- Email: [email protected]
Management of biliary symptoms after bariatric surgery
The American Journal of Surgery (2015) -, -–-
Management of biliary symptoms after bariatric surgery Joel R. Brockmeyer, M.D.a, Brandon T. Grover, D.O., F.A.C.S.b, Kara J. Kallies, M.S.c, Shanu N. Kothari, M.D., F.A.C.S.b,* a
Minimally Invasive Bariatric Surgery and Advanced Laparoscopy Fellowship, Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA; bDepartment of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA; c Department of Surgery Research; Gundersen Medical Foundation, La Crosse, WI, USA
KEYWORDS: Biliary system; Bariatric surgery; Cholelithiasis; Endoscopic retrograde cholangiopancreatography
Abstract BACKGROUND: Biliary disease requiring intervention can be complicated in the postbariatric surgery patient. METHODS: A retrospective review was completed to identify patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from September 2001 to September 2014, and those who underwent biliary intervention were identified. RESULTS: A total of 1527 patients underwent bariatric surgery during the study period. Of the 1,112 patients without prior cholecystectomy, 91 (8%) had biliary symptoms requiring intervention. Ninety patients underwent cholecystectomy, with 86 successfully completed laparoscopically. Six patients required laparoscopy-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography along with cholecystectomy to clear gallstones from the common bile duct. Three patients who had undergone cholecystectomy before bariatric surgery developed primary common bile duct stones. CONCLUSIONS: Surgery for biliary disease after bariatric surgery can be completed successfully with minimal complications, and percutaneous transgastric endoscopic retrograde cholangiopancreatography has a high success rate of access to and clearance of the biliary tree. Ó 2015 Elsevier Inc. All rights reserved.
Bariatric surgery is one of the most commonly performed elective general surgery operations in the United States.1 Some bariatric surgeries, such as laparoscopic Roux-en-Y gastric bypass (LRYGB), alter the foregut and midgut anatomy to aid in long-term weight loss.2 As obese patients have a higher incidence of biliary disease, previous bariatric surgery may complicate treatment. The incidence The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-608-775-5187; fax: 11-608-7754460. E-mail address: [email protected] Manuscript received April 9, 2015; revised manuscript July 21, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.07.003
of asymptomatic cholelithiasis in the general population found by transabdominal ultrasonography ranges from 2% to 15%.2 Risk factors have been identified and include obesity, female sex, age more than 40 years, white ethnicity, premenopausal state, pregnancy, use of oral contraceptives, estrogen replacement therapy, diabetes, and family history. An additional risk factor includes rapid changes in weight, either gain or loss, such as is seen in bariatric surgery.3 Prevention of biliary complications with ursodiol has been studied previously by Sugerman et al4 in a prospective, double-blinded, randomized controlled trial which showed that the use of ursodiol postoperatively can prevent
2
The American Journal of Surgery, Vol -, No -, - 2015
gallstone formation. If cholelithiasis does occur postoperatively and complications of those stones occur, treatment is variable. Treatment for symptomatic cholelithiasis includes laparoscopic cholecystectomy with or without cholangiography to evaluate the biliary anatomy. If choledocholithiasis is found, it may be treated with laparoscopic transcystic common bile exploration at the time of cholecystectomy. If a patient presents with choledocholithiasis after LRYGB, then traditional endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct (CBD) are more difficult because of the altered anatomy.2 The objective of this study was to review our institution’s longitudinal experience with bariatric surgery patients who required biliary interventions postoperatively.
There were 415 patients (30%) with a history of cholecystectomy before bariatric surgery; 380 before LRYGB and 35 before LSG. Of the 380 patients in the LRYGB group with a previous cholecystectomy, 65 of the cholecystectomies were completed as open surgeries with the remainder completed laparoscopically. Three of the 380 patients required laparoscopy-assisted ERCP after LRYGB to clear the CBD of stones. Of the 35 patients undergoing LSG with previous cholecystectomy, 5 were performed via an open approach. No patient in this group had a history of ERCP (Fig. 1). One cholecystectomy was completed at the time of LRYGB. Ninety-one patients (8%) of the 1,112 without prior cholecystectomy had biliary symptoms requiring intervention after their bariatric surgery: 2 patients after LSG (1.6%) and 89 patients after LRYGB (9.0%; Fig. 2). All but 2 of the patients underwent intraoperative cholangiography to evaluate the biliary system at the time of cholecystectomy. Of the 89 LRYGB patients, 84 were successfully completed laparoscopically. One patient underwent percutaneous cholecystostomy tube placement for cholecystitis while undergoing end-of-life care for metastatic bladder cancer. In 4 patients, open cholecystectomies were completed successfully. The 1st was performed in 2004 as a planned open procedure during an exploratory laparotomy for ischemic bowel secondary to arterial embolus. Two patients were converted to open cholecystectomies with CBD explorations when intraoperative cholangiography revealed large CBD stones that were not conducive to ERCP or laparoscopic transcystic CBD exploration. One of these 2 patients had a preoperative diagnosis of choledocholithiasis; the other was diagnosed at the time of intraoperative cholangiography. The final conversion to open cholecystectomy occurred in a patient with perforated emphysematous cholecystitis with liver abscess. Cholecystectomies performed in the 2 patients who underwent LSG were completed laparoscopically and required no interventions to the CBD. In the 90 patients who underwent cholecystectomy, the surgical indications varied from biliary colic or dyskinesia (n 5 59), cholecystitis (n 5 15), choledocholithiasis (n 5 6), and biliary pancreatitis (n 5 7). The surgical indication for cholecystectomy could not be found in the medical record for 3 patients. The overall incidence of cholecystectomy for biliary colic or dyskinesia was 3.86%, .98% for cholecystitis, .39% for choledocholithiasis, and .46% for biliary pancreatitis in the postoperative period. Of the 88 cholecystectomies performed on patients after LRYGB, 6 patients required laparoscopy-assisted percutaneous transgastric ERCP to clear gallstones from the CBD, with a 100% success rate of clearing the CBD. Only 3 of these patients were diagnosed with choledocholithiasis preoperatively. In some of these cases, the on-call gastroenterologists were made aware of the possible need for laparoscopy-assisted ERCP preoperatively allowing for 4 of these to be performed concomitantly with cholecystectomy. The other 2 were completed on postoperative days 2 and 6 after laparoscopic cholecystectomy.
Methods A retrospective review of our institution’s prospective bariatric surgery registry was completed to identify patients who underwent LRYGB or laparoscopic sleeve gastrectomy (LSG) from September 2001 to September 2014. Past surgical history was reviewed for cholecystectomy before LRYGB or LSG. A query of our institution’s electronic medical record system was completed to identify patients who underwent cholecystectomy or ERCP after bariatric surgery. If patients reported undergoing cholecystectomy at an outside hospital, it was documented in our bariatric surgery registry. The presence of any CBD stones and any additional interventions to clear CBD stones were noted, as were any postoperative or postprocedure complications. The surgical technique for LRYGB was standardized between the 3 bariatric surgeons and has been previously described in detail.5 Surgical technique for LSG varied slightly among the surgeons with a 36F to 38F Maloney bougie used for sizing the sleeve. The greater omentum is sutured to the staple line at the surgeon’s discretion. Our protocol is to only perform concomitant cholecystectomy at the time of bariatric surgery if the patient has imaging and symptoms consistent with biliary disease.
