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Original article

Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass

Federico A. Ceppa, M.D., Daniel J. Gagné, M.D.,* Pavlos K. Papasavas, M.D.,Philip F. Caushaj, M.D.

Temple University School of Medicine, Clinical Campus at Western Pennsylvania Hospital, Pittsburgh, Pennsylvania

Received June 1, 2006; revised August 13, 2006; accepted August 27, 2006

bstract Background: Access and endoscopic evaluation of the bypassed stomach is difficult after laparo-scopic Roux-en-Y gastric bypass. We propose a minimally invasive technique to access thebypassed stomach after Roux-en-Y gastric bypass for endoscopic diagnosis and treatment.Methods: First, we established carbon dioxide pneumoperitoneum to a pressure of 12–15 mm Hg.Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm leftupper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of thestomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into thestomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneumwas decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with arunning suture or linear stapler.Results: Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Fivepatients had biliary pathologic findings. Four of these patients underwent successful endoscopicretrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was un-successful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinalbleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleedingduodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Twopatients evaluated for chronic abdominal pain had negative endoscopy findings. No complicationsdeveloped.Conclusions: Laparoscopic transgastric endoscopy is a safe and minimally invasive approach forthe evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergoneRoux-en-Y gastric bypass. (Surg Obes Relat Dis 2007;3:21–24.) © 2007 American Society for

Surgery for Obesity and Related Diseases 3 (2007) 21–24

Bariatric Surgery. All rights reserved.

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Roux-en-Y gastric bypass (RYGB) is the most com-only performed bariatric surgery in the United States [1].his operation creates bypassed structures that include mostf the stomach, duodenum, and proximal jejunum. Endo-copic access to the bypassed structures, as well as theiliary tree and pancreatic duct, is inherently difficult after

Supported in part by a research grant from Tyco/United States Surgicalorporation

Presented at the 2005 Annual Meeting of the Society of Americanastrointestinal Endoscopic Surgeons, Hollywood, Florida, April 2005

*Reprint requests: Daniel J. Gagné, M.D., Department of Surgery,600N, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pitts-urgh, PA 15224.

hE-mail: dgagne@wpahs.org

550-7289/07/$ – see front matter © 2007 American Society for Bariatric Surgeroi:10.1016/j.soard.2006.08.018

YGB. With the exponential number of gastric bypassrocedures performed for the treatment of morbid obesity,any patients will present with pathologic features in the

ypassed structures that will require diagnostic and thera-eutic interventions [2].

Gastrointestinal bleeding in RYGB patients may necessitateransgastric endoscopy after a negative endoscopic evaluationf the upper and lower gastrointestinal tract. In a retrospectiveeries of 3000 cases of open RYGB, 8 patients (0.3%) devel-ped bleeding from peptic ulcer disease in the bypassed gas-rointestinal tract [3–6]. Perforation of the bypassed stomachecondary to peptic ulcer disease after RYGB is rare (0.26%)5,7–9]. Rare cases of gastric malignancies after gastric bypass

ave also been reported [10–14].

y. All rights reserved.

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22 F. A. Ceppa et al. / Surgery for Obesity and Related Diseases 3 (2007) 21–24

Because of the difficulty in accessing the biliary treendoscopically after RYGB, some bariatric surgeons per-orm routine cholecystectomy at RYGB and have reportedositive pathologic findings in 80–90% of gallbladders re-oved [15–17]. The reported incidence of gallstone forma-

ion after RYGB is �30%, although with the use of urso-iol, it may decrease to 2% [18]. However, patientompliance with ursodiol has been reported to be poor. Thencidence of choledocholithiasis is unknown; however,iven the frequent development of gallstones with rapideight loss, the incidence is likely to become greater asore of these operations are performed.The problem of accessing the bypassed structures is not

ew, and several different access techniques have beenescribed [19–27]. The long 90–150-cm Roux limb makesndoscopic access very difficult, if not impossible. Thenability to insufflate the bypassed stomach with air, a tech-ique routinely used for percutaneous gastric access, com-licates a possible interventional radiology attempt at access19]. In addition, barium contrast studies are unable toeflux sufficiently up the Roux limb to show the gastricucosa.We reported the use of laparoscopic-assisted transgastric

ndoscopy of the bypassed structures and biliary tree in002 [28]. We have now successfully performed transgas-ric endoscopy on a series of 10 patients.

