# Laparoscopic-Assisted Transgastric Endoscopic Retrograde Cholangiography (LTG-ERCP): An Option for Managing Choledocholithiasis in a Patient With Prior Bariatric Surgery at a Community Hospital

## TL;DR

A new surgical technique called LTG-ERCP successfully treated bile duct stones in a patient who had weight-loss surgery.

## Contribution

This case demonstrates the successful use of LTG-ERCP for choledocholithiasis in a post-bariatric surgery patient at a community hospital.

## Key findings

- LTG-ERCP successfully removed bile duct stones in a patient with prior gastric bypass surgery.
- The procedure was performed in a community hospital setting without complications.
- Combining LTG-ERCP with cholecystectomy resolved the patient's symptoms effectively.

## Abstract

Endoscopic retrograde cholangiography (ERCP) has become a mainstay in managing choledocholithiasis. Conventional endoscopic access to the ampulla of Vater becomes impossible after Roux-en-Y gastric bypass (RYGB) due to modified anatomy. In specialized centers with advanced gastrointestinal capabilities, techniques like double-balloon endoscopy can be utilized for biliary decompression. However, facilitating patient transfer to these centers can be difficult due to a common postoperative issue in a large population. Laparoscopic transgastric (LTG)-ERCP has been gaining popularity because of its high success rates and ability to carry it out in community healthcare settings. Here we present a case of choledocholithiasis in an RYGB patient successfully managed with LTG-ERCP at a community hospital. Our patient was a 51-year-old female with a history of sleeve gastrectomy with conversion to gastric bypass who presented to the emergency department for evaluation of severe epigastric pain and nausea. Laboratory testing was consistent with elevated bilirubin and alkaline phosphatase levels (1.5 mg/dl and 140 U/L, respectively). Abdominal ultrasound showed biliary sludge in the common bile duct (CBD). Subsequent magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the CBD measuring up to 1 cm with multiple stones in the biliary system. After a multidisciplinary discussion between the GI and surgery teams, an LTG-ERCP along with cholecystectomy was performed, and CBD stones were successfully removed, resulting in the resolution of the patient’s symptoms, and the patient was discharged home without any complications. LTG-ERCP is considered a safe and effective approach for managing biliary obstruction after RYGB. This procedure has the advantage of endoscopic biliary decompression and cholecystectomy being performed in a single setting.