Results A total of 1,527 patients underwent bariatric surgery at our institution during the study period. Of these, 1,366 underwent LRYGB, and 161 underwent LSG. The average age of patients who underwent LRYGB was 44.4 years (range, 18 to 69 years). Patients who underwent LSG were slightly older, with a mean age of 46.2 years (range, 21 to 67 years). Both LRYGB and LSG groups were composed of 19% males. Mean initial body mass index (BMI) of patients who underwent LRYGB and LSG was 47.98 kg/m2 and 45.33 kg/m2, respectively. Mean excess BMI loss at 1 year was higher for LRYGB patients than LSG patients with 66.4% (range, 10.7% to 133.5%) and 63.7% (range, 24.3% to 107.7%), respectively.
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
Figure 1
Biliary interventions before and after bariatric surgery.
Three patients who had undergone cholecystectomy before bariatric surgery developed primary CBD stones after bariatric surgery (diagnosed greater than 2 years after cholecystectomy); all in patients who underwent LRYGB. Two of these patients underwent successful laparoscopy-assisted transgastric ERCP, and 1 patient required percutaneous transhepatic laser-assisted stone fragmentation and extraction. Interventions occurred between 36 days and 11.6 years from bariatric surgery (median, 1.7 years). Interventions in
Figure 2
3
the 2 patients who underwent LSG occurred at 56 days (1.9 months) and 168 days (5.6 months). Fig. 3 illustrates the timing of biliary interventions after LRYGB. The slope of the curve plateaus at approximately 24 months after LRYGB. A total postoperative complication rate of 5.56% occurred after cholecystectomy. Postoperative complications included organ space surgical site infection (n 5 1), bile leak (n 5 2), urinary retention (n 5 1), and pancreatitis (n 5 1). One bile leak was found to be from a duct of
Biliary outcomes for patients who underwent LRYGB vs LSG.
The American Journal of Surgery, Vol -, No -, - 2015
4
Figure 3
Timing of biliary interventions after laparoscopic Roux-en-Y gastric bypass.
Luschka by hepatobiliary iminodiacetic acid (HIDA) scan. The other was found in a patient who underwent a partial cholecystectomy due to acute cholecystitis and leaked from the cystic duct. It was discovered during laparoscopy-assisted ERCP during the same procedure. No complications occurred with the transgastric ERCPs or the open cholecystectomies. There were no mortalities and no CBD injuries associated with any of the procedures.
Comments Biliary disease remains a common disease in obese patients. Patients with a BMI greater than 40 kg/m2 have been found to have a risk of cholelithiasis 8 times that of patients with a lower BMI.6 Rapid weight loss from bariatric surgery increases the chances of developing cholelithiasis. Reported incidence of cholelithiasis after LRYGB occurs approximately 30% of the time with a range in the literature of 6.7% to 52.8%.4,7,8 This is due to many changing physiologic factors after bariatric surgery including hypersaturation of bile with cholesterol, increased mucin production acting to decrease nucleation time, and gallbladder hypomotility.2,9 A significant decrease in gallbladder emptying has been seen after LRYGB that also contributes to biliary sludge and stone formation.10 Our total incidence of patients developing biliary symptoms requiring intervention was 8.0%; 9.0% after LRYGB and 1.6% after LSG. For other surgical groups that have a similar policy as ours for performing cholecystectomy only in patients who develop symptoms and imaging supporting symptomatic biliary disease postoperatively, a surgical rate of 4% to 8% has been reported.11,12 Our rate of cholecystectomy after LRYGB is slightly higher than these
reported numbers with a much lower rate than reported in our patients who undergo LSG. It is possible that the greater postoperative weight loss after LRYGB than after LSG may contribute to the higher rate. Because the duodenum is not bypassed in LSG, it is possible that the gallbladder hypomotility is not as pronounced, leading to decreased stone and sludge formation. There is also a likely lead time bias, as we have a mature LRYGB program and introduced LSG later in our series. With a longer followup duration in the LSG group, the prevalence of postoperative biliary symptoms may increase. Our indications for cholecystectomy occurred at a rate similar to those reported in the literature. In a recent metaanalysis by Warschkow et al13 that included approximately 4,000 patients, using a similar breakdown of surgical indications, 5.3% (95% confidence interval [CI], 3.2% to 7.9%) of the total bariatric patients underwent subsequent cholecystectomy for biliary colic or dyskinesia. Our data demonstrated that 3.86% of the total bariatric patients underwent cholecystectomy for the same indication. The meta-analysis reported a rate of 1.0% (95% CI, .7% to 1.4%), vs .98% in our series for cholecystitis. Their rate of cholecystectomy due to choledocholithiasis was .2% (95% CI, .07% to .4%) vs .39% in our series. Finally, .2% patients (95% CI, .1% to .4%) underwent cholecystectomy for biliary pancreatitis in the meta-analysis compared to .46% in our series. Minimal complications were associated with postbariatric surgery laparoscopic cholecystectomy. In their meta-analysis, Warschkow et al13 showed an overall surgery-related complication rate of 1.8% with a 95% CI of .7% to 3.4%. Our data showed a slightly higher complication rate. A total surgery-related complication rate of 5.56% occurred in patients who required cholecystectomy after bariatric surgery. All the complications occurred in
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
Figure 4 Laparoscopy-assisted transgastric ERCP showing a dilated common bile duct. Reprinted from Kothari SN. Bariatric surgery and postoperative imaging. Surg Clin North Am 2011;91:158; with permission.
