Mo1309 Intraoperative ERCP With Guidewire Assisted Rendezvous Cannulation; A Laparo-Endoscopic Way to Avoid Post ERCP Pancreatitis

Abstract

Mo1309 Intraoperative ERCP With Guidewire Assisted Rendezvous Cannulation; A Laparo-Endoscopic Way to Avoid Post ERCP Pancreatitis Fredrik Swahn*, Sara Regner, Lars Enochsson, Lars R. Lundell, Henrik Thorlacius, Urban Arnelo Gastrocentrum Surgery, CLINTEC, Stockholm, Sweden; Department of Surgery, Clinical Sciences, Malmo Skane University Hospital, Malmo, Sweden Background: Laparoscopic cholecystectomy (LC) can be combined with endoscopic retrograde cholangiopancreatography (ERCP) in conjunction with transcystic guidewire assisted rendezvous (RV) cannulation in the management of common bile duct stones (CBDS). The aim of this study was to examine whether this approach is associated with a lower pancreatic proenzyme leakage rate than conventional (CV) ERCP cannulation technique. Methods: Patients (n 122) with symptomatic gallstone disease, without ongoing pancreatitis, cholangitis, cholecystitis or previous sphincterotomy were prospectively enrolled in this case control designed study. Forty of these patients had an LC where the per-operative cholangiogram suggested CBDS including a laparo-endoscopic (LE) RV. Another 41 patients with retained CBDS cholecystolithiasis underwent CV ERCP. Patients (n 41) submitted to LC and cholangiographie with negative findings served as a control group. Post-procedural pancreas amylase, trypsinogen-2 and procarboxy-peptidase B (proCAPB) blood concentrations were analyzed in all patients as well as perand post-procedural complications and CBDS clearance rates. Results: Post ERCP pancreatitis (PEP) occurred in 3 of the 41 (7%) patients submitted to CV ERCP as compared to none in the RV ERCP group (p 0.11, n.s.). Laboratory values suggestive of acute pancreatic injury such as pancreas amylase 4 hours after ERCP were 2.0 4.2 [SD] cat/L in the CV ERCP group, 0.5 0.33 cat/L in the RV ERCP group (P-value 0.0015). At 8 hours the corresponding values were 3.5 9.0 cat/l and 0.6 0.4 cat/l, respectively (p 0.03). ProCAPB after 4 hours was 90.7 237.7 nmol/L compared to 7.2 8.0 nmol/L after RV ERCP (p 0.0001) and after another 4 hours of observation corresponding values were 111.7 287.3 nmol/L and 7.9 7.6 nmol/L (p 0.0001) respectively (Fig.1). Trypsinogen-2 levels at 24 hours after procedure were 317.8 547.1 g/L in the CV ERCP group, 145.6 67.2 g/L (p 0.03) after RV ERCP and 134.0 80.3 g/L among the controls. No major per-or post procedural complications were observed in either groups. Post procedural concentrations of pancreas amylase (p 0.003) and proCAPB (p 0.002) were significantly correlated with pancreatic duct cannulation and opacification. Albeit that the final outcome in both study groups eventually reach complete stone clearance, there was a significant (p 0.01) advantage for the RVgroup (n 38/40, 95%) during the index procedure, compared with the CV-group (29/41, 71%). Conclusion: One-stage LE ERCP in conjunction with guidewire assisted RV cannulation minimizes pancreatic enzyme leakage compared with CV cannulation technique. These results suggests that RV technique is an important LE therapeutic method that can be employed to prevent PEP and thereby should be the preferred technique for transpapillary CBDS extraction in conjunction with LC.