Laparoscopy-assisted ERCP after biliopancreatic diversion.

Therapeutic biliary endoscopy after biliopancreatic diversion (BPD) for morbid obesity is not possible through the anatomical route. In the case of a long excluded afferent limb, the possibility to reach endoscopically the papilla through a surgical gastrostomy or jejunostomy has been reported. A case of laparoscopy-assisted ERCP performed 4 years after laparoscopic BPD with distal gastrectomy, is reported. Access to the papilla was obtained laparoscopically by enterotomy, insertion of a trocar into a jejunal loop 40 cm distal to the ligament of Treitz and passage of the duodenoscope through the trocar to the papilla. A guidewire was laparoscopically advanced into the cystic duct, and bile duct cannulation was achieved using the rendez-vous technique; endoscopic sphincterotomy and extraction of stones were successful. Laparoscopic cholecystectomy was performed and the enterotomy was sutured. The clinical course was uneventful.