Joshua S Winder, MD1, Ryan M Juza, MD2, Eric M Pauli, MD1. 1Penn State Milton S. Hershey Medical Center, 2University Hospitals Cleveland Medical Center
Introduction: For patients with a gallbladder in situ, choledocholithiasis is a potentially challenging condition. Both two-session (Endoscopic Retrograde Cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY)) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an Antegrade Wire, Rendezvous Cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP).
Methods: An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/post-operative laboratory values, complications and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. A papillotome is backloaded on the wire and advanced directly into the biliary tree. Standard ERCP maneuvers to clear the bile duct are then performed.
Results: Thirty-two patients (22 female, age 19-77, BMI 21-50kg/m2) underwent intraoperative ERCP via AWRC technique during CCY. Sixteen underwent CCY for acute cholecystitis. Twelve patients underwent trans-gastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 30 min. Twenty-eight patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intra-operative complications associated with the ERCP and no patients developed PEP. One patient with severe biliary pancreatitis preoperatively had no clinical worsening postoperatively. Three patients developed a postoperative subhepatic abscess requiring drainage. One patient was taken for upper endoscopy due to acute blood loss anemia which was negative for sphincterotomy site bleeding, and one patient underwent early repeat ERCP due to occlusion of the biliary stent.
Conclusion: AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post-sphincterotomy bleeding. Single-stage CCY/ERCP utilizing AWRC eliminates two-stage management of choledocholithiasis and may reduce PEP rates. Further study is necessary.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94984
Program Number: S149
Presentation Session: Flexible Endoscopy II
Presentation Type: Podium