Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center.

backgroundObesity is a prevalent issue in today's society, increasing the number of gastric weight loss surgeries (Bowman et al. in Surg Endosc. https://doi.org/10.1007/s00464-016-4746-8 , 2016; Choi et al. in Surg Endosc. https://doi.org/10.1007/s00464-013-2850-6 , 2013; Paranandi et al. in Frontline Gastroenterol. https://doi.org/10.1136/flgastro-2015-100556 , 2015; Richardson et al. in http://www.ingentaconnect.com/content/sesc/tas , 2012). This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP) as the traditional is technically difficult, requiring a longer endoscope with a reported success rate of less than 70% (Roberts et al. in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016032/ , 2008). A solution is laparoscopic-assisted ERCP (LA-ERCP) via gastrostomy. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients.

methodsAn IRB-approved retrospective chart review was performed on patients with prior gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure involved two bariatric surgeons and one gastroenterologist. The gastric remnant was secured to the abdominal wall with a purse-string suture and transfascial stay sutures. After gastrostomy creation of a duodenoscope was inserted to perform ERCP. Biliary sphincterotomy, dilation, and stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital readmission, and bile leak.

resultsThirty-two patients met inclusion criteria. The majority of indications for LA-ERCP was choledocholithiasis (16/32). The remainder of cases included indications such as abnormal LFTs with biliary dilation (11/32), acute pancreatitis (2/32), cholangitis (2/32), and bile leak (1/32). LA-ERCP was successfully performed in all patients. Biliary sphincterotomy and stone extraction were performed on 31/32 patients. One patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved on POD2. The median length of stay was 2 days.

conclusionLA-ERCP is a safe and feasible alternative to open surgery and can be safely implemented at community hospitals with adequately trained providers. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.