Laparoscopic Biliary Revision for Choledocholithiasis After Roux-en-Y-Gastric Bypass: A Case Report and Discussion of Management Strategies

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic ductal diseases in post-bariatric surgery patients, particularly after Roux-en-Y gastric bypass (RYGB). Standard ERCP is technically challenging in these patients due to altered anatomy and long limb length, which limit access to the biliary tree. In a meta-analysis by Ayoub et al, device-assisted ERCP achieved papilla identification in approximately 80% of cases, with cannulation success in 73% and therapeutic success in 73% [1]. These limitations have led to growing use of intraoperative or hybrid solutions such as laparoscopic-assisted ERCP, which achieves 95% technical and 94% clinical success but carries an overall complication rate of about 20% [1,2]. These figures highlight the procedural difficulty and relatively modest efficacy of device-assisted ERCP compared with laparoscopy-assisted approaches.

With rising numbers of bariatric surgeries, these limitations have driven growing interest in intraoperative solutions. This case report illustrates how complex laparoscopically assisted biliary revision can effectively address these challenges.

Case Report

A 31-year-old man with cholecystitis and early cholangitis was admitted to our institution for further management. He had undergone bariatric surgery due to obesity, with a body mass index (BMI) of 50.5 at the time. The surgery and perioperative course were uneventful. Six months after RYGB surgery, he presented to our emergency department with sharp, radiating pain in the right lower abdomen extending to the right flank. Suspecting urolithiasis, an abdominal CT scan was performed, revealing a previously known cholelithiasis and a dilated ureter after a stone’s passage. He was discharged with analgesic therapy on the presumption of a spontaneously passed kidney stone and remained symptom-free for several months. Approximately 12 months after the RYGB surgery, he visited another tertiary hospital with epigastric pain and diarrhea that had started the previous day. At this point in time, he had already lost a substantial amount of weight, resulting in a BMI of 27.9. Laboratory tests revealed a leukocyte count of 17.32/μl, elevated liver enzymes (AST 555 U/L, ALT 388 U/L, GGT 345 U/L, AP 290 U/L), and cholestasis markers, including a direct bilirubin level of 51.4 μmol/L. CRP levels were initially within the normal range. Given his known history of cholelithiasis, an abdominal ultrasound was performed, which revealed multiple gallstones, sludge, and mild edema of the gallbladder wall. Suspecting cholecystitis with early cholangitis due to choledocholithiasis and biliary obstruction, empirical intravenous antibiotic therapy with ceftriaxone was initiated, and he was transferred to our institution for further management. Although cholestasis and abnormal liver function test results would generally support preoperative MRCP, we chose not to perform MRCP because he presented with acute cholecystitis and early cholangitis requiring timely surgical source control. MRCP would not have altered the need for laparoscopic cholecystectomy or biliary assessment in a patient with Roux-en-Y gastric bypass anatomy; therefore, intraoperative cholangiography was planned to provide immediate diagnostic information with therapeutic potential. Therefore, the patient underwent laparoscopic cholecystectomy with biliary revision and intraoperative cholangiopancreatography. Intraoperatively, the cystic duct was found to be of favorable caliber, permitting catheterization without resistance. The stones identified on cholangiography were small (<5 mm) and mobile, suggesting that trans-cystic extraction would be feasible. Given these findings, stone removal was achieved using a balloon catheter via the cystic duct, avoiding the need for conversion to laparoscopic-assisted ERCP. This decision was based on real-time assessment of duct diameter, stone burden, and accessibility, underscoring the importance of individualized intraoperative evaluation in RYGB anatomy. The stones were successfully extracted via the cystic duct with a single balloon catheter, eliminating the need for a complex ERCP, which would have required laparoscopic-assisted navigation of the endoscope thru the remnant stomach or the biliopancreatic limb (Figures 1, 2). In case of an unsuccessful trans-cystic extraction and after repeated balloon sweeps, or if impacted, proximally located stones were identified on cholangiography and an escalation to laparoscopic-assisted ERCP was planned with the gastroenterology team on site. As an alternative, laparoscopic choledochotomy or a biliary drainage could have been performed if endoscopic access proved unfeasible. The postoperative course was uneventful, and the patient was discharged after 3 days in stable condition with a good general status with normal bilirubin levels at 17 μmol/L and improving liver enzymes (AST 36 U/L, ALT 125 U/L).

Discussion

EPIDEMIOLOGY:

This case illustrates the technical feasibility of trans-cystic bile duct exploration in a highly selected post-RYGB patient with favorable anatomy and should not be interpreted as evidence of superiority or general applicability. Management of choledocholithiasis after bariatric surgery, particularly RYGB, presents a complex challenge requiring careful consideration. The increasing prevalence of bariatric surgery has amplified the incidence of related complications due to altered gastrointestinal anatomy. Traditional risk factors for cholelithiasis, such as advanced age, female sex, genetic predisposition, pregnancy, diabetes, dyslipidemia, and obesity are magnified in this population. Patients undergoing bariatric procedures often present multiple predisposing factors, thereby exponentially increasing their susceptibility to gallstone formation [3]. Epidemiological data underscores this condition’s clinical relevance. Studies show 28.9% of post-bariatric surgery patients develop gallstones, with 15.7% experiencing symptoms within 3 years. The incidence of cholecystitis and gallstone-related complications is 5.5 times higher than in the general population, emphasizing the need for thorough post-RYGB management [4].

