Kevin L Grimes, MD, Kirpal Singh, MD, Maurice E Arregui, MD. St. Vincent Hospital.
Introduction
As more patients undergo Roux-en-Y gastric bypass, the population with altered anatomy continues to increase. This presents a challenge when duodenal access is required for ERCP. One technique, first described by Peters & Gagne in 2002, is laparoscopic transgastric ERCP. A handful of case series have been published (the largest includes 28 cases), but to our knowledge none addresses the complications of this procedure. We reviewed our experience with 84 transgastric ERCPs.
Methods
Retrospective review was conducted of gastric bypass patients who underwent transgastric ERCP in our practice. Patients were identified by office records, and a review of operative reports, discharge summaries, office notes, and laboratory data was performed. Access site infection was defined by “infection” appearing in the records or antibiotics being prescribed.
Results
Forty patients underwent 84 transgastric ERCPs (mean 2.1, range 1-14) in our practice from 2004-2013. Fifty-eight were for sphincter of Oddi dysfunction, 21 for pancreatic duct stenosis and/or chronic pancreatitis, 4 for choledocholithiasis, and 1 for gallstone pancreatitis. Ninety-three percent were female, 23% had diabetes mellitus, mean age was 49 (range 23-69), and median follow-up was 15 months (range 2 weeks – 8 years). One patient was lost to follow-up.
Selective cannulation was achieved in 94% of cases. Patients expected to undergo repeat ERCP had a G-tube placed in the remnant stomach rather than closure of the gastrotomy. Two patients (5%) were converted from laparoscopic to open access of the remnant stomach.
Overall, bowel injury occurred in 5/84 (5.9%) cases: 2/40 (5%) during initial laparoscopic access and 3/44 (6.8%) during repeat access via an existing gastrostomy. There were 3 duodenal perforations: 2 were ERCP-related, caused by precut sphincterotomy, and were managed non-operatively; the third, which required operative intervention, was caused by dilation of the existing gastrostomy site with Savary dilators. One posterior stomach wall laceration during placement of the access trocar was repaired with endoscopic clips, and 1 false tract was created during gastrostomy site dilation, which required no intervention.
Access site infection occurred in 4.8% overall: 2/40 (5%) during initial access and 2/44 (4.5%) during repeat access. The only infection that required debridement was following repeat access.
Discussion
Roux-en-Y gastric bypass eliminates the normal approach to the duodenum for ERCP. Laparoscopic transgastric access is feasible but associated with complications. Conversion to open procedure occurred in 5% of patients, access site infection in approximately 5%, and bowel injury in 5.9%. Infections ranged from mild cellulitis to deep abdominal wall abscess, and the rate is consistent with that of PEG site infections, which is reported from 1%–12%. Both patients that required operative intervention (abdominal wall abscess & duodenal perforation) had complications from repeat access. Gastrostomy dilation may increase the risk of complications compared with initial laparoscopic access. Our study is limited by its retrospective design, which may underestimate the complication rate, and by our homogenous patient population (93% female, 69% sphincter of Oddi dysfunction). It is uncertain whether these results would generalize to male patients or calculus biliary disease.
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