Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass

Abstract

Background:

The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS.

Materials and Methods:

We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed.

Results:

Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days.

Conclusion:

IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

Introduction

Morbid obesity is a multifactorial disease that is usually treated by bariatric surgery with good results. Amidst the multiple consequences that it generates for health, the commitment at the cardiovascular, metabolic, psychological, and trauma levels among others, stands out.^1–3 The incidence of cholelithiasis in obese patients is 20%,^4,5 and rises to 37% after a Roux-en-Y gastric bypass (RYGB).^4,6 Taking into account that the prevalence of cholelithiasis in Buenos Aires, Argentina is 21.9% in the general population,⁷ many authors suggest solving the problem of gallstones by scheduling a cholecystectomy before bariatric surgery.⁸ In any case, the risk of a common bile duct stone (CBDS) complication remains latent, since in many patients lithiasis de novo develops post-RYGB.

Minimally invasive surgery (MIS) plays a major role in the treatment of postoperative complications in bariatric surgery,^9,10 especially in biliary pathology. There are several approaches, of which the most used are endoscopic, laparoscopic, and percutaneous. Due to the anatomical modification, direct endoscopic access is not possible in patients with RYGB gallstones. For this reason, image-guided surgery (IGS) using different percutaneous procedures stands out as the first line of treatment in these patients.¹¹

Percutaneous transhepatic biliary drainage (PTBD) approach of the common bile duct (CBD) is presented as a feasible and safe minimally invasive procedure to treat post-RYGB choledocholithiasis.

Objectives

The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB using IGS.

Materials and Methods

This is a descriptive retrospective observational multicentric study on the treatment of CBDS in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The data collected were from patients admitted to two centers (DAICIM Foundation, Buenos Aires, Argentina, and Diagnomed, Buenos Aires, Argentina), who were treated by the same surgical team. The time period analyzed was 10 years (from 2009 to 2019). The following selection criteria were considered: (1) Inclusion criteria: patients with the presence of CBDSs and a history of RYGB; (2) Exclusion criteria: presence of gallbladder, presence of cholestatic jaundice, or acute cholangitis due to a cause other than lithiasis in the main bile duct (i.e., intrinsic or extrinsic biliary stenosis). Clinical diagnosis, blood tests, imaging studies (Ultrasound, Computed Tomography, or Magnetic Resonance Imaging), intravenous antibiotics, and percutaneous approach were performed in all cases.

Workflow

The patients were managed according to our algorithm (Fig. 1). The diagnosis of choledocholithiasis was made according to the symptoms of the patients, supported by blood tests and medical images. All patients were admitted and received parenteral fluids in addition to intravenous antibiotics, gastric protection, antiemetics, analgesics, and antispasmodics. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step lithiasis was removed. In the case of acute cholangitis, blood cultures were taken and antibiotics were administered according to the antibiogram.

FIG. 1.

Management algorithm for minimally invasive treatment of CBDS after RYGB. CBDS, common bile duct stone; RYGB, Roux-en-Y gastric bypass.

Technical aspects

The first step of treatment based on IGS consisted of PTBD. The procedures were carried out in an operating room equipped with fluoroscopy and ultrasonography, a using sterile technique. The patients were placed in the supine position, under general anesthesia. Right biliary access or left (using fluoroscopic guidance plus ultrasound in both approaches) was chosen according to the patient's anatomy and previous studies. With a 21G (Gauge) needle (Chiba Needle 21 G, Cook) guided by images, the intrahepatic bile duct was reached, and a sample of bile was taken for microbiological study. Contrast (Ultravist 300 mg/mL, Bayer, Germany) was then injected under fluoroscopy guidance to perform puncture cholangiography to verify the anatomy of the bile duct. In the next step, a 0.018″ guidewire (Guidewire 0.018″, Cook, USA) was introduced, and the needle was subsequently replaced by a 14 Fr (French) coaxial introducer (Neff Introducer Set, Cook). Then, the 0.018″ guidewire was removed, and keeping the introducer in position, a 0.035″ hydrophilic guidewire (Guidewire 0.035″ Roadrunner^®, Cook) was introduced. Subsequently, the introducer was removed and the entry site was progressively dilated (Dilators 8, 10, 12 Fr, Cook) and a 10.2 Fr internal/external biliary drain was placed (Biliary Catheter Drainage, Cook) (Fig. 2A). The patient remained hospitalized on antibiotic treatment until the second step was completed. At this time, once a safe fistulous tract had been formed (7–10 days approximately), the bile duct was instrumented percutaneously. It was started with a transfistular cholangiography, and then a 0.035″ hydrophilic guidewire was introduced into the biliary drainage catheter, into the duodenum. The catheter was removed, and the papilla was then dilated with a balloon (5 Fr, 4 cm × 10 mm, at a pressure of 20 mm Hg) (ATB Advance^® Balloon Catheter, Cook) (Fig. 2B). The objective of this step was to move the stones into the digestive tract in an antegrade manner. If this was not achieved, a basket (5 Fr, 2.5 cm × 1.8 cm) (Wittich Nitinol Stone Basket, Cook, USA) was used to remove the lithiasis in a transfistular manner. After the procedure, a control cholangiography was performed to check the absence of stones in the bile duct, and a biliary drainage catheter was left (Fig. 2C) until hospital discharge. The patients were discharged with the catheters, which were removed on an outpatient basis.

