CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 5 (2014) 249–252

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Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery Marialessia Milella a , Maryam Alfa-Wali a , Luca Leuratti a , James McCall b , Gianluca Bonanomi a,∗ a b

Department of Surgery, United Kingdom Department of Radiology, United Kingdom

a r t i c l e

i n f o

Article history: Received 31 October 2013 Received in revised form 25 February 2014 Accepted 4 March 2014 Available online 12 March 2014 Keywords: Gastric bypass PTC Choledocholithiasis Bariatric Laparoscopy

a b s t r a c t INTRODUCTION: Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE: We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1 cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10 mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION: Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION: Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner. © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones in these patients is also challenging due to the altered gastrointestinal anatomy. The Roux-en-Y reconstruction makes the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis difficult in such patients (Fig. 1). Various techniques have been proposed to treat bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP using direct cholangioscopy with the

aid of a gastroscope to perform a sphincterotomy in patients after a Roux-en-Y and a Billroth II gastrojejunostomy. Laparoscopic transgastric ERCP is another option for treating biliary tract disease in LRYGB patients. This involves a combined surgical and endoscopic procedure under general anesthetic. A gastrostomy is performed through the anterior wall of the greater curve of the excluded stomach with the introduction of a duodenoscope to perform the ERCP and a sphincterotomy. Laparoscopic or open biliary surgery and interventional radiology have been also reported.

2. Presentation of case ∗ Corresponding author at: Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom. Tel.: +44 0203 315 8463; fax: +44 0203 315 8282. E-mail address: [email protected] (G. Bonanomi).

We present the successful percutaneous trans hepatic (PTC) management of common bile duct retained stones after laparoscopic cholecystectomy in a patient who had a previous LRYGB.

http://dx.doi.org/10.1016/j.ijscr.2014.03.003 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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Fig. 2. The initial cholangiogram with an inset image of the MRCP showing the location of the stone in the bile duct (white arrow).

Fig. 1. Roux en Y gastric bypass – Anatomy.

A 59-year-old female presented as an emergency with right upper quadrant pain and vomiting. She had a LRYGB for morbid obesity with a body mass index (BMI) of 44.5 kg/m2 a year before. Her BMI at the time of admission was 30.9 kg/m2 , with an excess weight loss of 62%. Her past medical history included asthma, depression and a total abdominal hysterectomy. Blood tests showed a bilirubin of 8 (0–21) ␮mol/l, alkaline phosphatase (ALP) of 221 (30–130) iu/l and an alanine transaminase (ALT) of 199 (0–40) iu/l. An ultrasound scan performed at the time showed an acute cholecystitis and fatty infiltration of the liver. There was no evidence of intra or extrahepatic biliary tree dilatation and no ductal stones were demonstrated. She was discharged on antibiotic treatment and liver function tests normalized in the following weeks. An MRCP demonstrated several small gallstones with no evidence of intra or extrahepatic biliary tree dilatation or ductal stones. The acute symptoms resolved in a few days and 4 weeks later an elective laparoscopic cholecystectomy was performed with an uneventful post-operative period. The patient presented a month later complaining of epigastric pain radiating to the back and localized peritonism. Her bilirubin was 66 ␮mol/l, ALT 437 iu/l, ALP 849 iu/l and a normal amylase. An initial CT scan did not show any evidence of a perforation or collection. An MRCP showed mild intrahepatic duct dilatation, with a common bile duct (CBD) of 1 cm and a calculus within the distal CBD. She underwent a percutaneous trans hepatic cholangiogram (PTC) under local anesthetic (Fig. 2) through a right-sided anterior segmental duct puncture. The sphincter was dilated to 10 mm with a balloon catheter which was then used to push the stone into the duodenum leaving an 8-French internal-external drain. The patient clinically improved within a few hours with normally functioning

drainage. After 24 h, contrast was injected through the drain, showing no filling defects to suggest retained stones, and normal passage into the duodenum (Fig. 3). The drain was therefore withdrawn into the distal CBD and a repeat cholangiogram performed, which again showed no evidence of choledocolithiasis, demonstrating excellent drainage of the biliary tree and the internal-external drain was then removed on the same day. There was no bleeding or significant bile leak from the tract. The patient was discharged home after 2 days with improving liver function tests (bilirubin 35 ␮mol/l, ALT 121 iu/l, ALP 436 iu/l) and she recovered completely at follow-up six weeks later.

