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472
G. Jester et al.
50.7 Conclusion
Acute portal vein thrombosis is a rare event but can lead to severe complications if
left untreated. The clinician must have a personalized discussion with each patient
regarding the efcacy and risks associated with each anticoagulant treatment. VTE
treatment in obese patients undergoing bariatric surgery is challenging given the
paucity of data and the associated alterations in pharmacokinetics and pharmacodynamics. Direct oral anticoagulants cannot be routinely recommended for the treatment of portal vein thrombosis following bariatric surgery with current available
data [35]. Direct oral anticoagulants are preferred as prophylactic oral anticoagulants in most obese patients with BMI≤40kg/m2 because of their convenient xed
dosing. In the future, additional clinical trials focusing on patients at the extremes
of weight would be helpful to further delineate the best use of oral anticoagulants.
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G. Jester et al.
Chapter 51
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Gallstones andCholedocholithiasis
MarceloFalcão andCláudioVasconcelos
Highlights
• Choledocholithiasis can be present in 10% of people with cholelithiasis and can
be a technically challenging problem to treat the population after bariatric
surgery.
• Is more likely to nd patients with choledocholithiasis who had previously
undergone bariatric surgery.
• A reduction in body mass by at least 25% as a predictor for the formation of
gallstones after different bariatric procedures.
• ERCP is also graded in patients with biliodigestive derivations as having maxi-
mum class 3 difculty.
• The hybrid approach of laparoscopy-endoscopy for access to the bile duct,
whether transgastric or transenteric, is feasible and safe.
51.1 Introduction
51.1.1 Cholelithiasis
Metabolic imbalances related to obesity generate factors for the formation of gallstones, with mainly an increase in the synthesis and secretion of cholesterol.
Through its different methods, bariatric surgery leads to a signicant and rapid
M. Falcão
IFEC—Falcão Institute of Endoscopy and Surgery, Salvador, Bahia, Brazil
EBMSP—Bahiana School of the Medicine and Health Public, Salvador, Bahia, Brazil
C. Vasconcelos (*)
UFBA—Federal University of Bahia, Salvador, Bahia, Brazil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_51
475
476
Fig. 51.1 Changes in the composition of bile and increased concentration of mucin (18 times)
with an increase in calcium ions (40%). (Source: Own authorship)
M. Falcão and C. Vasconcelos
decrease in weight. Changes in the composition of bile, which is responsible for the
reduction of body mass, lead to a pronounced increase in the concentration of mucin
(18 times) with an increase in calcium ions (40%) (Fig.51.1) [1].
These changes lead to a high propensity to develop gallstones. A prospective
study conducted by Schiffman and published in 1991in Am. J. of Gastroenterology
[2] showed that in patients undergoing gastric bypass, signicant changes in the
composition of bile are generated, leading to the appearance of gallstones in 36% of
cases in approximately 6months and evolving as biliary mud in about 13% of cases.
In patients who have developed gallstones, almost half (41%) are symptomatic [1–3].
This high frequency led to the search for identifying risk factors for the occurrence of gallstones after bariatric interventions. It has been discovered that traditional risk factors for the appearance of gallstones are not predictive for the formation
of gallstones after bariatric surgery. In 2009, Li et al. published in Surgical
Endoscopy the results of a study that identies a reduction in body mass by at least
25%, as a predictor for the formation of gallstones after different bariatric procedures [4].
Bariatric surgery has become the most common elective surgery in the United
States [5]; in Brazil evaluating 8 years, the number of bariatric surgeries grew
84.73% between 2011 and 2018, according to a survey released by the Brazilian
Society of Surgery Bariatric and Metabolic (SBCBM) [6]. In 2018 alone, 63,969
bariatric surgeries were performed, and in the 8 years studied, approximately
424,000 obesity surgeries were performed in the country [6]. With the formation of
51 Gallstones andCholedocholithiasis
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477
gallstones at this frequency, we cannot help thinking about their complications,
given that the evolution of cholelithiasis and its complications are not different in
obese patients compared to the general population.