FIG. 2.

Treatment of CBDS after RYGB. Percutaneous approach. (A) Cholangiography showing stones within the CBD. (B) Balloon dilation to remove the stones. (C) PTBD and end of the procedure. CBD, common bile duct; CBDS, common bile duct stone; PTBD, percutaneous transhepatic biliary drainage; RYGB, Roux-en-Y gastric bypass. Color images are available online.

Statistical analysis

Statistical data were analyzed by computer programs (IBM SPSS Statistics 25.0). Results were expressed in percentage, range, and standard deviation. A 95% confidence interval was applied, and a value of P < .05 was established as statistically significant.

Bioethical aspects

All participants signed an informed consent. The study was approved by the Bioethics Committee of the participating institutions.

Results

Of a total of 1403 post-RYGB patients, 21 (1.4%) presented CBDS. Of these, 3 were excluded (all due to the presence of a gallbladder), and the remaining n = 18 patients were included (Table 1). Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic (in these cases the diagnosis was made by routine blood tests and ultrasonography) (Table 2).

Table 1.

Demographic Characteristics

Demographic characteristics
N	18
Age	46.9 ± 7.07 (range 38–65)
Sex
Female	10 (56.6% ± 0.51%)
Male	8 (44.4% ± 0.50%)
BMI	28.3 ± 3.40 (range 19.39–32.70)
Morbidity
HBP	9 (50% ± 0.51%)
DM	11 (61.1% ± 0.50%)
DLP	5 (27.7% ± 0.46%)
Apnea	1 (5.5% ± 0.23%)
Hypothyroidism	4 (22.2% ± 0.42%)

BMI, body mass index; DM, diabetes mellitus; DLP, dyslipidemia; HBP, high blood pressure.

Table 2.

Clinical Characteristics

Clinical characteristics		P
N	18
Symptoms
Pain	10 (55.5% ± 0.51%)	>.05
Fever	7 (38.8% ± 0.50%)
Nauseas	6 (75% ± 0.48%)
Vomiting	3 (16.6% ± 0.38%)
Ictericia	12 (66.6% ± 0.48%)
Coluria	8 (44.4% ± 0.51%)
Hypocolia	5 (27.7% ± 0.46%)
Blood test
WBC	8.433 ± 3.88 (range 3.400–16.000)	>.05
TB	4.16 ± 1.22 (range 1.9–6.2)
DB	2.91 ± 1.11 (range 1.0–5.5)
AP	401.9 ± 64.81 (range 311–556)
Diagnosis
Asymptomatic	3 (16.6% ± 0.38)	>.05
Choledochal syndrome	8 (44.4% ± 0.51)
Acute cholangitis	7 (38.8% ± 0.50)

AP, alkaline phosphatase; DB, direct bilirubin; TB, total bilirubin; WBC, white blood cell count.

Percutaneous treatment was performed in all these patients (Table 3). In 66.6% of cases a left approach was used, whereas in 33.3% the approach was right. All patients were treated with a balloon, whereas stone basket support was required in 6 of them.

Table 3.

Percutaneous Transhepatic Biliary Drainage for Common Bile Duct Stone After Roux-en-Y Gastric Bypass

Treatment
Clinical diagnosis	Percutaneous approach							Hospital stay		Hyperamylasemia (postoperative)
Clinical diagnosis	Left PTBD Izq	Right PTBD Der		Catheter	Balloon	Basket
Asymptomatic	2 (66.6% ± 0.57%)	1 (33.3% ± 0.57%)		10.2 Fr	3 (100% ± 0%)	0		5.6 (5–6) ± 0.57		0
Choledo Syndr	5 (62.5% ± 0.51%)	3 (37.5% ± 0.51%)		10.2 Fr	7 (100% ± 0%)	2 (25% ± 0.46%)		7.75 (5–15) ± 3.05		1 (12.5% ± 0.35%)
Cholangitis	5 (71.4% ± 0.48%)	2 (28.5% ± 0.48%)		10.2 Fr	8 (100% ± 0%)	4 (57.1% ± 0.53%)		11 (7–17) ± 3.69		2 (28.5% ± 0.48%)
Total	12 (66.6% ± 0.48%)	6 (33.3% ± 0.48%)	P ≥ .05	10.2 Fr	18 (100% ± 0%)	6 (33.3% ± 0.48%)	P ≥ .05	8.6 (5–17) ± 3.59	P ≥ .05	3 (16.6% ± 0.38%)	P ≥ .05

