LAPAROSCOPIC ASSISTED ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY FOLLOWING GASTRIC BYPASS: A 12-YEAR ASSESSMENT OF OUTCOMES AND LEARNING CURVE AT A HIGH VOLUME PANCREATOBILIARY CENTER
Samer S. Al Masri, University of Pittsburgh Medical Center, Pittsburgh, PA
Evaluation and treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant challenges. Laparoscopic Assisted- Endoscopic Retrograde Cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing transpyloric access to the pancreaticobiliary tree through the excluded gastric remnant. The aim of this study was to analyze a teritiary center’s outcomes and learning curve following LA-ERCP.
A retrospective review of all consecutive patients who underwent LA-ERCPs between 2007 and 2019 at a high volume pancreatobiliary unit was performed. LA-ERCP was performed using a two team approach: a surgical team for gastric remanant mobilization and access, and a gastroenterology team for ERCP through the gastric remnant. To identify the institutional learning curve for surgeons and gastroenterologists, CUSUM analyses were performed on LA-ERCP’s without concomitant procedures (e.g cholecystectomy). Multivariate (MV) models were constructed to identify predictors of outcomes.
A total of of 131 patients underwent LA-ERCP (median age, 60; 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the bile duct was achieved in all (100%) cases. Indications for LA-ERCP were choledocholithiasis (78%), sphincter of Oddi dysfunction/papillary stenosis (17.6%), bile leak following cholecystectomy (2.3%) and stenting/biopsy of a malignant strictures (2.3%). Median time between RYGB and LA-ERCP was 81 months and the median decrease in BMI was 35%. Median surgical and ERCP times were 128 (96-172) and 48 minutes (36-71) respectively. The median length of stay was 3 days (2-4) and the readmission rate was 13%. Major complications (Clavien >II) developed in 6 % of the cohort. However, the most common complication was a surgical site infection at the 15 mm (gastric remnant access) port site in 9.2%, while the incidence of ERCP-induced pancreatitis was 3.8%, comparable to conventional ERCP. Conversion to open surgery was required in 14 cases (10.6%). On MV analysis, predictors of conversion were a history of multiple abdominal operations (OR 10.4, P= 0.033) and the percent decrease in BMI (OR 1.1, P=0.037). CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 10 for the gastroenterology team after which operative times began to optimize. There was however, no statistically significant difference in other surgical outcomes.
LA-ERCP is a safe and feasible procedure for the diagnosis and treatment of various pancreaticobiliary pathologies following RYGB. It is associated with high success rates and minimal complications even within the early phase of the experience. In a high volume pancreatobiliary center with multiple surgeons and gastroenterologists, an institutional learning curve is suggested within the first 30 cases.
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