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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

 Retraction of an angulated duodenoscope can result in “peeling” of the coating of the endoscope (arrow).
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Related In: Results  -  Collection


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FI228-3:  Retraction of an angulated duodenoscope can result in “peeling” of the coating of the endoscope (arrow).

Mentions: Regarding the technical difficulty of the procedure, LA-ERCP has several advantages in contrast to BEA-ERCP, since ERCP can be performed with a standard side-viewing endoscope through a minimally invasive access to the stomach 214. The results of our patient cohort confirm the data from prior studies and show that the laparoscopy-assisted transgastric ERCP technique allows reliable access to the duodenum using standard side-viewing duodenoscopes. However, some technical aspects and pitfalls have also to be considered in this technique. Insufflation of carbon dioxide gas is advised during the endoscopic procedure, which has been demonstrated to be safer and superior to conventional room air endoscopic insufflation in the case of intraperitoneal gas leakage. Concomitant CCE after completion of the ERCP can be rendered more difficult due to bowel distension, which can be prevented by application of an intestinal clamp proximal to the angle of Treitz. Dissection and identification of the cystic duct, but suspending definitive CCE until ERCP is performed, is considered to be the safest option. This permits a less complicated insertion of a guidewire into the cystic duct when CBD access is difficult (rendezvous technique), which was necessary in 1/23 patients. However, there was no real preference with regard to the exact timing of concomitant CCE pre- or post-ERCP, which primarily depended on technical and logistical considerations and did not appear to influence the performance of both procedures 516. The purse-string on the greater curvature of the antrum of the gastric remnant has to be tightly fixed around the trocar to prevent loss of insufflation pressure. The gastrotomy should be made as lateral as possible along the greater curvature to permit smooth intubation of the pylorus. A 15 mm or 18 mm laparoscopic trocar is used to allow gentle maneuvering of the duodenoscope into the gastric remnant 151617. However, careless retraction of the endoscope in an angulated position can result in “peeling” of the coating of the duodenoscope (Fig. 3). Furthermore, there are some differences to standard biliary cannulation in performing LA-ERCP. Straightening of the scope is not possible and the major papilla has to be approached from a greater distance, making cannulation and performing sphincterotomy suboptimal. Therefore, to facilitate biliary cannulation, the 15 mm trocar needs to be oriented towards the pylorus, which usually requires an assistant to maintain torque and change positions.


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)

 Retraction of an angulated duodenoscope can result in “peeling” of the coating of the endoscope (arrow).
© Copyright Policy
Related In: Results  -  Collection

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

FI228-3:  Retraction of an angulated duodenoscope can result in “peeling” of the coating of the endoscope (arrow).
Mentions: Regarding the technical difficulty of the procedure, LA-ERCP has several advantages in contrast to BEA-ERCP, since ERCP can be performed with a standard side-viewing endoscope through a minimally invasive access to the stomach 214. The results of our patient cohort confirm the data from prior studies and show that the laparoscopy-assisted transgastric ERCP technique allows reliable access to the duodenum using standard side-viewing duodenoscopes. However, some technical aspects and pitfalls have also to be considered in this technique. Insufflation of carbon dioxide gas is advised during the endoscopic procedure, which has been demonstrated to be safer and superior to conventional room air endoscopic insufflation in the case of intraperitoneal gas leakage. Concomitant CCE after completion of the ERCP can be rendered more difficult due to bowel distension, which can be prevented by application of an intestinal clamp proximal to the angle of Treitz. Dissection and identification of the cystic duct, but suspending definitive CCE until ERCP is performed, is considered to be the safest option. This permits a less complicated insertion of a guidewire into the cystic duct when CBD access is difficult (rendezvous technique), which was necessary in 1/23 patients. However, there was no real preference with regard to the exact timing of concomitant CCE pre- or post-ERCP, which primarily depended on technical and logistical considerations and did not appear to influence the performance of both procedures 516. The purse-string on the greater curvature of the antrum of the gastric remnant has to be tightly fixed around the trocar to prevent loss of insufflation pressure. The gastrotomy should be made as lateral as possible along the greater curvature to permit smooth intubation of the pylorus. A 15 mm or 18 mm laparoscopic trocar is used to allow gentle maneuvering of the duodenoscope into the gastric remnant 151617. However, careless retraction of the endoscope in an angulated position can result in “peeling” of the coating of the duodenoscope (Fig. 3). Furthermore, there are some differences to standard biliary cannulation in performing LA-ERCP. Straightening of the scope is not possible and the major papilla has to be approached from a greater distance, making cannulation and performing sphincterotomy suboptimal. Therefore, to facilitate biliary cannulation, the 15 mm trocar needs to be oriented towards the pylorus, which usually requires an assistant to maintain torque and change positions.

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