Amylasemia NV (Normal Value) = 40 − 140 U/L; Left PTBD, Percutaneous transhepatic biliary drainage via left; Right PTBD, Percutaneous transhepatic biliary drainage Right access.

A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported (Table 3).

The average hospital stay was 8.6 days, being longer for those patients with a diagnosis of acute cholangitis, which was not statistically significant (Table 3).

Discussion

Bariatric surgery is one of the most popular procedures nowadays.¹² Its efficacy for the treatment of morbid obesity is well known, and it consists of standardized surgical techniques. RYGB is one of the most widely used types of bariatric surgery to treat this group of patients. The overall complication rate in bariatric procedures is 0%–10%,¹³ whereas in RYGB it is 0.2%–3.6%.¹⁴

Gallstones is an entity that affects a large part of the general population. It is associated with exogenous factors such as a diet rich in fat, prolonged fasting, and the intake of certain medications (contraceptives), and with endogenous factors such as metabolic disorders (dyslipidemia) and their consequences (obesity, hepatic steatosis). It has to add, in the context of a lithogenic bile. In the City of Buenos Aires, Argentina, the prevalence of cholelithiasis is 21.9%.⁷ Morbid obesity and gallstones are closely related. Some authors recommend performing a cholecystectomy in those patients with gallstones who are candidates for bariatric surgery.¹⁵ Despite this practice, the risk of this type of complication is not completely erased. Overweight patients who experience rapid weight loss are more likely to develop gallstones.¹⁶

The cholelithiasis complication rate in patients undergoing RYGB is 14.5%.¹⁷ These cases can be asymptomatic, or present a cholestatic jaundice or acute cholangitis as a clinical presentation. The presence of lithiasis in the CBD requires its extraction. Under normal anatomical conditions, the endoscopic approach using an Endoscopic Retrograde CholangioPancreatography is sufficient for its treatment. However, in a patient who underwent RYGB for obesity, the anatomy modifications secondary to this surgery do not allow the endoscope to access the duodenum. For this reason, in the context of performing minimally invasive procedures in these complex conditions, laparoscopic, endoscopic, percutaneous, and combined approaches have been described to manage these cases.^18–20 Laparoscopic access consists of an exploration of the bile duct either by transcystic approach (in the presence of a gallbladder) (Fig. 3), or by choledochotomy (Fig. 4). Once the bile ducts are accessed and washed, the lithiasis is removed using catheters and stone baskets. Endoscopic access is more difficult in those patients. Special endoscopes are used and require experienced operators due to the length between the mouth and the second portion of the duodenum after RYGB. Similar techniques use endoscopic ultrasound to access the bile duct transgastrically.²¹ Less widespread, we find the combined treatment that associates the use of the endoscope with the laparoscopic approach. It consists of a laparoscopic gastrotomy, through which the endoscope is inserted and the bile duct is explored and evacuated²² (Fig. 5). Finally, the percutaneous access is represented by PTBD (Fig. 2). It is a safe, minimally invasive procedure without the need for laparoscopic reoperation or endoscope access.²³ In experienced hands, the reported effectivity is ∼90%–95%, with an average complication rate of 1.68%.^24,25 The presence of cholelithiasis demands additional actions. In this context, Szulman et al. have described a percutaneous antegrade drainage technique for gallstones²⁶ with good results. On other occasions, it is necessary to remove the lithiasis using a stone basket. The percutaneous approach has the advantage of providing comprehensive management in these patients. On the one hand, it offers programmed therapy in the asymptomatic patient, and on the other hand it allows treating urgent and severe cases of cholestatic jaundice or acute cholangitis in two stages (first time PTBD, second time extraction of stones).²⁷ Of the total of 18 patients presented, all were successfully treated by percutaneous approach. The complication rate report was low, and all presented good postoperative evolution. From a technical point of view, both the right and left transparietohepatic access were used, although our group prefers the latter supported by ultrasound guidance. In those patients in whom the use of a dilatation balloon was not sufficient for the treatment of gallstones, this deficit was made up with the stone basket for transfistular extraction.

