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Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial
Choledocholithiasis after gastric bypass: a growing problem Received January 31, 2013; accepted February 3, 2014
Keywords:
’’’
In their manuscript, DuCoin et al. address an important and growing problem, namely, access to and treatment of common bile duct stones in patients with Roux-en-Y reconstructions. Roux-en-Y gastric bypass (RYGB) comprises half of all weight loss procedures performed in the United States [1]. Given the current rate of approximately 100,000–200,000 bariatric procedures/year, an additional 500,000 to 1 million Americans/decade, who are at higher-than-average risk for symptomatic gallstones, will have access to their biliary trees complicated by surgically altered anatomy. The authors offer a single center’s experience with a laparoscopic approach to internal drainage for choledocholithiasis after gastric bypass. While their approach represents an interesting option, it is not likely to be the first choice for treatment of choledocholithiasis in Roux-en-Y patients by a majority of surgeons. There has been a national trend away from open or laparoscopic common bile duct exploration, and there has been an increase in the use of endoscopic retrograde cholangiopancreatography (ERCP) for treatment of choledocholithiasis. It is becoming more difficult to train new surgeons to perform common bile duct exploration and for practicing surgeons and their operating room staff to remain facile with it. In addition, surgeons are performing fewer intraoperative cholangiograms, lessening their ability to define biliary anatomy and guard against bile duct injury during cholecystectomy. The steadily increasing numbers of patients with difficult biliary access only adds to the necessity for increasing the experience general surgeons have with routine bile duct imaging, biliary anatomy, and performance of routine biliary surgery including common bile duct exploration. In the meantime, it is likely that the majority of surgeons will continue to rely on treatments offered by medical and surgical endoscopists for most bile duct stones, or to consider referral to a hepatobiliary surgeon for those not
amenable to endoscopic therapy. However, the anatomic changes resulting from RYGB require specialized approaches for successful transoral ERCP such as balloon enteroscopy offered by experienced endoscopists or percutaneous access by interventional radiologists. This diverse expertise may not be available in some communities, mandating that the general surgeon devise an appropriate plan for the management of choledocholithiasis after RYGB. When choledocholithiasis has been confirmed, a very reasonable treatment option is combining laparoscopically guided transcutaneous access to the remnant stomach with transgastric ERCP. This approach is the most straightforward, reliable, and available approach for the majority of practitioners, significantly increasing the rate of biliary access and stone clearance compared with transoral ERCP in RYGB patients [2–4]. We applaud the authors for their refined laparoscopic skills and for reporting their results in Surgery of Obesity and Related Diseases, which helps bring continued emphasis to a problem likely to vex bariatric and general surgeons with increasing frequency. Disclosures ’’’ D. Wayne Overby, M.D.* UNC Chapel Hill, Chapel Hill, North Carolina William Richardson, M.D. General Surgery, Laparoscopic Surgery Oschner Clinic New Orleans, Louisiana
*
Correspondence: D. Wayne Overby, M.D., Assistant Professor Surgery, UNC Chapel Hill, 4035 Burnett Womack, CB 7081, Chapel Hill, NC 27599. http://dx.doi.org/10.1016/j.soard.2014.02.001 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 Q9 93 94 95 96 Q4 97 98 99 100 101 102 103 104 105 106 Q7107 108 109 110
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111 Robert Fanelli, M.D. 112 Q1 Minimally Invasive Surgery, Surgical Endoscopy 113 The Guthrie Clinic, Ltd 114 Q5 UMASS Medical School 115 Q6 Worcester, Massachusetts 116 117 References 118 119 [1] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. 120 Obes Surg 2013;23(4):427–36.
[2] Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009;70(6):1254–9. [3] Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012;75(4):748–56. [4] Falcão M, Campos JM, Galvão Neto M, et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg 2012;22(6):872–6.
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Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial
Choledocholithiasis after gastric bypass: a growing problem Received January 31, 2013; accepted February 3, 2014
Keywords:
’’’
In their manuscript, DuCoin et al. address an important and growing problem, namely, access to and treatment of common bile duct stones in patients with Roux-en-Y reconstructions. Roux-en-Y gastric bypass (RYGB) comprises half of all weight loss procedures performed in the United States [1]. Given the current rate of approximately 100,000–200,000 bariatric procedures/year, an additional 500,000 to 1 million Americans/decade, who are at higher-than-average risk for symptomatic gallstones, will have access to their biliary trees complicated by surgically altered anatomy. The authors offer a single center’s experience with a laparoscopic approach to internal drainage for choledocholithiasis after gastric bypass. While their approach represents an interesting option, it is not likely to be the first choice for treatment of choledocholithiasis in Roux-en-Y patients by a majority of surgeons. There has been a national trend away from open or laparoscopic common bile duct exploration, and there has been an increase in the use of endoscopic retrograde cholangiopancreatography (ERCP) for treatment of choledocholithiasis. It is becoming more difficult to train new surgeons to perform common bile duct exploration and for practicing surgeons and their operating room staff to remain facile with it. In addition, surgeons are performing fewer intraoperative cholangiograms, lessening their ability to define biliary anatomy and guard against bile duct injury during cholecystectomy. The steadily increasing numbers of patients with difficult biliary access only adds to the necessity for increasing the experience general surgeons have with routine bile duct imaging, biliary anatomy, and performance of routine biliary surgery including common bile duct exploration. In the meantime, it is likely that the majority of surgeons will continue to rely on treatments offered by medical and surgical endoscopists for most bile duct stones, or to consider referral to a hepatobiliary surgeon for those not
amenable to endoscopic therapy. However, the anatomic changes resulting from RYGB require specialized approaches for successful transoral ERCP such as balloon enteroscopy offered by experienced endoscopists or percutaneous access by interventional radiologists. This diverse expertise may not be available in some communities, mandating that the general surgeon devise an appropriate plan for the management of choledocholithiasis after RYGB. When choledocholithiasis has been confirmed, a very reasonable treatment option is combining laparoscopically guided transcutaneous access to the remnant stomach with transgastric ERCP. This approach is the most straightforward, reliable, and available approach for the majority of practitioners, significantly increasing the rate of biliary access and stone clearance compared with transoral ERCP in RYGB patients [2–4]. We applaud the authors for their refined laparoscopic skills and for reporting their results in Surgery of Obesity and Related Diseases, which helps bring continued emphasis to a problem likely to vex bariatric and general surgeons with increasing frequency. Disclosures ’’’ D. Wayne Overby, M.D.* UNC Chapel Hill, Chapel Hill, North Carolina William Richardson, M.D. General Surgery, Laparoscopic Surgery Oschner Clinic New Orleans, Louisiana
*
Correspondence: D. Wayne Overby, M.D., Assistant Professor Surgery, UNC Chapel Hill, 4035 Burnett Womack, CB 7081, Chapel Hill, NC 27599. http://dx.doi.org/10.1016/j.soard.2014.02.001 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 Q9 93 94 95 96 Q4 97 98 99 100 101 102 103 104 105 106 Q7107 108 109 110
SOARD : 1890 D. W. Overby et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
111 Robert Fanelli, M.D. 112 Q1 Minimally Invasive Surgery, Surgical Endoscopy 113 The Guthrie Clinic, Ltd 114 Q5 UMASS Medical School 115 Q6 Worcester, Massachusetts 116 117 References 118 119 [1] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. 120 Obes Surg 2013;23(4):427–36.
[2] Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009;70(6):1254–9. [3] Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012;75(4):748–56. [4] Falcão M, Campos JM, Galvão Neto M, et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg 2012;22(6):872–6.
121 122 123 124 125 126 127 128 129 130
