PMC4802126_01
Preoperative findings and final treatment. (a) Gastric bypass; (b) sump syndrome; (c) magnetic resonance of the liver showing cholangitic abscesses; (d) hepaticojejunostomy.
gr1.jpg
PMC4802126_01_gr1.jpg
fig0005
A 35 year-old female with a past medical history notable only for morbid obesity who underwent a Roux-en-Y gastric bypass operation in 2008 (Fig. 1a). One year later her weight loss was not satisfactory, and she developed obstructive jaundice which was managed in a general surgery department by open cholecystectomy, exploration of the common bile duct and creation of a side-to-side choledochoduodenostomy (Fig. 1b). Ultrasonography of the liver showed multiple hypo-echoic lesions, confirmed by magnetic resonance imagining to be cholangitic abscesses (Fig. 1c).
Intraoperative findings. (a) Initial choledochoduodenostomy; (b) accessory hepatic duct; (c) foot anastomosis of the Roux-en-Y Gastric Bypass; (d) hepaticojejunostomy started.
gr2.jpg
PMC4802126_01_gr2.jpg
fig0010
The previous choledochoduodenostomy was identified and taken down (Fig. 2a), and the common bile duct "cul-de-sac" was cleared of numerous stones and significant debris. IV of liver that had not been identified by preoperative imaging (Fig. 2b). It drained directly into the 2nd part of the duodenum, distal to the common bile duct. The jejunojejunostomy (new foot anastamosis) was performed approximately 40 cm distal to the previous foot anastamosis of the Roux limb (Fig. 2d), which increased length of her prior gastric limb from 90 cm to 130 cm.