Biliary and Pancreatic Duct Access after Bariatric Surgery

A variety of techniques are available to gain access to the biliary and pancreatic ducts after gastric bypass surgery. The best approach begins with a complete understanding of the patient's altered anatomy. Radiologic imaging of the ducts with magnetic resonance cholangiopancreatography or computed tomography is usually adequate for diagnostic information; however, if therapy is required, direct access to the ampulla is necessary. Trying to approach the duodenum using only endoscopic means may be successful in properly selected patients and is reasonable to pursue as a first line of attack, keeping in mind the risk of perforation when attempting to traverse long, angulated limbs of jejunum. If endoscopic access is not possible and the indication is not emergent, percutaneous placement of a gastrostomy tube with the help of an interventional radiologist is an excellent approach to gain access to the gastric remnant. This tube can be upsized to 24 Fr over time to accommodate a pediatric duodenoscope. For more emergent indications, laparoscopic access to the gastric remnant is an elegant minimally invasive approach. Whatever the method of access, it is important to understand the indications for the procedure and the patient's anatomy, and have good communication with your interventional radiologist and minimally invasive surgeon to assure success.