Direct Access Ercp: A Novel and Reliable Surgical Technique for Patients with Roux-en-y Anatomy

Cheryl Lin, MD, Robert J Aragon, MD, Aaron D Carr, MD, Mohamed R Ali, MD, FACS. Department of Surgery, University of California, Davis..

Background:  The universal need for surgically-assisted access to the biliary tree following Roux-en-Y gastric bypass (RYGB) has grown as the incidence of bariatric surgery has increased. Even with the availability of expert enteroscopy, interrogation of the biliopancreatic tree following RYGB is technically challenging and a significant proportion of patients will require surgically-assisted access. In our early experience, we utilized the typical approach of placing a 15-mm trocar directly into the gastric remnant and noted poor gastric fixation, slippage of the endoscope, difficulty in maintaining an air seal, and lack of sterility. Based on these initial challenges, our technique has evolved into a novel transgastric method that provides secure and gentle fixation of the remnant and enables easy diagnostic and therapeutic maneuvers of the biliopancreatic tract.

Methods:  Our technique involves initial placement of two peri-umbilical 5-mm ports and a small gel-sealed access system through a left upper quadrant incision. The gastric remnant is retrieved laparoscopically, delivered into the access system, and directly incised. A smaller wound protector is fitted through the gel seal, passed through the access system, and inserted into the remnant lumen. Deployment of the wound protector allows secure radial fixation of the gastrotomy to the anterior abdominal wall with equally-distributed tension on the stomach wall. Next, a 15-mm port is placed through the two interlocked systems directly into the gastric remnant to allow endoscopic access. Endoscopic retrograde cholangiopancreatogram (ERCP) is then performed. At the conclusion of the procedure, the inner system is removed, and the exteriorized gastrotomy is closed in two layers. Finally, the outer system is removed, and the incision is closed.

Results:  Eight patients, 34 to 61 years old, required direct access ERCP. Five patients had failed prior attempts to access the papilla by enteroscopy. Indications were choledocholithiasis (3), gallstone pancreatitis (1), sphincter of Oddi dysfunction (2), biliary stricture (1), and cholangitis (1). Endoscopic access to the biliary tree was successful in all cases. Mean operative time was 187±50 minutes. Mean length of stay was 2.25±1.3 days. At up to two years post-procedure, only two patients had unresolved symptoms. No conversions to open, no peri-operative complications, and no post-operative wound infections occurred.

Conclusions:  The distinguishing elements of this novel technique are the capability to protect the incision and provide air tight fixation of the gastric remnant to the anterior abdominal wall. This ensures direct alignment of the endoscope and gastric remnant, thus decreasing endoscope manipulation and minimizing scope torque and coiling. Repeat cannulation and full endoscopic surveillance of the remnant are also facilitated. This platform provides stability, and prevents dislodgement of the port during ERCP. The risk of gastric remnant injury is reduced because of the absence of traction sutures as well as the balanced radial distribution of tension on the wall of the stomach by the inner radial retractor. Additionally, wound contamination and gastric spillage are prevented by the outer gel-sealed system and the inner system, respectively. Our technique allows safe, easy, reliable, and reproducible direct gastric access for ERCP in post-RYGB patients. 

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