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ACG Case Rep J
ACG Case Rep J
ACGCRJ
AC9
ACG Case Reports Journal
2326-3253
Wolters Kluwer Maryland, MD

ACGCR-24-0602
10.14309/crj.0000000000001524
00039
3
Case Report
Endoscopy
Difficult to Pass: Cholangitis With Vertical Band Stenosis
Abrol Robinder DO rpabrol@utmb.edu
1
Mushtaq Muhammad DO 2
Muftah Abdullah MD aamuftah@utmb.edu
1
Samreen Sarah MD sasamree@utmb.edu
3
Yang Juliana MD 1jfyang@utmb.edu

1 Department of Internal Medicine, Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX
2 Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
3 Department of Bariatric Surgery, University of Texas Medical Branch, Galveston, TX
Correspondence: Muhammad Mushtaq, DO (mamushta@utmb.edu).
9 2024
19 9 2024
11 9 e0152429 6 2024
28 8 2024
© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

ABSTRACT

As techniques have been refined, more patients in the United States have undergone bariatric surgery for weight loss. These surgeries alter the gastrointestinal tract to restrict caloric intake. While most surgeons prefer sleeve gastrectomy and Roux-en-Y gastric bypass, some older procedures, like vertical band gastroplasty, have fallen out of favor due to late complications. In any bariatric procedure, endoscopy can be challenging if indicated due to altered anatomy. Here, we present a case of challenging anatomy due to remote vertical band gastroplasty in a patient presenting with cholangitis, highlighting the effective use of a lumen-apposing metal stent across a vertical band stenosis.

KEYWORDS:

vertical band stenosis
cholangitis
lumen-apposing metal stent (LAMS)
weight loss
OPEN-ACCESSTRUE
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pmcINTRODUCTION

The frequency of bariatric surgeries has increased in the United States since the 1990s.1 As minimally invasive techniques are refined, a larger patient population is eligible to undergo weight loss surgeries altering the anatomy of the gastrointestinal tract. Sleeve gastrectomy and Roux-en-Y gastric bypass remain the most frequently performed surgeries, and some older procedures, like vertical band gastroplasty (VBG), have fallen out of favor due to late complications. In certain clinical settings, these surgeries can pose obstacles for an endoscopist. In the bariatric surgery population requiring endoscopic retrograde cholangiopancreatography (ERCP), the endoscopist is often faced with a circuitous or restricted path to the ampulla.2 Here, we present a case of cholangitis in a patient with VBG requiring lumen-apposing metal stent (LAMS) placement before ERCP.

CASE REPORT

A 75-year-old woman with a medical history of remote VBG, lap band in 2005, and a history of gallstone pancreatitis with subsequent ERCP and cholecystectomy several months prior presented with abdominal pain.

On initial evaluation, laboratory work was significant for white blood cell count 25,000 U/L, total bilirubin 2.6 mg/dL, alkaline phosphatase 435 U/L, alanine transaminase 101 U/L, and aspartate aminotransferase 141 U/L. A computer tomography scan of the abdomen with intravenous contrast revealed dilation of the common bile duct (CBD) to 1.8 cm, with surrounding inflammation indicative of acute cholangitis. The patient received intravenous antibiotics. ERCP was planned due to concerns about cholangitis. Considering the patient's surgical history, esophagogastroduodenoscopy (EGD) was performed before attempting ERCP.

During the EGD procedure, a severe stenosis was identified at the VBG band site in the proximal stomach (Figure 1). Navigating this stenosis proved challenging. Despite using the over-the-guidewire technique, the duodenoscope could not pass through the narrowing successfully. A 20 mm × 10 mm Axios stent was placed across the defect (Figure 2). Subsequently, the waist of the LAMS was dilated to 20 mm using a through-the-scope balloon. Owing to the inability of the duodenoscope to traverse the LAMS, the EGD scope was used to perform ERCP.

Figure 1. Severe vertical band gastroplasty band site stenosis.

Figure 2.. Lumen-apposing metal stent placed across the vertical band gastroplasty band site stenosis.

A prior sphincterotomy was noted to be open. Affected stones were observed in the distal CBD. Successful cannulation of the CBD was achieved with a 0.025 mm wire preloaded onto a sphincterotome. Copious amounts of stones and sludge were removed from the bile duct using a 9–12 mm balloon (Figure 3). The patient showed significant improvement after the procedure. The patient was advised to have a repeat ERCP in 2 months but was lost to follow-up.

Figure 3. Successful common bile duct cannulation with biliary drainage in forward view.

DISCUSSION

VBG was first introduced in the 1980s as a restrictive surgical procedure for weight loss. A vertical line of staples runs in the proximal stomach, creating a separated gastric pouch along the lesser curvature. A ring of restrictive mesh or a silastic band is then placed along the proximal end of the pouch near the staple line.3 While initial weight loss was observed in most patients, longitudinal studies documented late complications in up to 56 percent of cases.3,4 These late complications include, but are not limited to, weight gain, erosion of the restrictive ring into the gastric lumen, and, as in our case, stenosis of the created outlet.3–6 Because of these complications, many surgeons have opted for surgical reversal or revision in patients with remote VBG.

Outlet stenosis occurs in up to a third of patients who underwent VBG.7 Patients typically present with nausea, vomiting, and food intolerance, and symptoms could manifest several years after surgery. Studies of endoscopic, surgery-sparing interventions like pneumatic dilation only yielded short-term benefits and necessitated multiple interventions.7,8 More recently, LAMS has been used as a more viable solution, considering high success rates in short benign gastric strictures.8 These stents not only allow for non-surgical alleviation of patient symptoms but, as discussed by Lim et al, radial force-induced tension and focal necrosis of the gastric mucosa aided in the subsequent removal of silastic rings after the placement of LAMS.7 LAMS deployment is a nonsurgical management approach for outlet stenosis in patients who have undergone VBG that can potentially spare further surgical risks.8

The association between obesity and cholelithiasis is well documented, and patients undergoing bariatric surgery are at an increased risk of stone formation in the immediate months post-op due to rapid weight loss.9 Further complications of gallstone disease, like cholangitis and choledocholithiasis, can be difficult to address in patients who have undergone bariatric surgeries due to altered anatomy. When the trans-papillary approach is technically impossible, percutaneous or surgically assisted routes have been pursued to decompress the biliary tree. In patients who have undergone Roux-en-Y gastric bypass needing ERCP, endoscopic ultrasound-directed transgastric ERCP with LAMS is successful in over 90 percent of cases.10 While normal postsurgical anatomy should not prevent ERCP in patients post-VBG, stenosis of the created outlet can limit direct endoscopy, as we saw in our case.

In our case, a severe stenosis was noted during the initial endoscopy of a patient admitted with cholangitis. Despite the absence of dysphagia-type symptoms, the endoscope could not pass through the narrowing initially. A LAMS was placed across the stenosis and dilated to facilitate endoscopic passage. Subsequently, the ampulla was successfully cannulated in a forward view, and choledocholithiasis was cleared. Our case further supports using LAMS to address endoscopic challenges in the bariatric patient population.

DISCLOSURES

Author contributions: R. Abrol, M. Mushtaq, A. Muftah, and S. Samreen: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; Drafting the work or reviewing it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. M. Mushtaq is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.
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