Biliary - ERCP after Gastric Bypass Surgery
Comments:
1. The description gastric bypass can mean one of two possible surgically-altered anatomical states. The cartoon on the left shows the type of bypass used to palliate gastric outlet obstruction and involves a side-to-side loop gastrojejunostomy. This video will concentrate on the type shown on the right which shows the commonest surgical bypass for the treatment of obesity. This involves creation of a small proximal gastric pouch, partitioned from the remainder of the stomach and emptying into an end-to-side gastrojejunostomy which is reconstructed as a Roux-en-Y jejunojejunostomy to maintain continuity with the duodenum, pancreas and biliary systems as shown.
2. The jejunojejunostomy, commonly known as the Y anastomosis, may be created either as an end-to-side or a side-to-side anastomosis. This will present the endoscopist with either a two lumen or three lumen choice of routes to the papilla as shown in this cartoon.
3. While it is optimal to reach the papilla with a duodenoscope, as in this example, it is usually too short and too flexible. New overtubes may facilitate this in the future but most centers currently use a small caliber colonoscope, enteroscope or double balloon enteroscope to reach the papilla and either attempt ERCP with a very limited range of accessories or to place a guidewire and backload a duodenoscope over it. The double balloon enteroscope has also been used in this situation.
4. In this patient, the typical three choices appear at the Y anastomosis and the correct route to the papilla must be selected. It is often the most difficult of the three options. Once entered, the afferent loop is traversed with the assistance of external compression with lead-gloved hand until the papilla is reached, a guidewire placed and a therapeutic duodenoscope backloaded. Access and therapy are then similar to the reversed situation found in the Billroth 2 patient and here cannulation of the pancreatic duct is achieved, a guidewire placed and a stent inserted. A reverse sphincterotome is then used to complete the biliary sphincterotomy.
6. This case demonstrates another approach by placing a guidewire transhepatically and using this to pass other accessories such as this sphincterotome antegrade or retrograde to achieve the objective.
7. Endoscopic management of pancreaticobiliary problems after gastric bypass surgery for obesity remains a challenge.
| Contributed by: |
David Carr-Locke, M.D. Director of Endoscopy Brigham and Women's Hospital |
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Citation: Carr-Locke, D. (Feb 28 2006). Biliary - ERCP after Gastric Bypass Surgery. The DAVE Project. Retrieved Sep, 9, 2010, from http://daveproject.org/viewfilms.cfm?film_id=359 Times viewed since Feb 2006: 8165 |
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