51.1.2 Choledocolithiasis
Choledocholithiasis can be present in 10% of people with cholelithiasis and can be
a technically challenging problem to treat the population after bariatric surgery,
due to the altered upper gastrointestinal anatomy. Considering the rapid increase
in the number of procedures, he is more likely to nd patients with choledocholithiasis, who had previously undergone bariatric surgery, in our health institutions [6].
The experience available to treat these patients is still limited to large centers
with adequate expertise and technology. Several approaches have been studied and
tried in an attempt to solve this problem; however, the appropriate technique and
technology will depend on the type of bariatric surgery performed and its anatomical alteration in the upper digestive tract [6]. It is accepted that the laparoscopic
gastric band (LAGB) and the laparoscopic vertical gastrectomy (Sleeve) are surgeries where access to the oral biliary tree is maintained and the endoscopist can use a
conventional duodenoscope. The perspective of approaching patients who have
already undergone Roux-en-Y gastric bypass (RYGB) or a biliopancreatic such as
duodenal switch (DS) [6] is different.
In the scale of difculty gradation in endoscopic retrograde cholangiopancreatography (ERCP) adopted by ASGE (America Gastrointestinal Endoscopy), which
divides the procedures into three degrees, the cholangiogram or pancreatogram in
patients with Billroth II is considered grade 2 and any therapeutic intervention in
these patients, classied as grade 3 [7]. In the HOUSE classication, ERCP is also
graded in patients with biliodigestive derivations as having maximum class 3 difculty [8].
Solutions for endoscopic treatment of choledochal lithiasis in patients with bariatric surgery (nonabsorbable, restrictive, and mixed) are shown in Table51.1 [9].
Table 51.1 Endoscopic
treatment of choledochal
lithiasis in patients with
bariatric surgery
• Percutaneous transhepatic anterograde
endoscopic access
• Assisted laparoscopic transenteric/gastric
endoscopic access
• Laparoscopic exploration of the conventional
common bile duct
• Endoscopic access by balloon enteroscopy
(double or single)
478
M. Falcão and C. Vasconcelos
51.2 ERCP inPatients withSurgically Altered Anatomy
The postoperative anatomy in Roux-en-Y reconstruction is characterized by short
(<50cm) or long (>100cm) loops, depending on the type of surgery (Fig.51.2). In
patients with Roux-en-Y derivation, several attempts using duodenoscopes, pediatric colonoscopes, and oblique vision endoscopes have been reported with a low
success rate of 33–67% [10]. Balloon enteroscopy is more effective in this regard,
so several authors [11–16] reported therapeutic success in ERCP with 88% assisted
balloon enteroscopy in patients with small bowel loop segments smaller than
150cm, compared with only 33% for length between 150 and 225cm and 0% for
lengths greater than 225cm.
It must be taken into account that ERCP assisted by enteroscopy requires specialized accessory catheters due to the length (200cm) and diameter (2.2–2.8mm)
of the working channel of the commonly used enteroscopy [11]. The arrival on the
market of a single-balloon and double-balloon enteroscopy with a 3.2mm channel
facilitates the passage of accessories over 2mm in diameter, including metallic
prostheses, especially in situations in which the endoscope is very angled [17–19].
Due to the technical difculty of performing broad papillotomy with frontal vision
devices, dilation of the papillae with a balloon, after a small papillotomy, is frequently used in these patients. The removal of gallstones is performed with usual
accessories (Fig.51.3).
The risk of complications in ERCP with assisted balloon enteroscopy ranges
from 0 to 19.5% of the procedures [20]. In a review of 32 articles, major complications occurred in 32 of 945 (3.4%) procedures, with perforation being the most
frequent (13) and sometimes fatal, followed by pancreatitis (11), bleeding (3), and
cholangitis (1). There was also a death attributed to cerebral gas embolism [21].
Fig. 51.2 Entero-enteroanastomosis in a patient
with Roux-en-Y bypass.
