A hybrid endo-laparoscopic therapy for common bile duct stenosis of a choledocho-duodenostomy after a Roux-en-Y gastric bypass

The essential growth of the number of Roux-en-Y gastric bypass procedures will obviously be accompanied by an increase of cases of common bile duct lithiasis. It seems evident that a close cooperation between surgeon and endoscopist will be needed on a routine basis. A laparoscopic-assisted transgastric ERCP is a well-documented approach to investigate the pancreatico-biliary tree in patients where the duodenum has been bypassed as in Roux-en-Y gastric bypass. In this case we present the possibility of assisting the endoscopist not only by providing access to the gastric remnant but also by helping with laparoscopic instruments during duodenoscopy. A formally obese woman who had benefited from a RYGB developed recurrent jaundice despite a precedent common bile duct exploration and choledocho-duodenostomy. A laparoscopic-assisted transgastric endoscopy revealed an obstructed choledocho-duodenostomy caused by accretions around a migrated clip. The obstructing clip could be extracted by laparoscopic instruments under endoscopic control.