PREVENTIVE MEASURES:

An important consideration in this clinical context is the approach to prophylactic cholecystectomy, which includes patients without cholelithiasis or with asymptomatic gallstones undergoing bariatric surgery. While concurrent laparoscopic cholecystectomy during laparoscopic RYGB may seem logical to prevent gallstone formation and related complications, it poses notable challenges. Prophylactic cholecystectomy can increase operative time, morbidity, and hospitalization. Longitudinal studies show a low subsequent cholecystectomy rate of 6.8% after RYGB, mostly for uncomplicated biliary disease, making it generally unnecessary for patients without symptoms [5]. However, in low-risk patients, shared decision-making between the surgeon and patient is recommended to weigh the risks and benefits of a concurrent cholecystectomy. For patients without concurrent cholecystectomy, asymptomatic gallstones should not be treated postoperatively; interventions are indicated only for symptomatic gallbladder disease [4]. In our case, no concurrent cholecystectomy was performed during the RYGB surgery. During the emergency admission 6 months after RYGB surgery, the patient presented with pain in the right hemi-abdomen, raising the question of whether there was already underlying symptomatic gallbladder disease, since no urolith was found in the CT scan. Despite the known cholecystolithiasis, it is important to note that CT imaging has limited sensitivity for detecting small gallstones or biliary sludge. Therefore, while a biliary cause cannot be fully excluded, the presence of sudden-onset, sharp pain, radiating to the flank, and hematuria, as well as imaging findings consistent with a recent ureteral stone passage, make urolithiasis the more likely diagnosis. This case highlights the diagnostic challenge of distinguishing between biliary and renal causes of flank or right upper-abdominal pain in post-bariatric patients. Furthermore, the patient remained symptom-free for several months after surgery. The literature shows that ursodeoxycholic acid (UDCA) can prevent cholelithiasis and reduce cholecystectomy rates after bariatric surgery. Postoperative UDCA administration during rapid weight loss is usually recommended for eligible patients to prevent biliary complications [6]. Despite the known cholelithiasis and underlying traditional risk factors, such as diabetes, dyslipidemia, and obesity, no postoperative administration of UDCA took place in our case.

DIAGNOSTIC APPROACHES:

A research-based directive by Manes et al underscores the value of MRCP as a non-invasive diagnostic tool, suggesting that its broader application in post-RYGB patients could improve diagnostic accuracy and guide intervention strategies [7]. The European Society of Gastrointestinal Endoscopy (ESGE) guideline recommends use of MRCP to diagnose common bile duct (CBD) stones in patients with abnormal liver function tests (LFTs) and/or CBD dilation on ultrasonography when no morphological diagnosis of CBD stones or cholangitis is present. There is no specific recommendation for MRCP in suspected CBD stones in post-RYGB patients (for planning of an intervention).

The leading diagnosis in our case was an acute cholecystitis with early cholangitis due to choledocholithiasis. During laparoscopic cholecystectomy, intraoperative cholangiography was planned to assess the need for bile duct revision. This could be achieved either via the cystic duct or, if necessary, through the biliopancreatic limb or remnant stomach. Given favorable anatomy (wide cystic duct, small stones), primary revision via the cystic duct was performed successfully, rendering LA-ERCP unnecessary. Although the ESGE criteria would have supported preoperative MRCP, intraoperative cholangiography was preferred due to its higher sensitivity and immediate therapeutic potential within the same session.

THERAPEUTIC STRATEGIES:

Conventional endoscopic retrograde cholangiopancreatography (ERCP) is often impractical, requiring innovative and resource-intensive approaches such as transoral ERCP with double-balloon enteroscopy (DBE), laparoscopically assisted transgastric ERCP (LA-ERCP), surgical bile duct exploration (laparoscopic or open), or endoscopic ultrasound-directed transgastric ERCP (EDGE). Reported technical success, clinical success, and complication rates are summarized in Table 1. Choi et al compared ERCP via transmural gastrostomy with DBE for managing choledocholithiasis in RYGB patients [8]. They found a higher success rate in accessing the papilla with ERCP via gastrostomy (97% vs 78%) but noted a higher complication rate (14.5% vs 3.1%), reflecting the procedural risks associated with both endoscopic and surgical aspects. These findings highlight the need to balance procedural success with potential morbidity when choosing a management approach.

For cases where conventional or DBE-assisted ERCP is not feasible, surgical options like laparoscopic or open bile duct exploration are vital. Alzahrani et al [9] reported that surgical approaches, including LA-ERCP, allow simultaneous bile duct revision and cholecystectomy when indicated, offering distinct advantages in institutions with the requisite surgical and endoscopic expertise. These findings reinforce that laparoscopic-assisted cholangiopancreatography has high efficacy in post-bariatric patients, achieving technical success rates between 92.9% and 97.9% [9].

