The Role of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Care Surgery

Cory Richardson, MD, Ashley Pistorio, MD, Charles R St. Hill, MD, MSc, Matthew Johnson, MD, Katie Lyons, Nathan I Ozobia, MD, FACS. University of Nevada School of Medicine.

INTRODUCTION: The feasibility and utility of surgeon performed intra-operative ERCP (INOPERC) has firmly been established in previous studies performed by our group at UNSOM/UMC. Furthermore, several studies at our institution have reported success with performing ERCP exclusively in the supine position, most notably with our One-Step Laparoscopic Cholecystectomies. The ability to perform ERCP intra-operatively on a patient in the supine position allows great versatility for the Acute Care Surgeon to exclusively manage patients with acute hepatopancreaticobiliary (HPB) conditions and complications. Acute Care Surgery is an evolving branch of General Surgery that now has its own service in many General Surgery Programs. Over the past four years, over 200 INOPERC have successfully been performed by our surgical service for a variety of indications. This paper will highlight select cases where surgeon-performed ERCP played a role in the management of patients with various HPB conditions.

METHODS AND PROCEDURES The following patients were admitted through the emergency room at University Medical Center of Southern Nevada where they presented with a variety of acute complaints. Cases selected were as follows: 1. Obstructive jaundice 2. Biliary pancreatitis 3. Biliary leak following penetrating abdominal injury 4. Cholangitis All patients selected were admitted to the surgical service and underwent appropriate surgical and medical workups. Operative procedures were completed in either a One-Step or a Two-Step approach. For the patients with obstructive jaundice and biliary pancreatitis, INOPERC was performed in the supine position during the same anesthesia as the laparoscopic cholecystectomy. ERCP performed prior to the lap chole (in the case of acute cholangitis) and in the case of penetrating abdominal injury were performed in the prone position.

RESULTS All cases selected were successfully treated with some variation or combination of lap chole, intra-operative cholangiogram, and ERCP with papillotomy, stent placement, or other necessary ERCP adjunctive measure. All aspects of the procedures were performed exclusively by surgical residents under direct supervision of an attending surgical endoscopist. Selective cannulation of the common bile duct was achieved in 100% of ERCPs. There were no morbidities or mortalities and no complications to report.

CONCLUSIONS ERCP is an additional tool for the appropriately trained Acute Care Surgeon to apply in the management of patients admitted to a surgical service. It can be used alone or in combination with other surgical procedures and can be safely performed in a variety of patient positions. Surgeons trained in ERCP can use this skill for diagnostic and therapeutic purposes in general surgery and trauma patients. ERCP has a steep learning curve but the UNSOM/UMC Las Vegas experience led by Dr. Nathan Ozobia has shown that surgical residents can be trained to independently perform both diagnostic and therapeutic ERCP under strict supervision and guidelines.

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