Single Institution Experience with Laparoscopic-Assisted Transgastric ERCP

Katherine Habenicht Yancey, MD, Michael McCormick, Myron S Powell, MD, Adolfo Z Fernandez, MD, Carl J Westcott, MD, Stephen S McNatt, MD. Wake Forest Baptist Medical Center

Background: Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is used to diagnose and treat patients with altered anatomy in which transoral endoscopy for biliary disease is not technically feasible. This procedure is now an accepted pathway for patients status post Roux-en-y gastric bypass who present with diagnosis of choledocholithiasis and associated pathologies (concomitant cholelithiasis, cholecystitis, cholangitis, gallstone pancreatitis). We describe our experience at our institution to add to the body of literature about this rarely performed operation.

Methods: An electronic medical record chart search of our tertiary referral hospital was performed dating from September 2012 to September 2015, identifying patients who underwent LAERCP per operative records. These charts were retrospectively reviewed for demographic and clinical data, as well as outcomes.

Results: Eleven patients (10 female) were identified. Average age was 57 years (range 41-67). Mean BMI at time of intervention was 35.2 (± 7.39). Mean time since bypass was 7.5 years. Mean preoperative total bilirubin was 1.49 mg/dL, white blood cell count was 8.4×103, alkaline phosphatase was 263 U/L. Mean length of stay at our institution was 3.2 days. Three patients underwent simultaneous cholecystectomy with intraoperative cholangiogram. Three patients underwent cholecystectomy with abnormal cholangiogram within 48 hours at referring institution prior to our intervention.  Remaining patients had cholecystectomy on average 9 years previously. Mean follow-up was 7.4 months.

One gastrostomy tube was left in place and used for an additional transgastric ERCP for retained common bile duct stones and removal of biliary stent 6 weeks postoperatively, and was successfully removed. A second patient was converted to open procedure, suffered post-ERCP pancreatitis and acute renal failure, required critical care admission, hemodialysis, and percutaneous drainage of retroperitoneal abscess with subsequent video-assisted retroperitoneal debridement for pancreatic necrosis evacuation. No patients suffered morbidity related to the surgical access of the stomach. We encountered no perioperative mortality.

Conclusion: Biliary obstruction after roux-en Y gastric bypass occurs in a small patient population, but requires LAERCP for reliable clearance of the common bile duct. Our case series demonstrates 1/11 (9%) patients with morbidity beyond that seen with transoral ERCP in patients without altered anatomy. We conclude that the procedure is effective in stone removal and may carry complication rates are slightly higher than typical transoral ERCP.  

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