May et al investigated LA-ERCP outcomes in post-RYGB patients, particularly those with sphincter of Oddi dysfunction [10]. Their study demonstrated that LA-ERCP effectively addresses anatomical barriers, achieving high success rates when performed by skilled multidisciplinary teams. However, the procedure’s complexity demands substantial institutional resources, emphasizing the need for customized treatment based on available expertise and patient-specific factors. Hence, LA-ERCP has a substantial learning curve and technical demands. These approaches carry a notable adverse event rate of 19%, including risks such as port-site infections, gastric leaks, and even severe complications like bowel perforation [9]. Alternative methods such as endoscopic ultrasound-directed transgastric ERCP (EDGE) have shown slightly higher technical success (95.5%) and a lower complication rate (6.5%), making them increasingly viable options, particularly in centers equipped for advanced endoscopic interventions [11]. Recent meta-analyses further support these observations. Gkolfakis et al reported pooled technical success rates of 97.9% for EDGE, 99.1% for LA-ERCP, and 87.3% for enteroscopy-assisted ERCP, with higher adverse event rates for LA-ERCP (15.1%) and EDGE (13.1%) compared with enteroscopy (5.7%) [2]. Similarly, Antonini et al confirmed that EDGE has success comparable to LA-ERCP while offering significantly shorter procedural times and no increase in complications [12]. A recent narrative review by Khara et al summarized the evolution of ERCP techniques in RYGB anatomy and emphasized that the choice between LA-ERCP and EDGE should depend on institutional expertise and resource availability [13]. Additionally, the European Society of Gastrointestinal Endoscopy (ESGE) recognizes EDGE as a promising minimally invasive alternative for managing biliary diseases in patients with Roux-en-Y gastric bypass anatomy [14]. Their recommendation is graded as weak, based on low-quality evidence, reflecting the limited but growing clinical experience with this technique [14].

INSTITUTIONAL CONSIDERATIONS:

In summary, managing choledocholithiasis in post-bariatric patients requires an individualized approach, factoring in anatomical, institutional, and clinical considerations. Innovative techniques and advanced imaging modalities provide promising solutions. However, decision-making must be guided by the availability of specialized resources and interdisciplinary expertise. The choice between LA-ERCP and alternatives like EDGE or balloon enteroscopy-assisted ERCP should consider both success rates and complication profiles (Table 1). Although EDGE seems to reduce the risk of major surgical complications, it introduces its own risks such as stent migration (13.3%) and requires multiple sessions in some cases. Therefore, laparoscopic-assisted procedures remain preferable when simultaneous surgical intervention, such as cholecystectomy or stone removal, is warranted. As demonstrated in our case, intraoperative cholangiography followed by cystic duct stone extraction obviated the need for a full LA-ERCP, such as gastrotomy of the remnant stomach, but preparedness for escalation remains a cornerstone of safe management.

LIMITATIONS:

This report describes a single case and therefore cannot be generalized. The management review presented was not conducted as a systematic review, and the technical feasibility of the described approach remains highly dependent on institutional experience and operator expertise.

Conclusions

The value of this case lies not in proposing a new technique, but in demonstrating careful patient selection and intraoperative adaptability when applying established biliary surgical principles in altered anatomy in post-RYGB patients with favorable anatomy, such as a wide cystic duct and small, mobile stones. The success of this strategy highlights the importance of intraoperative flexibility, allowing real-time adaptation based on anatomical findings and imaging results. Management of choledocholithiasis after RYGB should be tailored to institutional expertise, available resources, and patient-specific anatomy. Intraoperative judgment with a predefined escalation strategy if stone clearance proved unsuccessful is essential. Against this background, alternative approaches must be carefully weighed with respect to their efficacy and risk profiles. While laparoscopically assisted ERCP via gastrostomy achieves high success in biliary access, its significantly higher complication rate makes it less suitable, especially for high-risk patients. DBE, although technically demanding and time-intensive, can offer a safe alternative with low morbidity. Emerging alternatives like EDGE may offer comparable efficacy with fewer complications, warranting consideration in multidisciplinary planning. However, for us, laparoscopically assisted biliary revision over the cystic duct is as a feasible option for managing choledocholithiasis in post-RYGB patients. It provides reliable biliary access and allows simultaneous surgical interventions, such as cholecystectomy or a switch to LA-ERCP as an immediate second-line approach if the first attempt fails. A stepwise approach is suggested. Biliary revision thru bile duct exploration can be viewed as a practical modality in centers equipped with the necessary expertise and resources. While this case supports the potential value of trans-cystic revision as an alternative to more complex approaches, the findings should be interpreted within the context of a single-case experience. Considering our case and the available evidence a case of acute cholecystitis biliary revision through intraoperative bile duct exploration could be viewed as a first-line approach, but requires validation through larger studies and comparative data. A critical component is the role of institutional expertise. Institutional capabilities and real-time surgical findings should guide the optimal approach. Therefore, intraoperative bile duct exploration by cholangiography should be routinely practiced and taught in specialized centers when indicated. Refining these techniques and establishing standardized protocols will further improve outcomes and reduce complications.