(Source: Own authorship)
51 Gallstones andCholedocholithiasis
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Fig. 51.3 Dilatation of the
papilla with a TTS balloon
in a gastrectomy patient at
BII. (Source: Images
provided by Dr. Victor
Galvão)
479
51.3 Transgastric andTransenteric ERCP Assisted
by Laparoscopy
The introduction of the duodenoscope directly into the stomach or small intestine
loop allows the papilla to be reached. The duodenoscope, in addition to being widely
available, makes it possible to perform ERCP using conventional techniques and
accessories. Access to the bile duct in duodenal switch (DS)-type biliopancreatic
surgery, for LA-ERCP, has the preference of transenteric access, with the introduction of the trocar in the slender biliopancreatic loop, and can use the traditional
duodenoscope as well as its accessories; however, the view of work from the papilla
to the endoscopist is inverted, making him perform every approach with extreme
technical difculty, requiring from the endoscopist a greater experience in advanced
endoscopy, as described by Marchesini JCD et al. in 2017 (Fig. 51.4) [9]. Also,
Mutignemi etal. [22] reported this technique successfully in a patient with a normal
bile duct diaphragm (3 mm) and is considered high risk and very challenging
procedure.
480
Fig. 51.4 Duodenoscope
directly into the stomach or
small intestine loop.
(Source: Marchesini JCD
etal. in 2017)
M. Falcão and C. Vasconcelos
Fig. 51.5 Transgastric ERCP. (Source: Own authorship)
In RYGB, non-surgical access to the excluded stomach to perform ERCP can be
done through gastrostomy guided by ultrasound or computed tomography. However,
this method has important disadvantages such as the need to mature and dilate the
path in a few weeks, limiting its use to elective situations, temporary permanence of
the gastrostomy tube after the procedure, risk of serious complications including
peritonitis, gastric perforation, tube migration through gastric wall, stula, hemorrhage, fragmentation of the tube, and leak [23–25].
In this sense, ERCP through transgastric access by laparoscopy in patients with
RYGB was rst described in 2002 [26]. Since then, it has been used with high success in this situation [27–31] (Fig.51.5). In a multicenter study that included 388
patients, success in reaching the papilla was achieved in 98% and cannulation of the
desired duct in 98%, and the desired intervention was performed in 97% [32].
Two studies directly compared ERCP with balloon-assisted enteroscopy to
laparoscopy- assisted ERCP (LA-ERCP). LA-ERCP was superior to ERCP-EBA to
papilla identication, cannulation rate, and therapeutic success [33, 34], but there
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481
were more complications in the LA-ERCP group in one of the studies: complications occurred in 11 procedures of LA-ERCP (14.5%), in 10 ways related to gastrostomy [34]. Grimes etal. observed a complication rate of 14% (6/42) in the group
of patients undergoing transgastric ERCP assisted by laparoscopy. Conversion to
open surgery occurred in one case due to the inability to maneuver the duodenoscope through the pylorus [25].
During laparoscopy, the excluded stomach is identied, and a gastrostomy can
be performed using a “hook” (Fig.51.6). The ideal area for gastrotomy is chosen by
assessing the mobility of the stomach and the possibility of pulling it toward the
abdominal wall. According to Facchiano, gastrotomy should generally be performed
in the antrum, 6–8cm from the pylorus.
After that, two points are passed through the abdominal wall and then on the two
opposite sides of the gastrotomy to anchor the stomach. These two points will subsequently be used to lift the stomach and pull it toward the abdominal wall. A 15mm
trocar is inserted through the abdominal wall and introduced into the stomach
through the gastrotomy, and the stomach can be xed to the abdominal wall by pulling the threads on the outside of the abdomen (Fig.51.7).
Fig. 51.6 Laparoscopic
gastrostomy. (Source: Own
authorship)
Fig. 51.7 Locator was
inserted in the excluded
stomach. (Source: Image
courtesy of Dr. Victor
Galvão)
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