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Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients.

Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez PH, Badaoui A - Endosc Int Open (2015)

Bottom Line: Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions.All patients successfully underwent biliary cannulation and sphincterotomy.Mean hospital stay was 2.8 days (range 2 - 4).

View Article: PubMed Central - PubMed

Affiliation: Cliniques Universitaires Saint-Luc, Brussels, Belgium ; AZ Sint-Jan Hospital Brugge-Oostende, Bruges, Belgium.

ABSTRACT

Background: Performing endoscopic retrograde cholangiopancreatography in bariatric patients who underwent Roux-en-Y gastric bypass surgery is challenging due to the long anatomical route required to reach the biliopancreatic limb.

Aim: Assessment of the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography.

Methods: A retrospective multicenter observational consecutive-patient cohort study of all patients in the period May 2008 to September 2014 with a history of Roux-en-Y gastric bypass who presented with complicated biliary disease and who underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography. The laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure was similar in all centers and was performed through a 15 mm or 18 mm trocar that was inserted in the gastric remnant. Cholecystectomy was performed concomitantly when indicated.

Results: In total, 23 patients underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure. Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions. Indications included ascending cholangitis, choledocholithiasis, and biliary pancreatitis. Of the 23 patients, 13 underwent concomitant cholecystectomy. All patients successfully underwent biliary cannulation and sphincterotomy. No endoscopic procedure-related complications (i. e. bleeding, pancreatitis or retroperitoneal perforation) occurred. Mean hospital stay was 2.8 days (range 2 - 4).

Conclusions: Transgastric endoscopic retrograde cholangiopancreatography is a feasible approach in the treatment of pancreaticobiliary disease in Roux-en-Y gastric bypass patients, without major complications in our series and allows endoscopic treatment and cholecystectomy to be performed consecutively in a single procedure. In Roux-en-Y gastric bypass patients without a history of prior cholecystectomy presenting with complicated gallstone disease, combining cholecystectomy and transgastric endoscopic retrograde cholangiopancreatography as a first-line approach may be a valid treatment strategy.

No MeSH data available.


Related in: MedlinePlus

 Standard laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LA-ERCP) steps. a, b Formation of a gastrotomy on the anterior side of the greater curvature of the gastric remnant near the antrum; c insertion of a 15 mm trocar into the gastric remnant through the gastrotomy; d the trocar is secured with a purse-string suture; e, f ERCP with sphincterotomy and stone extraction; g suture of the gastrotomy incision.
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FI228-2:  Standard laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LA-ERCP) steps. a, b Formation of a gastrotomy on the anterior side of the greater curvature of the gastric remnant near the antrum; c insertion of a 15 mm trocar into the gastric remnant through the gastrotomy; d the trocar is secured with a purse-string suture; e, f ERCP with sphincterotomy and stone extraction; g suture of the gastrotomy incision.

Mentions: The LA-ERCP technique was similar in all cases. Standard laparoscopic access to the abdominal cavity was accomplished with insertion of four trocars. When indicated, CCE was performed. The standard LA-ERCP steps are shown in Fig. 2 and Video 1. First of all, mobilization of the greater curve of the antrum was achieved. A gastrotomy and purse-string suture were fashioned on the anterior side of the greater curvature of the gastric remnant near the antrum. An additional 15 mm or 18 mm trocar (Endopath® Xcel®, Ethicon, Johnson & Johnson Medical, Diegem, Belgium) was placed in the left upper quadrant and inserted into the gastrotomy in the center of the purse-string suture. The purse-string suture was tightened and the gastric remnant was lifted up to the anterior abdominal wall. The biliopancreatic limb was occluded with an intestinal clamp to prevent “over-insufflation” of the small bowel which obscures perioperative visualization. Finally, a side-viewing endoscope (TJF 160 R, distal end outer diameter of 13.5 mm, Olympus Corp, Tokyo, Japan) was introduced through the 15 mm or 18 mm trocar secured into the gastrotomy, and ERCP was performed under fluoroscopic guidance. Carbon dioxide gas, which has been demonstrated to be safer and superior to conventional room air insufflation, was used during endoscopic insufflation in all procedures. After removal of the scope and the 15 mm trocar, the purse-string was tied and the gastrotomy incision was sutured.


Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients.

Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez PH, Badaoui A - Endosc Int Open (2015)

 Standard laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LA-ERCP) steps. a, b Formation of a gastrotomy on the anterior side of the greater curvature of the gastric remnant near the antrum; c insertion of a 15 mm trocar into the gastric remnant through the gastrotomy; d the trocar is secured with a purse-string suture; e, f ERCP with sphincterotomy and stone extraction; g suture of the gastrotomy incision.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4612229&req=5

FI228-2:  Standard laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LA-ERCP) steps. a, b Formation of a gastrotomy on the anterior side of the greater curvature of the gastric remnant near the antrum; c insertion of a 15 mm trocar into the gastric remnant through the gastrotomy; d the trocar is secured with a purse-string suture; e, f ERCP with sphincterotomy and stone extraction; g suture of the gastrotomy incision.
Mentions: The LA-ERCP technique was similar in all cases. Standard laparoscopic access to the abdominal cavity was accomplished with insertion of four trocars. When indicated, CCE was performed. The standard LA-ERCP steps are shown in Fig. 2 and Video 1. First of all, mobilization of the greater curve of the antrum was achieved. A gastrotomy and purse-string suture were fashioned on the anterior side of the greater curvature of the gastric remnant near the antrum. An additional 15 mm or 18 mm trocar (Endopath® Xcel®, Ethicon, Johnson & Johnson Medical, Diegem, Belgium) was placed in the left upper quadrant and inserted into the gastrotomy in the center of the purse-string suture. The purse-string suture was tightened and the gastric remnant was lifted up to the anterior abdominal wall. The biliopancreatic limb was occluded with an intestinal clamp to prevent “over-insufflation” of the small bowel which obscures perioperative visualization. Finally, a side-viewing endoscope (TJF 160 R, distal end outer diameter of 13.5 mm, Olympus Corp, Tokyo, Japan) was introduced through the 15 mm or 18 mm trocar secured into the gastrotomy, and ERCP was performed under fluoroscopic guidance. Carbon dioxide gas, which has been demonstrated to be safer and superior to conventional room air insufflation, was used during endoscopic insufflation in all procedures. After removal of the scope and the 15 mm trocar, the purse-string was tied and the gastrotomy incision was sutured.

Bottom Line: Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions.All patients successfully underwent biliary cannulation and sphincterotomy.Mean hospital stay was 2.8 days (range 2 - 4).

View Article: PubMed Central - PubMed

Affiliation: Cliniques Universitaires Saint-Luc, Brussels, Belgium ; AZ Sint-Jan Hospital Brugge-Oostende, Bruges, Belgium.

ABSTRACT

Background: Performing endoscopic retrograde cholangiopancreatography in bariatric patients who underwent Roux-en-Y gastric bypass surgery is challenging due to the long anatomical route required to reach the biliopancreatic limb.

Aim: Assessment of the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography.

Methods: A retrospective multicenter observational consecutive-patient cohort study of all patients in the period May 2008 to September 2014 with a history of Roux-en-Y gastric bypass who presented with complicated biliary disease and who underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography. The laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure was similar in all centers and was performed through a 15 mm or 18 mm trocar that was inserted in the gastric remnant. Cholecystectomy was performed concomitantly when indicated.

Results: In total, 23 patients underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure. Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions. Indications included ascending cholangitis, choledocholithiasis, and biliary pancreatitis. Of the 23 patients, 13 underwent concomitant cholecystectomy. All patients successfully underwent biliary cannulation and sphincterotomy. No endoscopic procedure-related complications (i. e. bleeding, pancreatitis or retroperitoneal perforation) occurred. Mean hospital stay was 2.8 days (range 2 - 4).

Conclusions: Transgastric endoscopic retrograde cholangiopancreatography is a feasible approach in the treatment of pancreaticobiliary disease in Roux-en-Y gastric bypass patients, without major complications in our series and allows endoscopic treatment and cholecystectomy to be performed consecutively in a single procedure. In Roux-en-Y gastric bypass patients without a history of prior cholecystectomy presenting with complicated gallstone disease, combining cholecystectomy and transgastric endoscopic retrograde cholangiopancreatography as a first-line approach may be a valid treatment strategy.

No MeSH data available.


Related in: MedlinePlus