Gianluca Bonanomi

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery

INTRODUCTION Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.

Dercum's disease as a cause of weight loss failure after gastric bypass surgery

Roux-en-Y gastric bypass (RYGB) is an established surgical treatment of morbid obesity that has produced encouraging results in the vast majority of patients [1]. However, suboptimal weight loss after bariatric surgery remains a challenge and warrants careful management [2]. We report a case of failure to lose weight after laparoscopic RYGB in an obese patient with features of Dercum’s disease, an often overlooked medical condition causing obesity refractory to diet and exercise intervention.

Management of Bariatric Emergencies by the General Surgeon

The epidemic of obesity affects almost all countries of the developed world and has led to a dramatic increase in the number of bariatric procedures worldwide. In the United Kingdom (UK), the adoption of weight loss surgery has been via dedicated regional bariatric centres, and there is a drive for shorter stays in hospital after surgery. Both these factors make it inevitable that almost every doctor sooner or later will encounter a patient who has undergone bariatric surgery, even if they do not work in a bariatric centre. Although safe, bariatric surgery has potential complications, which if recognised early and treated promptly can minimise the negative impact on outcomes.