FIG. 3.

Treatment of CBDS after RYGB. Laparoscopic approach. (A) Transcystic access in a patient with a gallbladder. (B, C) Exploration of the bile duct. The procedure ends with a cholecystectomy. CBDS, common bile duct stone; RYGB, Roux-en-Y gastric bypass. Color images are available online.

FIG. 4.

Treatment of CBDS after RYGB. Laparoscopic approach. (A) Access to the bile duct by choledochotomy in a patient without a gallbladder. (B, C) Exploration of the bile duct. The procedure ends with a primary choledochorrhaphy. CBDS, common bile duct stone; RYGB, Roux-en-Y gastric bypass. Color images are available online.

FIG. 5.

Treatment of CBDS after RYGB. Combined laparoscopic and endoscopic approach. (A) Laparoscopic gastrotomy. (B) Endoscopic access to the second portion of the duodenum. Exploration of the bile duct (ERCP). (C) The procedure ends with the removal of the endoscope and a gastrorrhaphy. CBDS, common bile duct stone; ERCP, endoscopic retrograde cholangiopancreatography; RYGB, Roux-en-Y gastric bypass. Color images are available online.

IGS through percutaneous procedures is a valid option to treat these cases.^28,29 Advances in this field of MIS are due to the development of technology applied to medicine. Enhanced medical imaging equipment, high-definition screens, 3D tomographic and MRI reconstructions, and the application of navigation systems can be listed. To all this we should add the manufacture of specific devices (needles, introductors, catheters, stents, and so on). These aspects have positioned IGS as one of the main treatment options for patients with complex pathologies.^30–35 Of course, technology alone is not enough to solve the complications of cholelithiasis that can become serious. In addition, technical experience and extensive knowledge of the bile duct are required to be successful in these procedures.³⁶ For this reason, the management of these patients should be the responsibility of high-volume centers in the treatment of complex biliary pathology.³⁷

The main limitation of this study is the small number of cases and restrospective design, which is why randomized and multicenter clinical trials are required to define the best treatment for these complications.

Conclusion

IGS is an interesting option for the treatment of post-RYGB choledocholithiasis. PTBD is feasible and safe for this group of patients. It also has the advantages of being a minimally invasive procedure.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Sinha

, Kling

. A review of adolescent obesity: Prevalence, etiology, and treatment. Obes Surg, 2009; 19:113–120.

Catenacci

, Hill

, Wyatt

. The obesity epidemic. Clin Chest Med, 2009; 30:415–444.

Ricci

, Gaeta

, Rausa

, et al. Early impact of bariatric surgery on type II diabetes, hypertension, and hyperlipidemia: A systematic review, meta-analysis and meta-regression on 6,587 patients. Obes Surg, 2014; 24:522–528.

Palermo

, Acquafresca

, Coelho Ferreira

, et al. Biliary Disease and Bariatric Surgery. In: Lutfi R, Palermo M, Cadière GB (eds). Global Bariatric Surgery The Art of Weight Loss Across the Borders. Switzerland: Springer 2018, :pp. 425–436.

Amaral

, Thompson

. Gallbladder disease in the morbidly obese. Am J Surg, 1985; 149:551–557.

Guzmán

, Sepúlveda

, Rosso

, et al. Incidence and risk factors for cholelithiasis after bariatric surgery. Obes Surg, 2019; 29:2110–2114.

Palermo

, Berkowski

, Córdoba

, et al. Prevalence of cholelithiasis in Buenos Aires, Argentina. Acta Gastroenterol Latinoam, 2013; 43:98–105.

Plecka Östlund

, Wenger

, Mattsson

, et al. Population-based study of the need for cholecystectomy after obesity surgery. Br J Surg, 2012; 99:864–869.

Palermo

, Davrieux

, Serra

, et al. Percutaneous image-guided surgery in complications after bariatric surgery. J Laparoendosc Adv Surg Tech A, 2020; 30:967–972.

10.

Palermo

, Davrieux

, Acquafresca

, et al. Percutaneous image-guided abdominal interventions for leaks and fistulas following sleeve gastrectomy and Roux-en-Y gastric bypass. Obes Surg, 2019; 29:2051–2058.

11.

Giménez

ME.

Percutaneous image-guided surgery. Int J Gastrointest Interv, 2019; 8:2–5.

12.

Angrisani

, Santonicola

, Iovino

, et al. Bariatric surgery worldwide 2013. Obes Surg, 2015; 25:1822–1832.

13.

Weller

, Hannan

. Relationship between provider volume and postoperative complications for bariatric procedures in New York State. J Am Coll Surg, 2006; 202:753–761.

14.

