IBC Oxford University Poster Abstract 11 - Accessing common bile duct stones after one anastomosis gastric bypass—same destination via different route

Abstract Background Laparoscopic Mini Gastric Bypass/One Anastomosis Gastric Bypass (MGB/OAGB) excludes the common bile duct (CBD) from traditional diagnostic and therapeutic treatment options with Endoscopic Retrograde Cholangiopancreatography (ERCP). Accessing CBD becomes limited and challenging due to altered MGB/OAGB anatomy. Due to the initial rapid weight loss, MGB/OAGB patients have an increased risk of developing cholelithiasis as well as choledocholithiasis. Case Presentation This technique demonstrates how to safely treat this rare problem by performing a combined laparoscopic and endoscopic approach—Trans-gastric ERCP. Methods A 53-year-old female with an initial BMI of 41 kg/m2 and an absolute weight of 134 kg, underwent MGB/OAGB 6 months ago. She had normal liver function tests (LFTs) and an ultrasound abdomen preoperatively. She lost 21 kgs of body weight over 5 months postoperatively. She had a history of laparoscopic cholecystectomy done 20 years ago, so she was not started on the Ursodeoxycholic-acid regimen post-operatively. She was admitted given the history of severe episodic epigastric pain for one week. There were no other complaints. Results She was evaluated and showed deranged LFTs including significantly raised serum alkaline phosphatase (ALP) and Gamma glutamyl transferase (GGT) levels, which raised suspicion of some biliary pathology. MRCP abdomen revealed dilated CBD of 24 mm with lower CBD calculus sized 9.8 mm, with sludge or a possible stricture. She underwent Laparoscopic Trans-gastric ERCP. Access was made by creating a gastrotomy in the remnant of the stomach for placement of an endoscope. Getting access to the remnant of the stomach was challenging due to dense adhesions from the previous two surgeries and smaller gastric remnants because of the long and loose gastric pouch of OAGB/MGB as compared to Roux-en-Y gastric bypass. Retrieval of stones and dilatation of lower CBD stricture area was done along with taking biliary stricture brush cytology. Complete clearance of CBD was done with multiple balloon sweeps and endoscopic papillary balloon dilatation was done up to 12 mm. The gastrotomy performed on the remnant of the stomach was closed. Post-surgery her LFTs become normal and biliary brush cytology reported negative for malignancy. Conclusion Treating the Bile duct pathology endoscopically after MGB/OAGB is technically challenging and requires multidisciplinary teams. It can be managed safely and effectively at centres with both high endoscopic and bariatric expertise.