patients who had undergone LRYGB. Bile leak was the most common complication. One leak that required percutaneous drain placement was localized to a duct of Luschka by the HIDA scan. The other was a cystic duct stump leak that occurred after a laparoscopic partial cholecystectomy. This patient also underwent a percutaneous transgastric ERCP during the same procedure because of filling defects seen on intraoperative cholangiogram. The cystic duct leak was recognized, and a biliary stent was placed. One patient developed pancreatitis because of a retained CBD stone that was not seen initially on intraoperative cholangiogram. Table 1
5 The stone passed without any further interventions. One patient required placement of a Foley catheter due to urinary retention postoperatively. One patient had both a superficial surgical site infection at the camera port site, as well as an organ space surgical site infection within the gallbladder fossa. The superficial infection was treated with wound care and antibiotics. The intra-abdominal abscess was treated with percutaneous drainage. In this patient, no bile leaks were seen on the HIDA scan. Our higher complication rate may be due to the small sample size of patients who have undergone subsequent cholecystectomy. For patients found to have choledocholithiasis, multiple techniques have been described to relieve the obstruction. It is important to perform routine intraoperative cholangiography in patients who have undergone LRYGB as it is the last time to evaluate the biliary tree easily. If choledocholithiasis is suspected preoperatively, magnetic resonance cholangiopancreatography can be performed preoperatively to properly inform the patient for possible laparoscopy-assisted ERCP as well as having someone skilled in ERCP available during the procedure if choledocholithiasis is confirmed. If choledocholithiasis is discovered at the time of cholecystectomy on intraoperative cholangiography, the ductal system may be flushed with saline. Intravenous administration of glucagon in 1-mg ampules may facilitate passage of the stone with relaxation of the sphincter of Oddi. If these techniques fail, minimally invasive techniques for exploration of the biliary ductal system can be completed using fluoroscopic or endoscopic methods. These techniques are usually accomplished through the cystic duct, but exploration can be completed through a ductotomy in the CBD based on the experience, skill, and comfort of the surgeon. If all of these minimally invasive techniques fail, or before performing a formal CBD exploration through a ductotomy in a patient with a previous LRYGB, percutaneous
Literature review of case reports of transgastric endoscopy
Publication First author year 15
2004 Pimentel Ceppa16 2007 Nakao17 2007 Patel18 2008 Roberts19 2008 2009 Dapri20 Gutierrez21 2009 Peeters22 2009 Sebastian23 2009 Badaoui24 2010 Bertin25 2011 2012 Saleem26 Richardson142012
Transgastric endoscopy
CBD success
n
n
Complications
1 10 1 8 6 1 32 1 1 1 22 15 13
1 4 1 8 6 1 28 1 1 1 20 15 11
None None None None None None Gastrostomy leak (n 5 2), pancreatitis (n 5 1), wound infection (n 5 1) Pancreatitis (n 5 1) None None Abdominal wall hematoma (n 5 1), retroperitoneal perforation (n 5 1) None None
CBD 5 common bile duct. Adapted from Grover BT, Kothari SN. Biliary issues in the bariatric population. Surg Clin North Am. 2014;94:413–425; with permission.
6
The American Journal of Surgery, Vol -, No -, - 2015
transgastric ERCP through the remnant stomach can be completed through coordination between the surgeon and an ERCP-trained specialist. Our technique for transgastric ERCP occurs with the patient under general anesthesia.2 The patient is positioned supine, appropriately prepped, and sterilely draped. Laparoscopic access to the peritoneal cavity is achieved, and pneumoperitoneum established with carbon dioxide insufflation. Three ports are used initially, 2 working ports and 1 port for the laparoscope. The abdomen is explored, and the presence of any internal hernias evaluated. The remnant stomach is found, and the greater curvature is positioned with graspers under the left upper abdominal wall below the costal margin. Stay sutures are placed on the remnant stomach to provide countertraction. Insufflation pressure is reduced at this time. A 15-mm trocar is placed percutaneously through the abdominal wall and into the held remnant stomach. The trocar enters the remnant stomach through the greater curvature to allow the endoscopist direct access to the pylorus. A bowel clamp is placed on the small intestine distal to the ligament of Treitz to prevent excess bowel dilation. The pneumoperitoneum is evacuated, and the standard side-viewing ERCP scope is placed through the 15-mm trocar (Fig. 4). Once the endoscopist has completed any necessary interventions, the trocar is removed from the stomach, and the gastrotomy closed with a linear stapling device or intracorporeal suturing. Hemostasis is verified, and any spilled gastric contents evacuated. The fascial incision of the 15-mm port site is closed with a suture passer. A total of 8 patients who had undergone LRYGB required transgastric ERCP to clear CBD stones. Six were completed at the time of laparoscopic cholecystectomy. Two patients who had a previous cholecystectomy before LRYGB developed CBD stones requiring transgastric ERCP. One additional patient with a previous cholecystectomy required percutaneous transhepatic cholangiography with laser-assisted stone fragmentation and percutaneous stone extraction. All 8 transgastric ERCPs were successful at removing the CBD stone without any complications. A review from Richardson et al14 in 2012 found 13 studies of transgastric ERCP (Table 1). One hundred twelve patients underwent laparoscopic or open transgastric ERCP with successful cannulation of the CBD in all but 1 patient.15–26 Complication rates were low and included gastrostomy leak (n 5 2), pancreatitis (n 5 2), wound infection (n 5 1), abdominal wall hematoma (n 5 1), and retroperitoneal perforation (n 5 1). Alhough no LSG patient in our series required ERCP for choledocholithiasis, normal anatomic access to the duodenum exists, and traditional ERCP can be completed.
for biliary disease after bariatric surgery can be completed successfully with minimal complications, making concomitant cholecystectomy with bariatric surgery unnecessary in most patients. Intraoperative cholangiography should be used in all patients who have undergone LRYGB. The use of percutaneous transgastric ERCP has a high success rate of access into and clearance of the biliary tree with minimal complications.
Conclusions Biliary disease in our bariatric surgery population occurred at a rate similar to the general population. Surgery
References 1. Nguyen NT, Nguyen B, Shih A, et al. Use of laparoscopy in general surgical operations at academic centers. Surg Obes Relat Dis 2013; 9:15–20. 2. Grover BT, Kothari SN. Biliary issues in the bariatric population. Surg Clin North Am 2014;94:413–25. 3. Barbara L, Sama C, Morselli Labate AM, et al. A population study on the prevalence of gallstone disease: the Sirmione study. Hepatology 1987;7:913–7. 4. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91–6. 5. Kothari SN, Boyd WC, Larson CA, et al. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg 2005;15:323–9. 6. Igle´zias Branda˜o de Oliveira C, Adami Chaim E, da Silva BB. Impact of weight reduction on risk of cholelithiasis after bariatric surgery. Obes Surg 2003;13:625–8. 7. Amaral JF, Thompson WR. Gallbladder disease in the morbidly obese. Am J Surg 1985;149:551–7. 8. Shiffman ML, Sugerman HJ, Kellum JH, et al. Gallstones in patients with morbid obesity: relationship to body weight, weight loss and gallbladder bile cholesterol solubility. Int J Obes Relat Metab Disord 1993;17:153–8. 9. Desbeaux A, Hec F, Andrieux S, et al. Risk of biliary complications in bariatric surgery. J Visc Surg 2010;147:e217–20. 10. Bastouly M, Arasaki CH, Ferreira JB, et al. 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. Obes Surg 2009;19:22–8. 11. Kothari SN, Obinwanne KM, Baker MT, et al. A prospective, blinded comparison of laparoscopic ultrasound with transabdominal ultrasound for the detection of gallbladder pathology in morbidly obese patients. J Am Coll Surg 2013;216:1057–62. 12. Caruana JA, McCabe MN, Smith AD, et al. Incidence of symptomatic gallstones after gastric bypass: is prophylactic treatment really necessary? Surg Obes Relat Dis 2005;1:564–7. 13. Warschkow R, Tarantino I, Ukegjini K, 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. 14. Richardson JF, Lee JG, Smith BR, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg 2012;78:1182–6. 15. Pimentel RR, Mehran A, Szomstein S, et al. Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: a case report of a novel approach. Gastrointest Endosc 2004;59:325–8. 16. Ceppa FA, Gagne´ DJ, Papasavas PK, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21–4. 17. Nakao FS, Mendes CJ, Szego T, et al. Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass. Endoscopy 2007;39: E219–20.
