced endoscopic and surgical treatment options.
Management Considerations
- The management of cholelithiasis in patients with a prior Roux-en-Y gastric bypass is challenging due to the altered upper GI anatomy, which makes it difficult to reach the papilla, access the bile duct, and deliver appropriate therapy 1.
- These patients should be referred to centers that can offer advanced endoscopic and surgical treatment options necessary for stone extraction, as the standard endoscopic approaches may not be feasible 1.
- The increasing number of patients undergoing obesity surgery, including Roux-en-Y gastric bypass, has led to a growing need for specialized care in managing complications such as cholelithiasis 1.
- While the evidence is considered low-quality and the recommendation is weak, referral to a specialized center is still the recommended course of action due to the complexity of the case and the need for advanced treatment options 1.
From the Research
Management Options
- Treatment for cholelithiasis in patients with a prior Roux-en-Y gastric bypass should progress from least to most invasive options 2
- Options for management include endoscopic, surgical, percutaneous, or hybrid means with variable success rates 2
- Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP) is a safe and feasible alternative for gallstone cholangitis management in patients with Roux-en-Y gastric bypass 3
- Cholecystectomy can be performed laparoscopically in patients who develop symptomatic cholelithiasis after Roux-en-Y gastric bypass 4, 5, 6
Considerations for Cholecystectomy
- Prophylactic cholecystectomy is not necessary at the time of Roux-en-Y gastric bypass for patients with a normal gallbladder 6
- Concomitant cholecystectomy should be considered if an abnormal gallbladder or gallstones are found at the time of Roux-en-Y gastric bypass operation 6
- Cholecystectomy can be performed after Roux-en-Y gastric bypass if gallstones develop, and it is reasonable to perform cholecystectomy in the presence of cholelithiasis or after this procedure if gallstones develop 4
Complications and Risks
- Gallstone-related complications after Roux-en-Y gastric bypass are relatively common, and some of these complications, like acute pancreatitis, are known to have potentially severe outcomes 4
- The altered anatomy following Roux-en-Y gastric bypass poses a significant challenge in choledocholithiasis management 2
- LTG-ERCP should be performed in a referral center by a skilled endoscopist and surgeon following a standardized technique 3