Fig. 3. Cholangiogram following injection of contrast through the pigtail drain showing no filling defects to suggest retained stones.

CASE REPORT – OPEN ACCESS M. Milella et al. / International Journal of Surgery Case Reports 5 (2014) 249–252

3. Discussion Patients with morbid obesity have a higher incidence of gallstones compared to the general population, up to 50% as reported in the literature.1,2 Formation of gallstones after rapid weightloss is also a well-recognised phenomenon. Due to the rapid weight loss, the first year after LRYGB predisposes patients to the occurrence of gallstones.3 The mechanisms associated with gallstone formation include cholesterol supersaturation of the bile, increased mucin secretion and reduced gall bladder motility due to vagal nerve injury.4 There are no standard therapies after bariatric surgery we employ at our institution. We tend to treat patients with symptomatic gallstones on an individual basis by carrying out a laparoscopic cholecystectomy. We support the position that a laparoscopic cholecystectomy at the time of gastric bypass is not necessary in asymptomatic cholelythiasis. As demonstrated by Warschkow R in a recent meta-analysis,5 a prophylactic concomitant cholecystectomy during LRYGB should be avoided in patients without gallstones and exclusively be performed in patients with symptomatic biliary disease. Also, a 6-month prophylactic regimen of ursodiol, which is adopted by one third of bariatric surgeons, is not recommended because of the additional costs,6 patient compliance and the relative small reduction of cholecystectomy rates.7 As reported by Caruana JA in 2005,8 most newly formed gallstones after gastric bypass are likely asymptomatic, prophylactic cholecystectomy is not indicated, and ursodiol therapy may be better reserved for symptomatic patients who refuse cholecystectomy. Prior to the laparoscopic cholecystectomy the patient underwent an MRCP that did not show evidence of ductal stones and the liver function tests returned within normal limits, hence a combined procedure for stone clearance was not indicated. An on-tablecholangiogram could have identified the CBD stones but we do not routinely perform the investigation at our institution without clinical evidence. The management of CBD stones after LRYGB makes the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis difficult, due to the exclusion of the duodenum from the gastrointestinal tract and the long anatomic route from mouth to the major papilla. The Roux limb is at least 100 cm in length (Fig. 1). Several techniques have been proposed to treat bile duct stones in LRYGB patients. In 1998 Baron and Vickers described the creation of a surgical gastrostomy to access the gastric remnant. This technique requires the initial placement of a surgical gastrostomy in the excluded stomach and ERCP is then performed through the gastrostomy tract.9 Later, double balloon was introduced as a new endoscopic technique that allowed examination of the entire small bowel.10 Comparing ERCP via gastrostomy (GERCP) and double balloon enteroscopy (DBERCP), it has been shown that GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by gastrostomy maturation delay and higher morbidity.11–13 In a recent report14 the performance of percutaneous endoscopic gastrostomy (PEG) with immediate self-expandable metal stent (SEMS) placement allows antegrade transgastric ERCP during the same procedure. With the use of balloon assisted enteroscopy, retrograde PEG/SEMS in excluded stomach allows therapeutic ERCP without need for surgery. Also, in a retrospective study, Schreiner showed laparoscopy assisted ERCP had better outcomes compared with balloon enteroscopy assisted ERCP in LRYGB patients where the Roux limb and biliopancreatic is 150 cm or longer. In patients with less than 150 cm, balloon enteroscopy assisted ERCP should be considered first line if available.15 According to Martinez an antegrade biliary stenting following laparoscopic common bile duct exploration for cholelithiasis