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
18. Patel JA, Patel NA, Shinde T, et al. Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg 2008;74:689–93. 19. Roberts KE, Panait L, Duffy AJ, et al. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS 2008;12:30–6. 20. Dapri G, Himpens J, Buset M, et al. Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass. Surg Endosc 2009;23:1646–8. 21. Gutierrez JM, Lederer H, Krook JC, et al. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux-en-Y gastric bypass. J Gastrointest Surg 2009;13:2170–5. 22. Peeters G, Himpens J. A hybrid endo-laparoscopic therapy for common bile duct stenosis of a choledocho-duodenostomy after a Rouxen-Y gastric bypass. Obes Surg 2009;19:806–8. 23. Sebastia´n JJ, Resa JJ, Pen˜a E, et al. Laparoscopically assisted ERCP in a case of acute cholangitis in a patient with biliopancreatic diversion with distal gastric preservation. Obes Surg 2009;19:250–2. 24. Badaoui A, Malherbe V, Rosiere A, et al. ERCP by laparoscopic transgastric access and cholecystectomy at the same time in a patient with gastric bypass who was seen with choledocholithiasis. Gastrointest Endosc 2010;71:212–4. 25. Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc 2011;25:2592–6. 26. Saleem A, Levy MJ, Petersen BT, et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012;16:203–8.
Discussion Discussant Dr. Megan Gilmore (Mankato, MN): The management of biliary disease that develops in patients who have had previous bariatric surgery, particularly procedures in which the duodenum is bypassed, is challenging for both the experienced bariatric surgeon and for the general surgeon who may be caring for these patients years later. You noted the indication for surgery in 59 of the 90 patients who had cholecystectomy was secondary to biliary dyskinesia. This is 65% of the patients who had cholecystectomy. You pointed out that the incidence of biliary dyskinesia was similar to what was seen in other bariatric populations. However, in your conclusion, you indicated that the rate of biliary disease was similar to the general population. I was not able to find any good statistics on how frequently biliary dyskinesia is the primary indication for laparoscopic cholecystectomy; however, in my own general surgery experience, it seems that I primarily perform laparoscopic cholecystectomy due to complications of gallstones, such as symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis. In the bariatric population, there are certain patients who complain of vague chronic abdominal pain and nausea with no clear etiology. Did these patients all have biliary dyskinesia diagnosed with a low ejection fraction on hepatobiliary iminodiacetic acid scan, or did it include some of these patients with vague abdominal complaints?
7 Do you have any data on what the clinical outcome was in this group of patients? Second, you had preoperative diagnosis of choledocholithiasis in 6 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed at the time of cholecystectomy in 6 patients, although you stated that, in 2 patients, the common bile duct stones were diagnosed by intraoperative cholangiogram. Were the 6 patients with a preoperative diagnosis of choledocholithiasis the same 6 patients who had the ERCP, or were you able to call an endoscopist in at the time of surgery to perform an ERCP when needed? In 2 cases you opened for common bile duct exploration, were there any attempts at transcystic exploration before ERCP or before opening? When there is a preoperative diagnosis of cholelithiasis, should further imaging, such as magnetic resonance cholangiopancreatography (MRCP), be used to rule out choledocholithiasis and potentially spare the patient a second surgery if immediate ERCP is not available? Dr. Joel Brockmeyer: Those 59 patients not only had biliary dyskinesia, but it was also the symptomatic cholelithiasis group. They were combined together as noninfectious group just to match up with the meta-analysis, so it was a mixture of the 2. We definitely have patients in our practice who undergo, if you will, a diagnostic cholecystectomy, where they are having vague abdominal complaints, hepatobiliary iminodiacetic acid scans are borderline abnormal, and with these vague epigastric pains, we attempt a cholecystectomy. I don’t have the actual numbers, but this is about 50-50 of where they will get better without it or there’s something else going on that we just haven’t diagnosed at that time. The 6 patients who had choledocholithiasis diagnosed preoperatively, are not the same 6 patients who required laparoscopy-assisted ERCP. As you said, we did do 2 open common bile duct explorations. Both were performed due to large stones. Either an endoscopist was consulted or it was just obvious to the operating surgeon at that time that they would not be able to be cleared laparoscopically, so they were converted to open. Among the 90 patients who had a cholecystectomy, 8 underwent transcystic common bile duct exploration. Of those who were diagnosed, the 6 patients who were diagnosed with choledocholithiasis preoperatively, 4 are in the group who were just cleared with transcystic common bile duct explorations. Two went on to have ERCP. The vast majority of the time, an endoscopist was available. Our gastroenterology department is very helpful and they will come in, especially with advance notice when we’re taking a bariatric patient to have their gallbladder out, and they’ll be available. However, you do notice that one patient had to have a laparoscopyassisted ERCP on postoperative day 2, and 1 had to have it on postoperative day 6. That was because the endoscopist was not available at the time, and the transcystic common
8
The American Journal of Surgery, Vol -, No -, - 2015
bile duct exploration failed. Both patients were admitted to the floor and observed to see if the stones would pass on their own, and neither of those 2 did, requiring further intervention. MRCP is definitely a consideration in a bariatric patient, to ensure that you have the appropriate diagnosis when you’re taking the patient to the operating room. However, in a lot of the bariatric patients, particularly if it’s early postoperatively, they may not fit into our MRCP machine, as is unfortunately far more common than we would like in Wisconsin. Because of that, an intraoperative cholangiogram or an ERCP may be needed postoperatively to diagnose that. Dr. John Potts, III (Chicago, IL): I would just like to ask you about the 3 patients that you said developed common bile duct stones, primary common bile duct stones.
Dr. Joel Brockmeyer: Yes, sir. Of those 3 patients, the earliest following their cholecystectomy presented 4 years after, and then the longest was our longest presentation, 11.3 years after. By the time criteria, they would be primary common bile duct stones. They would not have gotten any imaging at the time of surgery for their bariatric surgery because they did have their gallbladders out. Dr. Juan Blondet (Irvine, CA): Can I ask you about those 2 patients that had intervention on postoperative day 2 and postoperative day 6? How do you manage those? Do you leave a G-tube in place to keep the stomach open? Dr. Joel Brockmeyer: They hadn’t accessed the stomach yet at that time. Because the endoscopist wasn’t available, and there was always the chance that the stone would pass on its own, they just had their cholecystectomy and intraoperative cholangiogram at that time. Both actually had transcystic common bile duct explorations that failed. They waited for the endoscopist to be available. Unfortunately, neither of the stones passed. They were taken back to the operating room for a 2nd anesthesia to access the stomach and perform the ERCP.
1. Did those individuals undergo imaging of their bile ducts sometime around their gastric bypass? 2. Did these really qualify as primary common bile duct stones? Was it more than 2 years after cholecystectomy? Were they soft, friable stones, and so forth?
