Laparoscopic-Assisted ERCP Rendezvous Procedure for Choledocholithiasis in Patient With Esophageal Stricture

Abstract

A 65-year old male with prior laryngeal cancer with radiation-induced esophageal stricture presented with abdominal pain. CT demonstrated a 1.3cm dilated lower CBD with stones, which was confirmed by MRCP. Standard ERCP could not be performed due to esophageal stricture. Given this, a decision was made to proceed with laparoscopic-assisted ERCP. The patient was taken to the OR, where he first underwent laparoscopic cholecystectomy. Subsequently, gastrotomy with 14 mm trocar placement was performed, through which the ERCP scope was introduced. Multiple attempts to cannulate the ampulla were made but due to a very distal position of the ampulla in the duodenum attempts were unsuccessful. Thus,the decision was made to remove the cholecystectomy clips and to attempt an intraoperative rendezvous procedure. A 0.035 guidewire was inserted using laparoscopic techniques through the cystic duct into the bile duct and eventually into the duodenum. The guidewire was grasped with rat tooth forceps by a gastroscope and brought out through the gastrostomy port. The duodenoscope was backloaded over the wire and bile duct access was then easily achieved. Sphincterotomy and balloon sphincteroplasty were performed, with retrieval of two large CBD stones. Patient tolerated the procedure without complications. Technique Highlights: ERCP is commonly used in the treatment of biliary disorders in patients with normal abdominal anatomy. However, in patients with altered anatomy, particularly those who have undergone Roux-en-Y gastric bypass, this method may be challenging. Several alternative techniques have involved the use of balloon enteroscopy or laparoscopy to facilitate access to the duodenum. Studies have shown higher success rates with laparoscopic assisted approaches. Laparoscopic-assisted ERCP allows access to the duodenum through a surgical gastrotomy. In cases, such as presented here, where cannulation remains difficult, a unique “rendezvous” technique can be attempted if surgical clips are removed. In this case, precut was avoided and hence exposing the patient to increased risk of bleeding and pancreatitis.