ethods

A retrospective review of a prospectively collected da-abase identified 8 patients (1.1%) who had undergone lapa-oscopic-assisted transgastric endoscopy from our cohort of00 patients who had undergone laparoscopic RYGB be-ween July 1999 and January 2005. Two additional patientsere referred to our practice for evaluation. Eight patientsad undergone laparoscopic RYGB and two had previously

able 1esults and outcomes of patients undergoing transgastric EGD

athologic features n Preoperative diagnosis Findings

iliary 5 Bile duct stricture (1) Bile duct stricturSymptomatic cholelithiasis

and suspicion of CBDdisease (2)

Bile duct strictur

Choledocholithiasis (2) CBD sludge (1)CBD stones (1)CBD impacted st

I bleed 3 GI bleeding GIST tumor duod

GI bleeding Duodenal ulcerGI bleeding Negative

bdominal pain 2 Abdominal pain Negative

EGD � esophagogastroduodenoscopy; ERCP � endoscopic retrogradetromal tumor; GI � gastrointestinal.

ndergone open gastric bypass. Eight patients had a retro-

olic/retrogastric Roux limb and two had an antegastric/ntecolic Roux limb. The indications for these 10 transgas-ric endoscopies are summarized in Table 1.

First, we established carbon dioxide pneumoperitoneumo a pressure of 12–15 mm Hg using a Veress needlehrough an umbilical incision. A 12-mm umbilical VisiportU.S. Surgical, Norwalk, CT) for the camera was placed.dditional trocars (5-mm right upper quadrant, 5-mm left

ower quadrant, and 15-mm left upper quadrant) were thenntroduced (Fig. 1). Ultrasonic shears were used to create aastrotomy on the anterior wall of the stomach, and aurse-string suture was placed around it. The pneumoperi-oneum was then decreased to 7–8 mm Hg to facilitatepproximation of the gastric remnant to the anterior abdom-nal wall. The purse-string suture was used for traction (Fig.). The 15-mm trocar was inserted into the gastrotomy, and

Procedure Outcome

Laparoscopic ERCP/sphincterotomy Resolution of symptomsLaparoscopic ERCP/sphincterotomy Resolution of symptoms

Laparoscopic ERCP/sphincterotomy Resolution of symptomsLaparoscopic ERCP/sphincterotomy Resolution of symptomsAttempted laparoscopic ERCP, open

CBD explorationResolution of symptoms

Laparoscopic transgastricendoscopy, biopsy

Chemotherapy

Laparoscopic transgastric endoscopy Open repair of bleeding ulcerLaparoscopic transgastric endoscopy Resolution of bleedingLaparoscopic transgastric endoscopy SMA syndrome (1)

giopancreatography; CBD � common bile duct; GIST � gastrointestinal

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Fig. 1. Port placement for laparoscopic transgastric endoscopy.

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23F. A. Ceppa et al. / Surgery for Obesity and Related Diseases 3 (2007) 21–24

he endoscope was inserted through this trocar. Evaluationf the gastric remnant and duodenum was then performed.owel graspers were used through the 5-mm ports to pre-ent distension of the distal bowel. Any additional proce-ures or manipulations with the endoscope (biopsy, endo-copic retrograde cholangiopancreatography [ERCP]) canlso be performed at this time. Once the evaluation wasompleted, the gastrotomy was closed with either a runninguture or a linear stapler.

esults

Ten patients underwent laparoscopic transgastric endos-opy (Table 1). These included 8 women (80%) and 2 men20%). The average age of the group was 44 years (range2–56). Laparoscopic transgastric endoscopy was per-ormed an average of 40.2 months (range 1–242, median1) after gastric bypass. At that time, these patients had lostn average of 64.6% (range 14.6–100.7%, median 65.1%)f their excess weight.

Five patients underwent attempted transgastric ERCP foriliary pathologic findings. One patient had presented withight upper quadrant pain after fatty meals even after cho-ecystectomy for cholelithiasis. This patient was diagnosedith a benign distal common bile duct stricture and was

reated with ERCP/sphincterotomy. Four patients had pre-ented with symptomatic cholelithiasis and suspicion ofholedocholithiasis. One patient had persistent hyper-ipasemia after gallstone pancreatitis and underwent laparo-copic cholecystectomy and ERCP/sphincterotomy (sludge,ut no stones, was found in the common bile duct). Oneatient had transient hyperbilirubinemia and underwentaparoscopic cholecystectomy and ERCP/sphincterotomyor a benign distal common bile duct stricture. One patientresented with choledocholithiasis and gallstone pancreati-

ig. 2. View of 15-mm port introduced into gastric remnant with purse-tring suture for traction.

is and underwent successful transgastric ERCP, sphincter- i

tomy, and stone extraction. One patient presented with aarge stone impacted at the ampulla of Vater. TransgastricRCP was attempted in this patient without success becausef difficulty in cannulating the ampulla. The patient under-ent open common bile duct exploration. The success ratef transgastric ERCP was 80%.