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and associated common bile duct stones is an effective and safe technique.16 Percutaneous trans hepatic cholangioscopic lithotomy (PTCSL), which was introduced to treat hepatolithiasis in 1981 by Nimura,17 can be an alternative option for this condition.18 The procedure is also a useful alternative therapy for conditions such as complicated retained stones, biliary stones in poor surgical candidates, and altered anatomy in patients who have received a gastrectomy. PTCSL is a technically easy and useful treatment for removal of CBD stones because of its easy approach and direct visualization of bile duct stones. However, this procedure has been generally restricted to cases in which conventional endoscopic procedures were unmanageable or unsuccessful. Additionally, it is generally safe and well tolerated despite long procedure time, especially in elderly or in patients in poor conditions. A success rate of 100% with complete stone removal and only minor and transient complications has been reported.18 We have adopted the percutaneous trans hepatic approach with papillary balloon dilatation proposed by Nagashima19 which could be considered the first choice in patients with altered anatomy such as having diverticuli near the papilla and following a Billroth II gastrectomy or LRYGB. One of the main advantages of this procedure is it can be performed under local anaestethic allowing successful clearance of the CBD with the expertise of an interventional radiologist, minimizing costs and avoiding more invasive procedures. In a large series of 261 patients treated with PTC a complication rate of 6.8% with no mortality has been reported. Major complications included cholangitis (2.7%), subcapsular bilioma (1.5/%), bile peritonitis (0.38%), CBD or duodenal perforation (0.38%), liver abscess (0.38%), subcapsular hematoma (0.38%) and artery transection (0.38%).20 Only one patient required surgical treatment due to duodenal perforation.20 In our experience, this percutaneous approach to manage CBD stones after LRYGB resulted safe and effective with no need for further endoscopic or surgical procedures. There is no specific limit to the number of stones to be extracted, however multiple stones could decrease the likelihood of complete clearance. Larger stones may be more difficult to push through the ampulla considering that a sphincterotomy cannot be achieved, but a balloon sphinteroplasty up to 14 mm (according to the stone and the CBD diameter) can be safely performed, preserving a normal papillary function. The same technique could also be successfully used if a concomitant biliary stricture is found.21 Transhepatic holmium laser lithotripsy could be another safe and effective way to clear large solitary or impacted CBD stones,18,22 but it has not yet a widespread use. We do not have the laser facilities at our institution, therefore, if the obstructed stone could not have been advanced or removed during the percutaneous transhepatic approach, our strategy would have been to perform a laparoscopy assisted ERCP.

4. Conclusion The obesity epidemic and the high prevalence of obesity related comorbidities, represent a worldwide public health problem.9 Surgical treatment of obesity is the most effective mean of weight loss in this patient population. Among all bariatric operation LRYGB is considered the gold standard. As a consequence, clinicians encounter an increasing number of pancreatobiliary pathology (e.g. choledocholithiasis) requiring ERCP within a Rouxen-Y anatomy.19 With the increase in global obesity, the need for bariatric surgery will be exponentially augmented, therefore the problem of biliary pathology is likely to increase as well. Bariatric centers therefore need to strategically plan resources such as

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interventional radiology in order to manage such problems safely, efficiently and in a cost effective manner. Conflict of interest statement None. Funding None Ethical approval Not required. Author contributions Milella – writing paper, Alfa-Wali – study concept, Leuratti – data collection, McCallan – Interventional Radiology, Bonanomi – Surgeon. References 1. Wattchow DA, Hall JC, Whiting MJ, Bradley B, Iannos J, Watts JM. Prevalence and treatment of gall stones after gastric bypass surgery for morbid obesity. BMJ 1983;286(6367):763. 2. Bastouly M, Arasaki CH, Ferreira JB, Zanoto A, Borges FG, Del Grande JC. Early changes in postprandial gallbladder emptying in morbidly obese patients undergoing Roux-en-Y gastric bypass: correlation with the occurrence of biliary sludge and gallstones. Obesity Surg 2009;19(1):22–8. 3. Falcao M, Campos JM, Galvao Neto M, et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obesity Surg 2012;22(6):872–6. 4. Li VK, Pulido N, Fajnwaks P, Szomstein S, Rosenthal R, Martinez-Duartez P. Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy. Surg Endosc 2009;23(7):1640–4. 5. Rene Warschkow, Ignazio Tarantino, Kristjan Ukegjini, et al. Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis. Obes Surg 2013;23:397–407. 6. Jaime Benarroch-Gampel, Lairson DR, Boyd CA, Sheffield KM, Vivian Ho, Riall TS. Cost-effectiveness analysis of cholecystectomy during Roux-en-Y gastric bypass for morbid obesity. Surgery 2012;152(September (3)):363–75.

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