Management of biliary symptoms after bariatric surgery Joel R. Brockmeyer, M.D.a, Brandon T. Grover, D.O., F.A.C.S.b, Kara J. Kallies, M.S.c, Shanu N. Kothari, M.D., F.A.C.S.b,* a
Minimally Invasive Bariatric Surgery and Advanced Laparoscopy Fellowship, Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA; bDepartment of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA; c Department of Surgery Research; Gundersen Medical Foundation, La Crosse, WI, USA
KEYWORDS: Biliary system; Bariatric surgery; Cholelithiasis; Endoscopic retrograde cholangiopancreatography
Abstract BACKGROUND: Biliary disease requiring intervention can be complicated in the postbariatric surgery patient. METHODS: A retrospective review was completed to identify patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from September 2001 to September 2014, and those who underwent biliary intervention were identified. RESULTS: A total of 1527 patients underwent bariatric surgery during the study period. Of the 1,112 patients without prior cholecystectomy, 91 (8%) had biliary symptoms requiring intervention. Ninety patients underwent cholecystectomy, with 86 successfully completed laparoscopically. Six patients required laparoscopy-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography along with cholecystectomy to clear gallstones from the common bile duct. Three patients who had undergone cholecystectomy before bariatric surgery developed primary common bile duct stones. CONCLUSIONS: Surgery for biliary disease after bariatric surgery can be completed successfully with minimal complications, and percutaneous transgastric endoscopic retrograde cholangiopancreatography has a high success rate of access to and clearance of the biliary tree. Ó 2015 Elsevier Inc. All rights reserved.
Bariatric surgery is one of the most commonly performed elective general surgery operations in the United States.1 Some bariatric surgeries, such as laparoscopic Roux-en-Y gastric bypass (LRYGB), alter the foregut and midgut anatomy to aid in long-term weight loss.2 As obese patients have a higher incidence of biliary disease, previous bariatric surgery may complicate treatment. The incidence The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-608-775-5187; fax: 11-608-7754460. E-mail address: [email protected] Manuscript received April 9, 2015; revised manuscript July 21, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.07.003
of asymptomatic cholelithiasis in the general population found by transabdominal ultrasonography ranges from 2% to 15%.2 Risk factors have been identified and include obesity, female sex, age more than 40 years, white ethnicity, premenopausal state, pregnancy, use of oral contraceptives, estrogen replacement therapy, diabetes, and family history. An additional risk factor includes rapid changes in weight, either gain or loss, such as is seen in bariatric surgery.3 Prevention of biliary complications with ursodiol has been studied previously by Sugerman et al4 in a prospective, double-blinded, randomized controlled trial which showed that the use of ursodiol postoperatively can prevent
2
The American Journal of Surgery, Vol -, No -, - 2015
gallstone formation. If cholelithiasis does occur postoperatively and complications of those stones occur, treatment is variable. Treatment for symptomatic cholelithiasis includes laparoscopic cholecystectomy with or without cholangiography to evaluate the biliary anatomy. If choledocholithiasis is found, it may be treated with laparoscopic transcystic common bile exploration at the time of cholecystectomy. If a patient presents with choledocholithiasis after LRYGB, then traditional endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct (CBD) are more difficult because of the altered anatomy.2 The objective of this study was to review our institution’s longitudinal experience with bariatric surgery patients who required biliary interventions postoperatively.
There were 415 patients (30%) with a history of cholecystectomy before bariatric surgery; 380 before LRYGB and 35 before LSG. Of the 380 patients in the LRYGB group with a previous cholecystectomy, 65 of the cholecystectomies were completed as open surgeries with the remainder completed laparoscopically. Three of the 380 patients required laparoscopy-assisted ERCP after LRYGB to clear the CBD of stones. Of the 35 patients undergoing LSG with previous cholecystectomy, 5 were performed via an open approach. No patient in this group had a history of ERCP (Fig. 1). One cholecystectomy was completed at the time of LRYGB. Ninety-one patients (8%) of the 1,112 without prior cholecystectomy had biliary symptoms requiring intervention after their bariatric surgery: 2 patients after LSG (1.6%) and 89 patients after LRYGB (9.0%; Fig. 2). All but 2 of the patients underwent intraoperative cholangiography to evaluate the biliary system at the time of cholecystectomy. Of the 89 LRYGB patients, 84 were successfully completed laparoscopically. One patient underwent percutaneous cholecystostomy tube placement for cholecystitis while undergoing end-of-life care for metastatic bladder cancer. In 4 patients, open cholecystectomies were completed successfully. The 1st was performed in 2004 as a planned open procedure during an exploratory laparotomy for ischemic bowel secondary to arterial embolus. Two patients were converted to open cholecystectomies with CBD explorations when intraoperative cholangiography revealed large CBD stones that were not conducive to ERCP or laparoscopic transcystic CBD exploration. One of these 2 patients had a preoperative diagnosis of choledocholithiasis; the other was diagnosed at the time of intraoperative cholangiography. The final conversion to open cholecystectomy occurred in a patient with perforated emphysematous cholecystitis with liver abscess. Cholecystectomies performed in the 2 patients who underwent LSG were completed laparoscopically and required no interventions to the CBD. In the 90 patients who underwent cholecystectomy, the surgical indications varied from biliary colic or dyskinesia (n 5 59), cholecystitis (n 5 15), choledocholithiasis (n 5 6), and biliary pancreatitis (n 5 7). The surgical indication for cholecystectomy could not be found in the medical record for 3 patients. The overall incidence of cholecystectomy for biliary colic or dyskinesia was 3.86%, .98% for cholecystitis, .39% for choledocholithiasis, and .46% for biliary pancreatitis in the postoperative period. Of the 88 cholecystectomies performed on patients after LRYGB, 6 patients required laparoscopy-assisted percutaneous transgastric ERCP to clear gallstones from the CBD, with a 100% success rate of clearing the CBD. Only 3 of these patients were diagnosed with choledocholithiasis preoperatively. In some of these cases, the on-call gastroenterologists were made aware of the possible need for laparoscopy-assisted ERCP preoperatively allowing for 4 of these to be performed concomitantly with cholecystectomy. The other 2 were completed on postoperative days 2 and 6 after laparoscopic cholecystectomy.
Methods A retrospective review of our institution’s prospective bariatric surgery registry was completed to identify patients who underwent LRYGB or laparoscopic sleeve gastrectomy (LSG) from September 2001 to September 2014. Past surgical history was reviewed for cholecystectomy before LRYGB or LSG. A query of our institution’s electronic medical record system was completed to identify patients who underwent cholecystectomy or ERCP after bariatric surgery. If patients reported undergoing cholecystectomy at an outside hospital, it was documented in our bariatric surgery registry. The presence of any CBD stones and any additional interventions to clear CBD stones were noted, as were any postoperative or postprocedure complications. The surgical technique for LRYGB was standardized between the 3 bariatric surgeons and has been previously described in detail.5 Surgical technique for LSG varied slightly among the surgeons with a 36F to 38F Maloney bougie used for sizing the sleeve. The greater omentum is sutured to the staple line at the surgeon’s discretion. Our protocol is to only perform concomitant cholecystectomy at the time of bariatric surgery if the patient has imaging and symptoms consistent with biliary disease.