Three patients were evaluated for gastrointestinal bleed-ng after negative upper and lower endoscopy findings. Oneatient had a gastrointestinal stromal tumor of the secondortion of the duodenum. The second patient had a bleedinguodenal ulcer that was oversewn using an open technique.he third patient had negative examination findings.

Two patients had presented with persistent abdominalain after multiple diagnostic studies and procedures. Bothatients had negative transgastric endoscopy findings. Onef these patients was eventually diagnosed with superioresenteric artery syndrome and underwent successful lapa-

oscopic duodenojejunostomy. No complications developedecondary to laparoscopic transgastric endoscopy.

iscussion

The popularity of RYGB surgery makes it imperativehat novel diagnostic and treatment modalities are created.y excluding most of the stomach, duodenum, proximal

ejunum, and biliary tree, endoscopic access becomes veryifficult.

Access to bypassed structures is not new, and severalechniques have been described to address this issue. Thentroduction of a pediatric colonoscope transorally follows aortuous route through the esophagus, gastric pouch, effer-nt limb, jejunojejunostomy, afferent limb, duodenum, and,nally, distal gastric remnant [20,21,24,25]. This methoday be cumbersome and requires great endoscopic exper-

ise. Also, its success rate is only 68%. Furthermore, withoux limbs of �150 cm, the transoral approach is moreifficult, if not impossible. The use of a pediatric colono-cope negates the ability to perform ERCP or sphincterot-my.

Percutaneous computed tomography or ultrasound-uided access of the gastric remnant is challenging becausef the inability to distend the remnant stomach with air19,23]. Percutaneous access to the remnant stomach isacilitated if a gastrostomy tube is placed at RYGB [22].obi et al. [22] described routine placement of a gastros-

omy tube with a radiopaque silastic ring around it at thenitial surgery. The silastic marker facilitates radiologicocalization of the bypassed stomach. However, even ifercutaneous access is facilitated with this technique, itequires serial dilations for placement of larger tubes andventual placement of the endoscope. Such an approachay not be practical in cases in which access to the by-

assed structures is emergent, such as with gastrointestinalleeding or choledocholithiasis. Furthermore, the very low

ncidence of patients requiring transgastric endoscopy does

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24 F. A. Ceppa et al. / Surgery for Obesity and Related Diseases 3 (2007) 21–24

ot justify routine use of gastrostomy tubes with their as-ociated morbidity (postoperative pain and risks of leak andound infection).Access to the remnant stomach has also been established

sing an open operative procedure and creation of a gastrot-my at the remnant stomach [26]. However, the potential forernia and wound infection complications with an open pro-edure makes the open technique undesirable.

Laparoscopic transgastric endoscopy is a great tool forhe diagnosis and treatment of any pathologic featuresithin the bypassed structures, including choledocholithia-

is, peptic ulcer disease, gastrointestinal malignancies, andhronic abdominal pain. Although many of these conditionsre rare, we have still used this technique in approximately% of our patients. With the increased popularity of lapa-oscopic RYGB, the necessity for this diagnostic modalityay increase.We successfully diagnosed 7 of 10 patients who underwent

aparoscopic transgastric endoscopy. It was not possible toake a firm diagnosis using endoscopy in the 2 patients with

hronic abdominal pain. However, we were still able to ruleut other potential conditions. Of the 5 patients who underwentRCP, 4 underwent successful cannulation and sphincterot-my. Transgastric ERCP failed in 1 patient with a large im-acted stone in the ampulla of Vater, although conventionalransoral ERCP would also have been difficult.

We have had no complications with laparoscopic trans-astric endoscopy. The procedure has a relatively low risknd is well tolerated by patients. One disadvantage of theechnique is the difficulty in cannulating the ampulla ofater. The angle approaching the ampulla is different thanith the standard transoral technique, creating some diffi-

ulty in cannulating the ampulla of Vater; however, anykilled endoscopist should be able to navigate this course.

onclusion

Laparoscopic transgastric endoscopy enables bariatricurgeons to use a safe and effective minimally invasiveechnique for the diagnosis and treatment of diseases withinhe bypassed structures.

isclosures

The authors have no commercial associations that mighte a conflict of interest in relation to this article.

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