Bellorin-Marin

, Pomp

Gastric Bypass. In: Lutfi R, Palermo M, Cadière G-B (eds). Global Bariatric Surgery. 1st ed. Switzerland: Springer 2018, pp. 97–111.

15.

Altieri

, Yang

, Nie

, et al. Incidence of cholecystectomy after bariatric surgery. Surg Obes Relat Dis, 2018; 14:992–996.

16.

Coupaye

, Castel

, Sami

, et al. Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass in obese patients: A prospective study. Surg Obes Relat Dis, 2015; 11:779–784.

17.

Sneineh

, Harel

, Elnasasra

, et al. Increased incidence of symptomatic cholelithiasis after bariatric Roux-En-Y gastric bypass and previous bariatric surgery: A single center experience. Obes Surg, 2020; 30:846–850.

18.

García

, Esquivel

, Palermo

. Common bile duct stones after Roux-en-Y gastric bypass: same issue, different ways to deal with. J Laparoendosc Adv Surg Tech A, 2020; 30:900–906.

19.

Palermo

, Fendrich

, Ronchi

, et al. Laparoscopic common bile duct exploration using a single-operator cholangioscope. J Laparoendosc Adv Surg Tech A, 2020; 30:989–992.

20.

Palermo

, Duza

, Caviglia

, et al. Treatment of bile duct stones by laparoscopy, endoscopy or combined approaches. Acta Gastroenterol Latinoam, 2015; 45:90–96.

21.

Majidah

Bukhari

, Kowalski

, Nieto

, et al. An international, multicenter, comparative trial of EUS-guided gastrogastrostomyassisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc, 2018; 88:486–494.

22.

Tzedakis

, Memeo

, Nedelcu

, et al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description. J Visc Surg, 2019; 156:381–386.

23.

Houghton

, Zeledón

, Acquafresca

, et al. Prospective comparison of bleeding complications between right and left approaches in percutaneous biliary drainage. Surg Laparosc Endosc Percutan Tech, 2019; 29:7–12.

24.

Saad

WEA

, Wallace

, Wojak

, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol, 2010; 21:789–795.

25.

Burke

, Lewis

, Cardella

, et al. Quality improvement guidelines for percutaneous transhepatic cholangiography and biliary drainage. Society of Cardiovascular and Interventional Radiology. J Vasc Interv Radiol, 1997; 8:677–681.

26.

Szulman

, Giménez

, Sierre

. Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: Lessons learned from treating 300 patients. J Vasc Interv Radiol, 2011; 22:346–353.

27.

Navuluri

, Hoyer

, Osman

, et al. Emergent treatment of acute cholangitis and acute cholecystitis. Semin Intervent Radiol, 2020; 37:14–23.

28.

Palermo

Advances in bariatric surgery. J Laparoendosc Adv Surg Tech A, 2020; 30:1.

29.

Maresceaux

, Soler

, Ceulemans

, et al. Image fusion, virtual reality, robotics and navigation. Effects on surgical practice. Chirurg, 2002; 73:422–427.

30.

Palermo

, Giménez

. Image-guided surgery: A new concept in minimally invasive surgery. J Laparoendosc Adv Surg Tech A, 2020:30:941.

31.

Davrieux

, Cuneo

. Image-guided surgery: A combined evolution of surgery and imaging method. Nov Res Sci, 2019; 1:1–5.

32.

Gimenez

, Davrieux

, Serra

, et al. Percutaneous image-guided surgery training: Model IHU-DAICIM. Surg Laparosc Endosc Percutan Tech, 2018; 28:e24–e29.

33.

Davrieux

, Giménez

, González

, et al. Mixed reality navigation system for ultrasound-guided percutaneous punctures: A pre-clinical evaluation. Surg Endosc, 2020; 34:226–230.

34.

Nicolau

, Soler

, Mutter

, et al. Augmented reality in laparoscopic surgical oncology. Surg Oncol, 2011; 20:189–201.

35.

Soler

, Nicolau

, Pessaux

, et al. Real-time 3D image reconstruction guidance in liver resection surgery. Hepatobiliary Surg Nutr, 2014; 3:73–81.

36.

Davrieux

, Davrieux

. Relationship between the Biliary Tree and the Fibonacci Sequence. Gastro Rev Med, 2019; 3. GMR. 000556 2019. DOI: 10.31031/GMR.2019.03.000556.

37.

Alvear Castro

, Gómez Rodríguez

, Houghton

, et al. Transhepatic percutaneous sustained dilation with multiple catheters for the management of hepaticojejunostomy benign stricture. J Laparoendosc Adv Surg Tech A, 2020; 30:948–952.