Abstract

Background

Obesity 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.

Methods

An 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.

Results

Thirty-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.

Conclusion

LA-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.

中文翻译：

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社区医院中心胃旁路手术患者的腹腔镜辅助ERCP结局

摘要

背景

肥胖是当今社会普遍存在的一种问题，增加胃减肥手术的数量（鲍曼等人在外科杂志Endosc。https://doi.org/10.1007/s00464-016-4746-8，2016年Choi等人。在外科杂志Endosc。https://doi.org/10.1007/s00464-013-2850-6，2013; Paranandi等人在前线Gastroenterol https://doi.org/10.1136/flgastro-2015-100556，2015；理查森等。在http://www.ingentaconnect.com/content/sesc/tas，2012年）中。这对胆道疾病提出了解剖学上的挑战，因为传统技术在技术上比较困难，因此需要内镜逆行胰胆管造影（ERCP），需要更长的内窥镜，据报道成功率不到70％（Roberts等，https：//www.ncbi。 nlm.nih.gov/pmc/articles/PMC3016032/，2008年）。一种解决方案是通过胃造口术进行腹腔镜辅助的ERCP（LA-ERCP）。我们在大量患者群体的教学社区医院中介绍我们在LA-ERCP方面的​​经验。

方法

经IRB批准的回顾性图表回顾是对2008年4月至2016年4月接受过LA-ERCP的先前胃旁路手术患者进行的。该程序涉及两名减肥医生和一名肠胃科医生。用荷包缝合线和经筋膜缝合线将胃残余物固定在腹壁上。胃造口术后，插入十二指肠镜以进行ERCP。按指示进行胆囊括约肌切开术，扩张和结石清除术。我们观察了术后结局的发生率，包括急性胰腺炎，再次手术，术后感染，疼痛控制，住院再入院和胆汁渗漏。

结果

32名患者符合纳入标准。LA-ERCP的大多数适应症是胆总管结石症（16/32）。其余病例包括胆道扩张LFTs异常（11/32），急性胰腺炎（2/32），胆管炎（2/32）和胆漏（1/32）。LA-ERCP在所有患者中均成功完成。31/32例患者行胆囊括约肌切开术和结石摘除术。一名患者在最近的腹腔镜胆囊切除术后进行了括约肌切开术和支架置入术，以防胆漏。一名患者发展为急性胰腺炎，胰腺酶升高，可通过POD2分解。中位住院时间为2天。

结论

LA-ERCP是开放手术的一种安全可行的替代方案，可以在社区医院中由训练有素的医护人员安全实施。我们的大型研究证明，在这个微创时代，LA-ERCP为胃旁路手术患者提供了一种安全的替代方案，减轻了痛苦并提高了满意度。