Results A total of 1,527 patients underwent bariatric surgery at our institution during the study period. Of these, 1,366 underwent LRYGB, and 161 underwent LSG. The average age of patients who underwent LRYGB was 44.4 years (range, 18 to 69 years). Patients who underwent LSG were slightly older, with a mean age of 46.2 years (range, 21 to 67 years). Both LRYGB and LSG groups were composed of 19% males. Mean initial body mass index (BMI) of patients who underwent LRYGB and LSG was 47.98 kg/m2 and 45.33 kg/m2, respectively. Mean excess BMI loss at 1 year was higher for LRYGB patients than LSG patients with 66.4% (range, 10.7% to 133.5%) and 63.7% (range, 24.3% to 107.7%), respectively.
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
Figure 1
Biliary interventions before and after bariatric surgery.
Three patients who had undergone cholecystectomy before bariatric surgery developed primary CBD stones after bariatric surgery (diagnosed greater than 2 years after cholecystectomy); all in patients who underwent LRYGB. Two of these patients underwent successful laparoscopy-assisted transgastric ERCP, and 1 patient required percutaneous transhepatic laser-assisted stone fragmentation and extraction. Interventions occurred between 36 days and 11.6 years from bariatric surgery (median, 1.7 years). Interventions in
Figure 2
3
the 2 patients who underwent LSG occurred at 56 days (1.9 months) and 168 days (5.6 months). Fig. 3 illustrates the timing of biliary interventions after LRYGB. The slope of the curve plateaus at approximately 24 months after LRYGB. A total postoperative complication rate of 5.56% occurred after cholecystectomy. Postoperative complications included organ space surgical site infection (n 5 1), bile leak (n 5 2), urinary retention (n 5 1), and pancreatitis (n 5 1). One bile leak was found to be from a duct of
Biliary outcomes for patients who underwent LRYGB vs LSG.
The American Journal of Surgery, Vol -, No -, - 2015
4
Figure 3
Timing of biliary interventions after laparoscopic Roux-en-Y gastric bypass.
Luschka by hepatobiliary iminodiacetic acid (HIDA) scan. The other was found in a patient who underwent a partial cholecystectomy due to acute cholecystitis and leaked from the cystic duct. It was discovered during laparoscopy-assisted ERCP during the same procedure. No complications occurred with the transgastric ERCPs or the open cholecystectomies. There were no mortalities and no CBD injuries associated with any of the procedures.
Comments Biliary disease remains a common disease in obese patients. Patients with a BMI greater than 40 kg/m2 have been found to have a risk of cholelithiasis 8 times that of patients with a lower BMI.6 Rapid weight loss from bariatric surgery increases the chances of developing cholelithiasis. Reported incidence of cholelithiasis after LRYGB occurs approximately 30% of the time with a range in the literature of 6.7% to 52.8%.4,7,8 This is due to many changing physiologic factors after bariatric surgery including hypersaturation of bile with cholesterol, increased mucin production acting to decrease nucleation time, and gallbladder hypomotility.2,9 A significant decrease in gallbladder emptying has been seen after LRYGB that also contributes to biliary sludge and stone formation.10 Our total incidence of patients developing biliary symptoms requiring intervention was 8.0%; 9.0% after LRYGB and 1.6% after LSG. For other surgical groups that have a similar policy as ours for performing cholecystectomy only in patients who develop symptoms and imaging supporting symptomatic biliary disease postoperatively, a surgical rate of 4% to 8% has been reported.11,12 Our rate of cholecystectomy after LRYGB is slightly higher than these
reported numbers with a much lower rate than reported in our patients who undergo LSG. It is possible that the greater postoperative weight loss after LRYGB than after LSG may contribute to the higher rate. Because the duodenum is not bypassed in LSG, it is possible that the gallbladder hypomotility is not as pronounced, leading to decreased stone and sludge formation. There is also a likely lead time bias, as we have a mature LRYGB program and introduced LSG later in our series. With a longer followup duration in the LSG group, the prevalence of postoperative biliary symptoms may increase. Our indications for cholecystectomy occurred at a rate similar to those reported in the literature. In a recent metaanalysis by Warschkow et al13 that included approximately 4,000 patients, using a similar breakdown of surgical indications, 5.3% (95% confidence interval [CI], 3.2% to 7.9%) of the total bariatric patients underwent subsequent cholecystectomy for biliary colic or dyskinesia. Our data demonstrated that 3.86% of the total bariatric patients underwent cholecystectomy for the same indication. The meta-analysis reported a rate of 1.0% (95% CI, .7% to 1.4%), vs .98% in our series for cholecystitis. Their rate of cholecystectomy due to choledocholithiasis was .2% (95% CI, .07% to .4%) vs .39% in our series. Finally, .2% patients (95% CI, .1% to .4%) underwent cholecystectomy for biliary pancreatitis in the meta-analysis compared to .46% in our series. Minimal complications were associated with postbariatric surgery laparoscopic cholecystectomy. In their meta-analysis, Warschkow et al13 showed an overall surgery-related complication rate of 1.8% with a 95% CI of .7% to 3.4%. Our data showed a slightly higher complication rate. A total surgery-related complication rate of 5.56% occurred in patients who required cholecystectomy after bariatric surgery. All the complications occurred in
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
Figure 4 Laparoscopy-assisted transgastric ERCP showing a dilated common bile duct. Reprinted from Kothari SN. Bariatric surgery and postoperative imaging. Surg Clin North Am 2011;91:158; with permission.
