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<p>Ampullary stenosis can be a late complication of Roux-en-Y gastric bypass (RYGB) causing biliary dyskinesia from ampullary sphincter hypertension (Heetun et al. in Eur J Gastroenterol Hepatol 23:327–333, 2011). Endoscopic management has limited efficacy with Roux anatomy. Thus, pancreatoduodenectomy (PD) may be performed (Wisneski et al. in HPB 22:1496–1503, 2020). In select cases, the morbidity of PD could be avoided using a transduodenal sphincteroplasty.</p><p>In this report, the case of a patient with ampullary stenosis after RYGB is described. After multiple endoscopic attempts failed to produce durable symptom relief, operative intervention was considered. Choledocho-duodenostomy was deemed technically feasible, but because this patient had preoperative imaging showing that the patient’s pancreatic duct communicated independently from the common bile duct (CBD) with the duodenum, robot-assisted transduodenal sphincteroplasty was the selected approach. With this procedure, an extended Kocher maneuver is required for adequate exposure. The lateral duodenal wall is anchored to the falciform ligament using a 2-0 absorbable stitch for retraction. A longitudinal duodenotomy is created along the duodenal wall opposite the major papilla. An 8-Fr catheter inserted through the ampulla into the CBD serves as a probe. Sphincterotomy is performed with electrocautery at the 11 o’clock position, dividing the ampullary sphincter until the CBD wall separates from the duodenal mucosa. A duct-to-mucosa anastomosis is performed using a 5-0 absorbable suture over the 8-Fr catheter, which is left in place: two stitches retracted from the superior CBD facilitate exposure. The duodenotomy is closed transversely with a 3-0 locking absorbable suture in two layers, and a leak test is performed.</p><p>The patient began oral intake the day after surgery. An upper GI showed no leak on postoperative day 2, and thus the patient was discharged home receiving a liquid diet on postoperative day 3.</p>

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Robot-Assisted Transduodenal Sphincteroplasty for Ampullary Stenosis After Roux-en-Y-Gastric Bypass

  • 期刊论文

  • 发表日期：

    2025年5月20日

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  • Raja R. Narayan,
  • Mark A. Eckardt,
  • Bonnie O. Wang,
  • Zhi Ven Fong,
  • Christopher C. Thompson,
  • Jiping Wang

摘要

Ampullary stenosis can be a late complication of Roux-en-Y gastric bypass (RYGB) causing biliary dyskinesia from ampullary sphincter hypertension (Heetun et al. in Eur J Gastroenterol Hepatol 23:327–333, 2011). Endoscopic management has limited efficacy with Roux anatomy. Thus, pancreatoduodenectomy (PD) may be performed (Wisneski et al. in HPB 22:1496–1503, 2020). In select cases, the morbidity of PD could be avoided using a transduodenal sphincteroplasty.

In this report, the case of a patient with ampullary stenosis after RYGB is described. After multiple endoscopic attempts failed to produce durable symptom relief, operative intervention was considered. Choledocho-duodenostomy was deemed technically feasible, but because this patient had preoperative imaging showing that the patient’s pancreatic duct communicated independently from the common bile duct (CBD) with the duodenum, robot-assisted transduodenal sphincteroplasty was the selected approach. With this procedure, an extended Kocher maneuver is required for adequate exposure. The lateral duodenal wall is anchored to the falciform ligament using a 2-0 absorbable stitch for retraction. A longitudinal duodenotomy is created along the duodenal wall opposite the major papilla. An 8-Fr catheter inserted through the ampulla into the CBD serves as a probe. Sphincterotomy is performed with electrocautery at the 11 o’clock position, dividing the ampullary sphincter until the CBD wall separates from the duodenal mucosa. A duct-to-mucosa anastomosis is performed using a 5-0 absorbable suture over the 8-Fr catheter, which is left in place: two stitches retracted from the superior CBD facilitate exposure. The duodenotomy is closed transversely with a 3-0 locking absorbable suture in two layers, and a leak test is performed.

The patient began oral intake the day after surgery. An upper GI showed no leak on postoperative day 2, and thus the patient was discharged home receiving a liquid diet on postoperative day 3.