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首页> 外文期刊>Obesity surgery >Management of Acute Gallstone Cholangitis after Roux-en-Y Gastric Bypass with Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography
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Management of Acute Gallstone Cholangitis after Roux-en-Y Gastric Bypass with Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography

机译：腹腔镜血管内窥镜逆行胆管胆胆胆囊胆管胆囊急性胆石性胆囊炎的管理

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BackgroundThe incidence of biliary lithiasis is increased after bariatric surgery due to rapid weight loss [1]. Trans-oral endoscopic management in cases of common bile duct gallstone complication is not possible in patients with Roux-en-Y gastric bypass (RYGB) due to the modified anatomy. Access to the biliary tree after RYGB with a classical direct surgical approach of common bile duct and choledocoscopy can be used, but may be complicated in situations of acute cholangitis because of the fragility of common duct, or in cases of previous cholecystectomy. Multiple alternatives have been described, such as percutaneous transhepatic cholangiography or laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP) [2, 3]. The aim of this video was to present the management of common bile duct gallstone complication after RYGB and the technical features of LTG-ERCP [4].MethodsWe present the case of a 79-year-old woman (98kg, BMI 40.2kg/m(2)) with a 24-month history of RYGB, who presented with gallstone cholangitis and septic shock. Imaging revealed a 16-mm dilatation of the common bile duct upstream of a biliary gallstone. A previous history of laparotic cholecystectomy leads us to favor LTG-ERCP.ResultsWe present the step-by-step LTG-ERCP technique. The laparoscopic procedure started with an excluded stomach dissection and gastrostomy on the great curvature at 10cm from the pylorus with a 15-mm extra-long port. The placement of the gastrotomy should be carefully chosen with respect to the antrum, in order to provide straightforward access to the pylorus. The transgastric endoscopic procedure should include sphincterotomy (if not formerly performed) and gallstone removal. The patient experienced no specific complication of LTG-ERCP. Control of sepsis was favorable with adapted antibiotic treatment. Hepatic cytolysis and cholestasis normalized within postoperative day 3. Postoperative imaging showed a reduction of the common bile duct diameter to 12mm. The patient required hemodialysis because of acute kidney injury. She finally left the hospital on postoperative day 16.ConclusionsLTG-ERCP is a safe and feasible alternative for gallstone cholangitis management in patients with RYGB. This procedure should be recommended for cases of cholangitis rather than laparoscopic choledocoscopy or a percutaneous transhepatic approach, especially in cases of prior cholecystectomy, or in patients where the BMI remains high. LTG-ERCP should be performed in a referral center by a skilled endoscopist and surgeon following a standardized technique.
机译：背景技术胆道岩性的发病率由于快速损失而在畜牧手术后增加[1]。由于修饰的解剖学，Roux-Zh-Y胃旁路（RYGB）的患者不可能在常见的胆管胆结石并发症中进行跨口腔内窥镜管理。可以使用普通胆管和胆固度的经典直接手术方法后进入胆汁树，并且可以在急性胆管炎的情况下，由于常见导管的脆弱性，或之前的胆囊切除术的病例可能是复杂的。已经描述了多种替代方案，例如经皮转膜胆管造影或腹腔镜血管内窥镜逆行胆管胰蛋白酶（LTG-ERCP）[2,3]。该视频的目的是在RYGB之后展示常见的胆管胆结构并发症的管理和LTG-ERCP的技术特征[4] .Methodswe出现了一个79岁女性的案例（98kg，BMI 40.2kg / m （2））具有24个月的RygB历史，他呈现出胆石胆管炎和脓毒症休克。成像显示胆石上游的常见胆管的16mm扩张。以前的raparotic胆囊切除术病史导致我们有利于LTG-ERCP.Resultwe介绍了逐步的LTG-ERCP技术。腹腔镜手术在从幽门螺杆菌上10cm的胃剖面和胃术，胃肠剖视图和胃术在10厘米上，具有15毫米的长端口。应仔细选择胃术的放置，以便提供对幽门的直接进入。血管内窥镜过程应包括晶体切开术（如果没有以前进行）和胆结石去除。患者没有特定的LTG-ERCP并发症。对脓毒症的控制有利于适应抗生素治疗。术后第3天内肝脏细胞分解和胆汁淤积。术后成像显示普通胆管直径的降低至12mm。由于急性肾损伤，患者需要血液透析。她终于在术后第16天离开了医院.Conclusionsltg-ERCP是RygB患者胆石胆管炎管理的安全可行的替代品。应推荐该程序，用于胆管炎的病例，而不是腹腔镜胆性镜检查或经皮的经皮，特别是在胆囊切除术的情况下，或在BMI仍然高的患者中。 LTG-ERCP应通过熟练的内窥镜和外科医生在标准化技术之后在推荐中心进行。

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