Management of Common Bile Duct Stones in Patient With Previous Gastric Bypass

Obesity is a well-known risk factor for gallstone formation. Moreover, surgery for obesity increases the risk for gallstone formation more than 3-fold the first 3 years after surgery. Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). This is mainly due to an increase in cholesterol stones that are often small, spherical, and hard, and thus tend to migrate to the common bile duct. The rapid increase in bariatric surgery over the last decade has resulted in an almost exponential increase in post-bariatric gallstone disease. Furthermore, in these patients, CBDS are difficult to extract by ERCP due to the altered upper gastrointestinal anatomy following GBP. 

Transgastric ERCP. An intraoperative gastrotomy in the excluded stomach is created in order to access the stomach and duodenum. The endoscope is entered through the gastrotomy and a routine ERCP with sphincterotomy is carried out. After the ERCP, the gastrotomy may either be closed intraoperatively or a gastrostomy may be left to provide access for later procedures.

Laparoscopic choledochotomy. An incision is made in the common bile duct distal to the confluence with the cystic duct. A choledochoscope is introduced into the incision and the stones extracted through the incision. After the stones have been extracted, the incision may either be closed primarily or a T tube may be placed in the incision, preparing for secondary cholangiography.

Another option is choledochoduodenostomy.