SSAT - AMPULLARY STENOSIS AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY: A NEW PHENOMENON IN THE POST-BARIATRIC SURGERY POPULATION

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AMPULLARY STENOSIS AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY: A NEW PHENOMENON IN THE POST-BARIATRIC SURGERY POPULATION
Andrew D. Wisneski^*, Jonathan Carter, Eric K. Nakakura, Andrew Posselt, Kenzo Hirose, Lygia Stewart, Carlos U. Corvera
Surgery, University of California San Francisco, San Francisco, CA

Introduction:
Roux-en-Y gastric bypass (RYGB) surgery is routinely performed for weight loss in morbidly obese patients. At our institution, we identified a small number of patients who developed benign ampullary stenosis after previously undergoing RYGB.
Cases:
Nine patients (4 male, 5 female) with mean age 56.3�7.6 years old at presentation, had previously undergone RYGB for morbid obesity a mean 8.9�4.8 years prior to diagnosis of ampullary stenosis (Table 1). All patients had obstructive liver function test patterns and either MRCP, ERCP, or cholangiogram confirming ampullary stenosis (Figure 1). The presenting complaints/diagnoses included: abdominal pain (4 patients), back pain (1 patient), incidental finding of elevated liver enzymes (1 patient), primary sclerosing cholangitis (1 patient), and ascending cholangitis (4 patients). 5 patients had cholecystectomy prior to presentation. 2 patients (1 male, 1 female) had comorbidities of systemic lupus erythematosus (SLE), and 3 patients had hypothyroidism. 3 patients had positive anti-nuclear antibody titers, which included both patients with SLE.
Management and Outcomes:
A variety of interventions were performed to treat the ampullary stenosis. 2 patients received transduodenal ampullectomies. 2 patients received choledochoduodenostomies (one with common duct stone removal). 1 patient underwent laparoscopic assisted transgastric ERCP with sphincterotomy and common duct stone extraction. 1 patient was managed only with percutaneous transhepatic biliary drainage. 1 patient, in whom pre-operative ampullary malignancy was suspected, underwent a pylorus sparing Whipple procedure. 1 patient underwent laparoscopic cholecystectomy as an initial diagnostic maneuver for abdominal pain. 1 patient, thought to have a diagnosis of primary sclerosing cholangitis, underwent liver transplant and died from postoperative complications. Together, these interventions yielded 3 ampulla specimens which were all negative for malignancy after pathologic analysis. All other hepatobiliary and cytopathology specimens were negative for any evidence of malignancy.
Discussion:
Nine cases of benign ampullary stenosis affecting patients who have undergone RYGB are presented. We postulate that metabolic or hormonal derangements after RYGB alter ampullary physiology causing dysfunction or benign stricture formation. Another possibility is an autoimmune mechanism since several patients carried diagnoses of SLE, primary sclerosing cholangitis, and hypothyroidism. We present this case series to raise attention to the entity of benign ampullary stenosis associated with RYGB. Additional mechanistic studies are necessary to further understand the pathophysiology of this peculiar clinical phenomenon.

Patient Characteristics
Patient Age at Diagnosis Sex Year of RYGB Presenting Symptoms/Diagnosis Intervention and Year Performed Relevant Pathology Past Medical History Notable Labs
1 54 Female 2012 Epigastric pain, nausea Transduodenal ampullectomy with sphincteroplasty, 2014 NA Hypothyroidism, nephrolithiasis, atrial fibrillation, hypertension, anxiety, depression ANA positive
2 50 Male 2006 Primary sclerosing cholangitis Liver transplant, 2015 (Deceased postoperatively) Liver biopsy: biliary obstruction, mild steatosis GERD, hypertension, anemia ANA positive
3 58 Female 2010 Right upper quadrant pain, cholangitis Percutaneous transhepatic biliary drain, 2014 Benign biliary brushings Heavy alcohol use NA
4 73 Female 2009 Weight loss, back pain, slightly elevated CA 19-9 Pylorus sparing Whipple procedure, 2015 Pre-op biliary brushings: malignant cytology. Ampulla (operative specimen): periampullary ulceration and fibrosis with sub-mucosal abscess. No tumor. Focal increase of plasma cells in periductal infiltrate, rare IgG4 cells. Systemic lupus erythematosus, aortic stenosis Pre-op CA 19-9: 37 (reference <36)
5 51 Male 2005 Incidentally elevated liver function enzymes Transduodenal ampullectomy with choledochoduodenostomy, 2016 Ampulla: No neoplasm identified Systemic lupus erythematosus, Raynauds syndrome, nephrolithiasis, hepatitis C, fatty liver ANA positive
6 53 Male 2005 Epigastric pain, cholangitis Open cholecystectomy and choledochoduodenostomy, 2016 Common bile duct margin: no high grade dysplasia or carcinoma Dilated viral cardiomyopathy, heavy alcohol use NA
7 63 Male 2007 Cholangitis Laparoscopic-assisted transgastric ERCP with sphincterotomy and common duct stone extraction, 2016 Stomach (gastrotomy site): gastric tissue with serosal fibrous adhesions Hepatitis C, hypertension, COPD, chronic pain NA
8 49 Female 1997 Cholangitis Common bile duct exploration, common duct stone extraction, choledochoduodenostomy, 2016 NA Hypothyroidism, fibromyalgia, migraines, endometriosis, obstructive sleep apnea, GERD, PTSD NA
9 56 Female 2006 Abdominal pain, nausea, emesis Laparoscopic cholecystectomy, 2016 Gallbladder: mild chronic cholecystitis. No calculi present. Hypothyroidism, asthma, GERD, anxiety, depression NA

Figure 1: Cholangiograms (upper row and bottom left) and trans-gastric ERCP (bottom right) demonstrating ampullary stenosis.

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