Gastrointestinal Complications of Obesity Surgery

John E. Pandolfino, MD; Brintha Krishnamoorthy, BS; Thomas J. Lee, MD

Disclosures
In This Article

Case II: Cholelithiasis and Choledocholithiasis

Case Presentation

The patient is a 58-year-old woman with a BMI of 70 kg/m2 who underwent a laparoscopic RYGBP without cholecystectomy at another institution 10 weeks before admission to a clinic. She had suddenly developed postprandial nausea and vomiting and appeared jaundiced. She had several gallbladder stones as well as a dilated common bile duct with a 1-cm stone in the distal common bile duct. The patient was transferred to our institution; her pain has since resolved.

On physical exam, she was in no acute distress. Her vital signs were as follows: temperature, 98.8°F; heart rate, 60 beats per minute; and blood pressure, 146/78. She was visibly jaundiced. Her abdomen had well-healed scars from her laparoscopic gastric bypass surgery. She had normal bowel sounds; her abdomen was soft; and she had moderate, right upper-quadrant tenderness to deep palpation. The patient had a gastrostomy tube, which had been placed in her gastric remnant during her gastric bypass operation. Results of laboratory studies revealed a white-blood-cell count of 5.9 x 103 cells/mm3; her electrolytes were normal. Her liver-function tests were elevated: alanine aminotransferase, 329 U/L; aspartate aminotransferase, 212 U/L; total bilirubin, 6.1 mg/dL; direct bilirubin, 4.5 mg/dL; and alkaline phosphatase, 280 U/L.

Management and Discussion

The patient was afebrile, and her symptoms had resolved over the previous day while given nothing by mouth; therefore, there was no immediate urgency to remove the stone or perform a cholecystectomy. Given her presenting symptoms, liver-function-test abnormalities, and results of ultrasound showing cholelithiasis and choledocholithiasis, no further diagnostic studies needed to be performed. Although cholecystitis is likely the most common complication of cholelithiasis in this patient population, choledocholithiasis presents a particularly unique problem in the gastric bypass patient. Removal or assessment of common bile duct stones with ERCP is virtually impossible by the normal endoscopic approach, given that the Roux limb is often 50-100 cm in length. However, ERCP can be performed in the operating room via a temporary gastrostomy to carry out the stone extraction, or in the case of this patient, even via her gastrostomy tube site after serial dilation. The latter was believed to be a poor option given the patient's superobesity, with difficulty in traversing her pannus with the duodenoscope, as well as in maintaining her stomach apposed to the peritoneum throughout the ERCP. Other options included percutaneous transhepatic cholangiography or an intraoperative cholangiogram for removal of the common bile duct stones.

Percutaneous transhepatic cholangiography was performed the next day and revealed a 1-cm common bile duct stone. After the papilla was dilated with a balloon, the stone was crushed, and the fragments were advanced through the papilla. The following day, the patient had a successful laparoscopic cholecystectomy without complications and was discharged on postoperative day 1 to a rehabilitation facility.

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