Gabriel Arevalo, MD, Jeffrey Marks, MDFACSFAGS. UH Cleveland Medical Center
One of the known reasons for difficult biliary cannulation during ERCP is altered anatomy such as in RYGBP. One of the approaches to access the papilla in this group of patients is laparoscopic transgastric ERCP. Although a reliable and highly successful technique, there are several factors that slightly increase the technical difficulties to achieve selective biliary cannulation. With the pt. in the supine position there is a less favorable lie of the duodenoscope, the ampulla is engaged in a semi long scope position, there is need for additional torque and change in the endoscopist stance. This video demonstrates the basic steps of laparoscopic transgastric ERCP with emphasis on the double wire technique as an alternative biliary cannulation strategy for situations in which the papilla is reached and positioned for cannulation, but the pancreatic duct remains cannulated, despite attempts to achieve selective biliary access.
Double wire technique: With the pancreatic duct cannulated and w/o contrast being injected, the wire is advance to distal the body of the pancreas; the sphincterotome (ST) is withdrawn, leaving the wire insitu. The pancreatic wire should straighten the intramural portion of the common bile duct. A new guide wire is loaded in to the ST and advanced down the biopsy channel. The ST is engaged into the papilla and is bowed to approximate the biliary direction and the bile duct is selectively cannulated. The pre-loaded guide wire is advance, and fluoroscopy w/o contrast confirms the selective bile duct cannulation. The pancreatic wire is then removed, and the reminder of the therapeutic biliary procedure is performed.
Transgastric ERCP is a challenging procedure and Double wire technique may facilitate increase success for selective biliary cannulation and may decrease the risk for post ERCP pancreatitis, by avoiding multiple cannulations of the pancreatic duct.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85677
Program Number: V098
Presentation Session: Friday Exhibit Hall Theater (Non CME)
Presentation Type: EHVideo