patients who had undergone LRYGB. Bile leak was the most common complication. One leak that required percutaneous drain placement was localized to a duct of Luschka by the HIDA scan. The other was a cystic duct stump leak that occurred after a laparoscopic partial cholecystectomy. This patient also underwent a percutaneous transgastric ERCP during the same procedure because of filling defects seen on intraoperative cholangiogram. The cystic duct leak was recognized, and a biliary stent was placed. One patient developed pancreatitis because of a retained CBD stone that was not seen initially on intraoperative cholangiogram. Table 1
5 The stone passed without any further interventions. One patient required placement of a Foley catheter due to urinary retention postoperatively. One patient had both a superficial surgical site infection at the camera port site, as well as an organ space surgical site infection within the gallbladder fossa. The superficial infection was treated with wound care and antibiotics. The intra-abdominal abscess was treated with percutaneous drainage. In this patient, no bile leaks were seen on the HIDA scan. Our higher complication rate may be due to the small sample size of patients who have undergone subsequent cholecystectomy. For patients found to have choledocholithiasis, multiple techniques have been described to relieve the obstruction. It is important to perform routine intraoperative cholangiography in patients who have undergone LRYGB as it is the last time to evaluate the biliary tree easily. If choledocholithiasis is suspected preoperatively, magnetic resonance cholangiopancreatography can be performed preoperatively to properly inform the patient for possible laparoscopy-assisted ERCP as well as having someone skilled in ERCP available during the procedure if choledocholithiasis is confirmed. If choledocholithiasis is discovered at the time of cholecystectomy on intraoperative cholangiography, the ductal system may be flushed with saline. Intravenous administration of glucagon in 1-mg ampules may facilitate passage of the stone with relaxation of the sphincter of Oddi. If these techniques fail, minimally invasive techniques for exploration of the biliary ductal system can be completed using fluoroscopic or endoscopic methods. These techniques are usually accomplished through the cystic duct, but exploration can be completed through a ductotomy in the CBD based on the experience, skill, and comfort of the surgeon. If all of these minimally invasive techniques fail, or before performing a formal CBD exploration through a ductotomy in a patient with a previous LRYGB, percutaneous
Literature review of case reports of transgastric endoscopy
Publication First author year 15
2004 Pimentel Ceppa16 2007 Nakao17 2007 Patel18 2008 Roberts19 2008 2009 Dapri20 Gutierrez21 2009 Peeters22 2009 Sebastian23 2009 Badaoui24 2010 Bertin25 2011 2012 Saleem26 Richardson142012
Transgastric endoscopy
CBD success
n
n
Complications
1 10 1 8 6 1 32 1 1 1 22 15 13
1 4 1 8 6 1 28 1 1 1 20 15 11
None None None None None None Gastrostomy leak (n 5 2), pancreatitis (n 5 1), wound infection (n 5 1) Pancreatitis (n 5 1) None None Abdominal wall hematoma (n 5 1), retroperitoneal perforation (n 5 1) None None
CBD 5 common bile duct. Adapted from Grover BT, Kothari SN. Biliary issues in the bariatric population. Surg Clin North Am. 2014;94:413–425; with permission.
6
The American Journal of Surgery, Vol -, No -, - 2015
transgastric ERCP through the remnant stomach can be completed through coordination between the surgeon and an ERCP-trained specialist. Our technique for transgastric ERCP occurs with the patient under general anesthesia.2 The patient is positioned supine, appropriately prepped, and sterilely draped. Laparoscopic access to the peritoneal cavity is achieved, and pneumoperitoneum established with carbon dioxide insufflation. Three ports are used initially, 2 working ports and 1 port for the laparoscope. The abdomen is explored, and the presence of any internal hernias evaluated. The remnant stomach is found, and the greater curvature is positioned with graspers under the left upper abdominal wall below the costal margin. Stay sutures are placed on the remnant stomach to provide countertraction. Insufflation pressure is reduced at this time. A 15-mm trocar is placed percutaneously through the abdominal wall and into the held remnant stomach. The trocar enters the remnant stomach through the greater curvature to allow the endoscopist direct access to the pylorus. A bowel clamp is placed on the small intestine distal to the ligament of Treitz to prevent excess bowel dilation. The pneumoperitoneum is evacuated, and the standard side-viewing ERCP scope is placed through the 15-mm trocar (Fig. 4). Once the endoscopist has completed any necessary interventions, the trocar is removed from the stomach, and the gastrotomy closed with a linear stapling device or intracorporeal suturing. Hemostasis is verified, and any spilled gastric contents evacuated. The fascial incision of the 15-mm port site is closed with a suture passer. A total of 8 patients who had undergone LRYGB required transgastric ERCP to clear CBD stones. Six were completed at the time of laparoscopic cholecystectomy. Two patients who had a previous cholecystectomy before LRYGB developed CBD stones requiring transgastric ERCP. One additional patient with a previous cholecystectomy required percutaneous transhepatic cholangiography with laser-assisted stone fragmentation and percutaneous stone extraction. All 8 transgastric ERCPs were successful at removing the CBD stone without any complications. A review from Richardson et al14 in 2012 found 13 studies of transgastric ERCP (Table 1). One hundred twelve patients underwent laparoscopic or open transgastric ERCP with successful cannulation of the CBD in all but 1 patient.15–26 Complication rates were low and included gastrostomy leak (n 5 2), pancreatitis (n 5 2), wound infection (n 5 1), abdominal wall hematoma (n 5 1), and retroperitoneal perforation (n 5 1). Alhough no LSG patient in our series required ERCP for choledocholithiasis, normal anatomic access to the duodenum exists, and traditional ERCP can be completed.
for biliary disease after bariatric surgery can be completed successfully with minimal complications, making concomitant cholecystectomy with bariatric surgery unnecessary in most patients. Intraoperative cholangiography should be used in all patients who have undergone LRYGB. The use of percutaneous transgastric ERCP has a high success rate of access into and clearance of the biliary tree with minimal complications.
Conclusions Biliary disease in our bariatric surgery population occurred at a rate similar to the general population. Surgery
References 1. Nguyen NT, Nguyen B, Shih A, et al. Use of laparoscopy in general surgical operations at academic centers. Surg Obes Relat Dis 2013; 9:15–20. 2. Grover BT, Kothari SN. Biliary issues in the bariatric population. Surg Clin North Am 2014;94:413–25. 3. Barbara L, Sama C, Morselli Labate AM, et al. A population study on the prevalence of gallstone disease: the Sirmione study. Hepatology 1987;7:913–7. 4. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91–6. 5. Kothari SN, Boyd WC, Larson CA, et al. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg 2005;15:323–9. 6. Igle´zias Branda˜o de Oliveira C, Adami Chaim E, da Silva BB. Impact of weight reduction on risk of cholelithiasis after bariatric surgery. Obes Surg 2003;13:625–8. 7. Amaral JF, Thompson WR. Gallbladder disease in the morbidly obese. Am J Surg 1985;149:551–7. 8. Shiffman ML, Sugerman HJ, Kellum JH, et al. Gallstones in patients with morbid obesity: relationship to body weight, weight loss and gallbladder bile cholesterol solubility. Int J Obes Relat Metab Disord 1993;17:153–8. 9. Desbeaux A, Hec F, Andrieux S, et al. Risk of biliary complications in bariatric surgery. J Visc Surg 2010;147:e217–20. 10. Bastouly M, Arasaki CH, Ferreira JB, et al. 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. Obes Surg 2009;19:22–8. 11. Kothari SN, Obinwanne KM, Baker MT, et al. A prospective, blinded comparison of laparoscopic ultrasound with transabdominal ultrasound for the detection of gallbladder pathology in morbidly obese patients. J Am Coll Surg 2013;216:1057–62. 12. Caruana JA, McCabe MN, Smith AD, et al. Incidence of symptomatic gallstones after gastric bypass: is prophylactic treatment really necessary? Surg Obes Relat Dis 2005;1:564–7. 13. Warschkow R, Tarantino I, Ukegjini K, 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. 14. Richardson JF, Lee JG, Smith BR, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg 2012;78:1182–6. 15. Pimentel RR, Mehran A, Szomstein S, et al. Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: a case report of a novel approach. Gastrointest Endosc 2004;59:325–8. 16. Ceppa FA, Gagne´ DJ, Papasavas PK, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:21–4. 17. Nakao FS, Mendes CJ, Szego T, et al. Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass. Endoscopy 2007;39: E219–20.
