What are the recommended steps and peri‑operative considerations for performing a laparoscopic‑assisted trans‑gastric ERCP in a patient with a prior Roux‑en‑Y gastric bypass?

Laparoscopic-Assisted Transgastric ERCP in Roux-en-Y Gastric Bypass Patients

Patients with Roux-en-Y gastric bypass requiring ERCP should be referred to specialized centers capable of performing laparoscopic-assisted transgastric ERCP, as conventional transoral ERCP is not feasible due to the altered anatomy. 1

Patient Selection and Pre-Operative Assessment

Key clinical indicators requiring ERCP in RYGB patients:

• Persistent epigastric pain with elevated liver enzymes suggesting choledocholithiasis 1
• Signs of cholangitis (fever ≥38°C, tachycardia ≥110 bpm, jaundice) requiring urgent intervention within 24-72 hours 1
• Tachycardia alone in RYGB patients warrants immediate imaging even without fever, as it may indicate biliary obstruction or internal hernia 1
• Persistent vomiting and nausea suggesting biliary obstruction or marginal ulcer 1

Pre-operative workup:

• Complete blood count, CRP, procalcitonin, serum lactate, liver function tests 1
• Cross-sectional imaging (CT or MRCP) to confirm biliary pathology and assess surgical anatomy 1
• Rule out pulmonary embolism if respiratory distress present, as PE is a leading cause of mortality post-bariatric surgery 1, 2

Recommended Surgical Technique

The laparoscopic transgastric approach is the preferred method with 94-100% success rates for gastric access and 98.5% ductal cannulation rates. 3, 4, 5

Step-by-Step Laparoscopic Approach:

1. Laparoscopic access to excluded stomach:

• Place standard laparoscopic ports for visualization 3, 5
• Identify the excluded gastric remnant (may require adhesiolysis) 3
• Create gastrotomy on anterior wall of excluded stomach 3
• Insert 15mm trocar through gastrotomy for endoscope passage 3, 5

2. Securing the gastrotomy:

• Place two traction sutures through abdominal wall on either side of gastrotomy to stabilize stomach and prevent air leak 3
• This technique minimizes peritoneal contamination risk 3

3. ERCP performance:

• Pass side-viewing duodenoscope through the 15mm intragastric trocar 3, 5
• Perform standard ERCP with sphincterotomy and stone extraction 5
• If sphincterotomy cannot be safely completed, use limited sphincterotomy supplemented by endoscopic papillary balloon dilation 1

4. Closure:

• Remove endoscope and trocar 3
• Close gastrotomy in two layers laparoscopically 3
• Consider simultaneous cholecystectomy if gallbladder in situ (performed in 31% of cases) 5

Alternative Techniques (When Laparoscopic Expertise Limited)

EUS-guided sutured gastropexy (ESTER technique):

• Achieves 90% technical success with same-session ERCP capability 6
• EUS puncture of excluded stomach through gastric pouch or jejunum 6
• Direct percutaneous gastrostomy with sutured gastropexy 6
• Allows duodenoscope passage through gastrostomy tract 6
• No adverse events reported in initial series 6

Percutaneous-assisted transprosthetic endoscopic therapy (PATENT):

• Balloon enteroscopy to access excluded stomach, followed by retrograde percutaneous gastrostomy 7
• Deploy esophageal self-expandable metal stent within gastrostomy tract 7
• Advance duodenoscope through SEMS for antegrade ERCP 7
• Leave gastrostomy tube to maintain tract patency 7

Peri-Operative Management

Anticoagulation considerations:

• Discontinue DOACs 3-5 days pre-procedure based on renal function 2
• Stop warfarin 5 days before to achieve INR ≤1.5 2
• Resume therapeutic anticoagulation 24-72 hours post-procedure once hemostasis confirmed 2
• Consider PPI prophylaxis given marginal ulcer risk in RYGB patients on anticoagulation 2

VTE prophylaxis:

• Combine pharmacological prophylaxis with mechanical methods and early ambulation 2
• VTE rates post-RYGB are approximately 0.4%, making prophylaxis essential 2

Timing considerations:

• Urgent ERCP (within 24 hours) for septic shock or cholangitis with deterioration despite antibiotics 1
• ERCP within 72 hours for cholangitis or persistent biliary obstruction 1

Expected Outcomes and Complications

Success rates:

• Gastric access: 100% 4
• Ductal cannulation: 98.5% 4
• Overall ERCP completion: 94% 5

Adverse events (14% overall): 4

• Gastrostomy-related (80% of complications): wound infections most common (3.7%) 4
• ERCP-related (20% of complications): post-ERCP pancreatitis most common (1.4%) 4
• No mortality reported in systematic review of 509 cases 4
• Major complication rate <1% (necrotizing pancreatitis reported) 5

Critical Pitfalls to Avoid

Common errors:

• Attempting conventional transoral ERCP in RYGB patients—anatomically impossible due to bypassed duodenum 1
• Delaying referral to specialized center—increases morbidity from untreated biliary obstruction 1
• Underestimating adhesions from prior surgery—may require open conversion 1
• Ignoring tachycardia as sole presenting sign—may indicate serious complication requiring urgent intervention 1

Post-operative surveillance:

• Monitor clinically for recurrent symptoms (jaundice, RUQ pain, fever) rather than routine imaging 8
• Repeat ERCP only if clinical or biochemical evidence of recurrent stones, not as routine surveillance 8
• Average length of stay: 3.7 days 5

Long-Term Considerations

Risk of recurrent biliary events:

• RYGB patients may have higher risk of primary CBD stone formation even years after cholecystectomy 5
• Average time from bypass to LAERCP: 6.9 years 5
• 43% of patients in one series had cholecystectomy >2 years before presenting with CBD stones 5