Laparoscopic Biliary Revision for Choledocholithiasis After Roux-en-Y-Gastric Bypass: A Case Report and Discussion of Management Strategies.

BACKGROUND Managing biliary and pancreatic duct diseases in post-bariatric surgery patients, particularly after Roux-en-Y gastric bypass (RYGB), can be difficult. Traditional methods like ERCP are often impractical due to altered anatomy. With the rising number of bariatric procedures worldwide, biliary complications in patients with altered gastrointestinal anatomy are becoming increasingly frequent. Standard ERCP often fails due to the long Roux limb and excluded stomach, prompting the adoption of alternative or hybrid techniques such as laparoscopic-assisted ERCP (LA-ERCP), double-balloon enteroscopy (DBE), or endoscopic ultrasound-directed transgastric ERCP (EDGE). This case report explores the effectiveness of laparoscopically assisted biliary revision in addressing choledocholithiasis in a patient after bariatric surgery. CASE REPORT A 31-year-old man with a history of RYGB surgery presented with cholecystitis and cholangitis. Diagnostic imaging revealed multiple gallstones and a biliary obstruction. The patient underwent laparoscopic cholecystectomy with biliary revision and intraoperative cholangiopancreatography. Intraoperatively, a wide cystic duct and small mobile stones were identified, allowing for successful balloon extraction. Postoperative recovery was uneventful. CONCLUSIONS This case highlights the feasibility of cystic duct revision in selected post-RYGB patients with favorable anatomy. It underscores the importance of intraoperative assessment, flexibility, and institutional expertise when managing choledocholithiasis in patients with altered anatomy. Assisted biliary revision over the cystic duct is a safe and efficient approach for managing choledocholithiasis in post-RYGB patients due to its high success rates and ability to combine biliary access with simultaneous surgical interventions. A stepwise approach should be considered. Continued refinement of intraoperative assessment and standardized protocols will enhance patient outcomes and reduce complications.