Andrew T Strong, MD1, Matthew T Allemang, MD1, S. Julie-Ann Lloyd, MD, PhD1, Matthew Dong, MD, MPH2, A. Daniel Guerron, MD3, John H Rodriguez, MD1, Jeffrey L Ponsky, MD1, Matthew Kroh, MD1. 1Section of Surgical Endoscopy, Dept. of General Surgery, Cleveland Clinic, 2The Mount Sinai Hospital, Department of Surgery, 3Duke Center for Metabolic and Weight Loss Surgery
Introduction: Evaluation and treatment of biliary pathology in patients who have previously undergone roux-en-y gastric bypass can be challenging. Percutaneous cholangiography and stenting is possible for some pathological conditions, but is not always indicated. Laparoscopic assisted transgastric endoscopic retrograde cholangiopancreatography (TGERCP) is becoming increasingly commonplace. Here we present a large single institution series.
Methods: We retrospectively identified patients who underwent TGERCP at our institution from January 2009 through September 2016. Demographic data, presenting symptoms, preoperative imaging studies operative details, and follow up to 30 days was collected.
Results: Fifty nine patients underwent TGERCP. Of these, 56 were completed laparoscopically while 3 required conversion to open. In one case, TGERCP attempt was aborted after inadvertent posterior gastrotomy at trocar insertion, and open biliary exploration was performed. Demographics included 51 female patients (86.4%), with a mean age was 54.6 +/- 9.8 years, and a median BMI of 31.8 m/kg2 (IQR 27.8 – 36.9). There were 49 patients (83.1%) who had previously undergone cholecystectomy, with seven completed concomitantly with prior gastric bypass operation. Presenting symptoms included post prandial right upper quadrant pain (n=17, 28.8%) constant right upper quadrant pain (n=33, 55.9%), and nausea (n=26, 44.1%). Twenty four (40.7%) had prior acute pancreatitis, 30 had liver serum maker abnormalities, and 6 had prior clinical jaundice. Ampullary stenosis was identified in 31 patients (53.4%), and choledocholithiasis in 17 patients (29.3%). Brushings performed in 10 patients (17.2%) were all negative for malignancy. The gastrotomy was closed in the majority of patients (n=48, 82.7%). Median length of stay was 2 days post-procedure. There were 4 intraoperative complications (6.9%). The most common complication was biochemical pancreatitis in 10 patients (17.2%), with 7 (11.9%) having clinical symptoms. Major complications included myocardial infarction, line-associated DVT and pneumonia (all in a single patient), organ space infection requiring drainage. Minor complications included transient bilirubin elevation (n=2, 3.4%), and superficial wound infection (n=4, 6.8%). At time of follow up, 62.1% of patients had symptom resolution.
Conclusions: Laparoscopically assisted TGERCP can be successfully performed in most cases, with a low risk of complications. This procedure is an important adjunct for centers performing gastric bypass surgery, and is probably best done by those most familiar with the altered foregut anatomy post gastric bypass. Moreover, for benign pathologies, and for patients without need for repeat TGERCP, the gastrotomy can be safely closed during the index procedure if no stent is placed.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79359
Program Number: P110
Presentation Session: Poster (Non CME)
Presentation Type: Poster
