Laparoscopic-assisted ERCP

Abstract

Background: Conventional ERCP has become the gold standard for visualization and extraction of common bile duct stones. Gastric bypass patients pose a unique challenge, especially in a community setting in which double-balloon ERCP is not readily available. Several modalities are available for this patient population, including: PTC, double balloon ERCP, and open/laparoscopic surgery. Our patient―a 71 year old female with history of cholecystectomy and multiple bariatric surgeries, including gastric bypass―was admitted and treated for cholangitis. IV antibiotics per sepsis protocol were initiated and definitive treatment was done by laparoscopic-assisted ERCP. Methods: The procedure was done under general endotracheal anesthesia. Five trocar technique was performed using 12 mm supraumbilical Hasson trocar for camera, 5 mm RUQ, RLQ and LLQ trocars for instruments, and 15 mm RUQ trocar for endoscope. Extensive lysis of adhesions were taken down with combined blunt and sharp dissection using harmonic scalpel and endoshears. The gastric remnant was identified and entered between two stay sutures using harmonic scalpel. Esophagogastroduodenoscope was inserted through 15mm RUQ port and gastrotomy. ERCP was then successfully performed by the gastroenterologist with extraction of two large stones and subsequent visualization of clear biliary tract on fluoroscopy. Gastrostomy was subsequently closed by endo-GIA 65 mm blue load and over-sewn with 3-0 silk sutures. Results: Operative time was approximately 180 minutes including intraoperative ERCP. Blood loss was estimated at 10cc. Successful entry into the gastric remnant and subsequent cannulation of Ampulla of Vater with extraction of 2 large common bile duct stones was achieved71-year-old and subsequent visualization of clear biliary tract on fluoroscopy was seen. The patient tolerated surgery well with normalization of abnormal labs by postoperative day 2 with subsequent discharge home in stable and improved condition. Conclusion: Laparoscopic-assisted ERCP may be a viable treatment modality for patients with history of multiple bariatric surgeries presenting with cholangitis, especially in a community setting where double-balloon ERCP is limited.