Transgastric Endoscopic Retrograde Cholangiopancreatography a Case Series and Description of Technique.

Transgastric Endoscopic Cholangiopancreatography: a Case Series and Description of Technique. Peter M. Bertin DO, Kirpal Singh MD, Maurice E. Arregui MD FACS. St Vincent Indianapolis, IN

Purpose: Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. We describe our technique, indications and outcomes in this group of patients.

Description and Methods: Data was collected by retrospective chart review of the experience of two surgeons in transgastric ERCP from July 2004 to October 2008 at a single institution. It involves 24 procedures in 18 patients. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in sixteen and recurrent pancreatits in two. The patient was placed in the supine position. Laparoscopy was most often used to gain access to the remnant stomach. Adhesions were lysed and a purse string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery and a 12mm trocar was inserted. It was secured with the purse string. A side viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. Intended interventions were sphincter of Oddi manometry, sphincterotomy, injection of botulinum toxin and placement of pancreatic duct stents.

Results: Laparoscopic access to the remnant stomach was attempted in all procedures except one that began open and those with preexisting gastrostomy tubes. This was successfully performed laparoscopically in 14; two required conversion to an open procedure. Preexisting gastrostomy tubes were present in seven. In the four patients who had prior open gastric surgery two of the four were converted to open. One retroperitoneal perforation was noted after sphincterotomy and attempted cannulation of the minor duodenal papilla without clinical repercussions. There were nineteen total attempts at manometery. Failure to cannulate the pancreatic duct occurred four times and on two occasions for the bile duct. Of 14 sphincterotomies one was felt to be incomplete. There was minor mucosal bleeding on dilation of 2 of the seven prior gastrostomy sites.

Conclusions: This demonstrates that bariatric patients with biliary pain can be successfully evaluated and treated for sphincter of Oddi dysfunction. The rate of success and complications does not appear to be deviate significantly from the standard procedure.

Session: Podium Presentation

Program Number: S104

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