Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass

Background: Pancreatobiliary access following Roux-en-Y gastric bypass (RYGBP) is challenging. We reviewed 32 cases of surgical gastrostomy for complex transgastric upper gastrointestinal endoscopy. Methods: Retrospective review of prospectively collected database of patients with history of RYGBP that had surgical gastrostomy for pancreatobiliary and duodenal access at a single institution from 2004-2008. Indication for procedure, surgical findings, successful cannulation, and complications are reported. Results: Thirty patients (25 female), with age ranging from 27 to 72, underwent 32 procedures. The indications to access the gastric remnant were sphincter of Oddi dysfunction (13), pancreatitis (six), common bile duct stone/obstruction (five), cholangitis (three), pancreatic mass evaluation (two), gastrointestinal bleed (two), and cystic duct leak after cholecystectomy (one). Mean operative time was 200 min (98-338) and estimated blood loss (mean) 85 cc (10-500). Laparoscopic gastrostomy was attempted in 28 cases with one conversion to open (3. 6%). Four planned open procedures were also performed. All 30 patients underwent successful endoscopy and 28 had an endoscopic retrograde cholangiopancreatography, all with successful cannulation of the pancreatobiliary tree (100%). Conclusions: Surgical gastrostomy is an effective means to gain access to the upper GI tract and pancreatobiliary tree following RYGBP. This technique should be considered when traditional endoscopic approaches are impossible.