J.R. Brockmeyer et al.
Biliary symptoms after bariatric surgery
18. Patel JA, Patel NA, Shinde T, et al. Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg 2008;74:689–93. 19. Roberts KE, Panait L, Duffy AJ, et al. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS 2008;12:30–6. 20. Dapri G, Himpens J, Buset M, et al. Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass. Surg Endosc 2009;23:1646–8. 21. Gutierrez JM, Lederer H, Krook JC, et al. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux-en-Y gastric bypass. J Gastrointest Surg 2009;13:2170–5. 22. Peeters G, Himpens J. A hybrid endo-laparoscopic therapy for common bile duct stenosis of a choledocho-duodenostomy after a Rouxen-Y gastric bypass. Obes Surg 2009;19:806–8. 23. Sebastia´n JJ, Resa JJ, Pen˜a E, et al. Laparoscopically assisted ERCP in a case of acute cholangitis in a patient with biliopancreatic diversion with distal gastric preservation. Obes Surg 2009;19:250–2. 24. Badaoui A, Malherbe V, Rosiere A, et al. ERCP by laparoscopic transgastric access and cholecystectomy at the same time in a patient with gastric bypass who was seen with choledocholithiasis. Gastrointest Endosc 2010;71:212–4. 25. Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc 2011;25:2592–6. 26. Saleem A, Levy MJ, Petersen BT, et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012;16:203–8.
Discussion Discussant Dr. Megan Gilmore (Mankato, MN): The management of biliary disease that develops in patients who have had previous bariatric surgery, particularly procedures in which the duodenum is bypassed, is challenging for both the experienced bariatric surgeon and for the general surgeon who may be caring for these patients years later. You noted the indication for surgery in 59 of the 90 patients who had cholecystectomy was secondary to biliary dyskinesia. This is 65% of the patients who had cholecystectomy. You pointed out that the incidence of biliary dyskinesia was similar to what was seen in other bariatric populations. However, in your conclusion, you indicated that the rate of biliary disease was similar to the general population. I was not able to find any good statistics on how frequently biliary dyskinesia is the primary indication for laparoscopic cholecystectomy; however, in my own general surgery experience, it seems that I primarily perform laparoscopic cholecystectomy due to complications of gallstones, such as symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis. In the bariatric population, there are certain patients who complain of vague chronic abdominal pain and nausea with no clear etiology. Did these patients all have biliary dyskinesia diagnosed with a low ejection fraction on hepatobiliary iminodiacetic acid scan, or did it include some of these patients with vague abdominal complaints?
7 Do you have any data on what the clinical outcome was in this group of patients? Second, you had preoperative diagnosis of choledocholithiasis in 6 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed at the time of cholecystectomy in 6 patients, although you stated that, in 2 patients, the common bile duct stones were diagnosed by intraoperative cholangiogram. Were the 6 patients with a preoperative diagnosis of choledocholithiasis the same 6 patients who had the ERCP, or were you able to call an endoscopist in at the time of surgery to perform an ERCP when needed? In 2 cases you opened for common bile duct exploration, were there any attempts at transcystic exploration before ERCP or before opening? When there is a preoperative diagnosis of cholelithiasis, should further imaging, such as magnetic resonance cholangiopancreatography (MRCP), be used to rule out choledocholithiasis and potentially spare the patient a second surgery if immediate ERCP is not available? Dr. Joel Brockmeyer: Those 59 patients not only had biliary dyskinesia, but it was also the symptomatic cholelithiasis group. They were combined together as noninfectious group just to match up with the meta-analysis, so it was a mixture of the 2. We definitely have patients in our practice who undergo, if you will, a diagnostic cholecystectomy, where they are having vague abdominal complaints, hepatobiliary iminodiacetic acid scans are borderline abnormal, and with these vague epigastric pains, we attempt a cholecystectomy. I don’t have the actual numbers, but this is about 50-50 of where they will get better without it or there’s something else going on that we just haven’t diagnosed at that time. The 6 patients who had choledocholithiasis diagnosed preoperatively, are not the same 6 patients who required laparoscopy-assisted ERCP. As you said, we did do 2 open common bile duct explorations. Both were performed due to large stones. Either an endoscopist was consulted or it was just obvious to the operating surgeon at that time that they would not be able to be cleared laparoscopically, so they were converted to open. Among the 90 patients who had a cholecystectomy, 8 underwent transcystic common bile duct exploration. Of those who were diagnosed, the 6 patients who were diagnosed with choledocholithiasis preoperatively, 4 are in the group who were just cleared with transcystic common bile duct explorations. Two went on to have ERCP. The vast majority of the time, an endoscopist was available. Our gastroenterology department is very helpful and they will come in, especially with advance notice when we’re taking a bariatric patient to have their gallbladder out, and they’ll be available. However, you do notice that one patient had to have a laparoscopyassisted ERCP on postoperative day 2, and 1 had to have it on postoperative day 6. That was because the endoscopist was not available at the time, and the transcystic common
8
The American Journal of Surgery, Vol -, No -, - 2015
bile duct exploration failed. Both patients were admitted to the floor and observed to see if the stones would pass on their own, and neither of those 2 did, requiring further intervention. MRCP is definitely a consideration in a bariatric patient, to ensure that you have the appropriate diagnosis when you’re taking the patient to the operating room. However, in a lot of the bariatric patients, particularly if it’s early postoperatively, they may not fit into our MRCP machine, as is unfortunately far more common than we would like in Wisconsin. Because of that, an intraoperative cholangiogram or an ERCP may be needed postoperatively to diagnose that. Dr. John Potts, III (Chicago, IL): I would just like to ask you about the 3 patients that you said developed common bile duct stones, primary common bile duct stones.
Dr. Joel Brockmeyer: Yes, sir. Of those 3 patients, the earliest following their cholecystectomy presented 4 years after, and then the longest was our longest presentation, 11.3 years after. By the time criteria, they would be primary common bile duct stones. They would not have gotten any imaging at the time of surgery for their bariatric surgery because they did have their gallbladders out. Dr. Juan Blondet (Irvine, CA): Can I ask you about those 2 patients that had intervention on postoperative day 2 and postoperative day 6? How do you manage those? Do you leave a G-tube in place to keep the stomach open? Dr. Joel Brockmeyer: They hadn’t accessed the stomach yet at that time. Because the endoscopist wasn’t available, and there was always the chance that the stone would pass on its own, they just had their cholecystectomy and intraoperative cholangiogram at that time. Both actually had transcystic common bile duct explorations that failed. They waited for the endoscopist to be available. Unfortunately, neither of the stones passed. They were taken back to the operating room for a 2nd anesthesia to access the stomach and perform the ERCP.
1. Did those individuals undergo imaging of their bile ducts sometime around their gastric bypass? 2. Did these really qualify as primary common bile duct stones? Was it more than 2 years after cholecystectomy? Were they soft, friable stones, and so forth?