Transjejunal Laparoscopic Assisted ERCP in a Patient with Roux-en-Y Hepaticojejunostomy

Abstract

Background and Objectives: Nowadays, with the increasing laparoscopic expertise and accessibility to modern surgical tools, laparoscopic assisted ERCP (LAERCP) has become an effective approach for the management of bile stone disease in patients with modified gastrointestinal anatomy. In contrast to patients with gastric bypass in whom a transgastric LAERCP approach is usually performed, the resultant anatomy of Roux-en-Y hepaticojejunostomy precludes a gastric approach as the newly formed bilioenteric anastomosis is not reachable through the stomach. Therefore, a transjejunal approach has been described as an alternative LAERCP technique. To the best of our knowledge this is the tenth case of transjejunal LAERCP reported worldwide. Materials and Methods: We present the case of a 50-year-old female with history of biliary injury during a cholecystectomy corrected with Roux-en-Y hepaticojejunostomy who presented to our center with manifestations of acute abdomen. After laboratory and image analysis, diagnosis of intrahepatic lithiasis was confirmed. The decision to perform a transjejunal LAERCP was made due to the complex anatomy in this patient. No complications were found during surgery and in the follow up period. Conclusions: Transjejunal LAERCP is an effective approach for endoscopic management of biliary complications in patients with Roux-en-Y hepaticojejunostomy and other modified gastrointestinal anatomy. Previous recommendations by more experienced teams have been reported, nonetheless, there are too few cases reported to make definitive recommendations and conclusions. In limited settings, such as ours, some of these recommendations may not be applicable. We are certain that, with the increasing expertise and innovations in laparoscopy surgery for the management of complications that cannot be addressed by endoscopic or noninvasive measures, more cases will be reported.

Laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture in a patient with Roux-en-Y hepaticojejunostomy

“…In addition, there is an increased probability of chyme, bacteria and air entering the biliary tract, as well as the increased levels of mucin and oxygen-free radicals that promote stone formation. [ 1 ]…”

“…[ 4 ] The new endoscopic approaches such as single or double-balloon enteroscopy is considered as an alternative approach for modified gastrointestinal anatomy patients. [ 1 ] Percutaneous transhepatic cholangioscopy (PTC) is another well-described alternative. It can precisely localise the affected bile duct, and it allows repeated interventions through the percutaneous tract.…”

“…Finally, post-procedural pain requiring analgesic administration has been described as a minor but remarkable disadvantage. [ 1 2 ] Percutaneous transjejunal biliary intervention, a relatively unfamiliar technique, has also shown promising results, although it has yet to be integrated into daily practice. [ 3 ] With the development of laparoscopy and clear appearance of its advantages such as lower rates of wound complications, less post-operative pain and early return to normal activity, we decided to use the laparoscopy approach for this procedure.…”

“…The treatment options for intrahepatic calculi and biliary strictures in patients with surgically modified gastrointestinal anatomy include percutaneous transhepatic treatment, peroral short double-balloon enteroscopy, percutaneous transjejunal biliary intervention, laparoscopic-assisted transjejunal endoscopic management (LATEM) and the conventional surgery. [ 1 2 3 ] Conventional surgery, however, is invasive and technically challenging, and it causes significant morbidity for these patients.…”

“…The objective of this report is to present a case of LATEM of intrahepatic duct calculi and anastomotic stricture in a patient with RYHJ, which to the best of our knowledge, is the 11 th case reported and the third case of direct access to the hepaticojejunostomy site reported worldwide. [ 1 ]…”