ERCP in patient with altered Upper GI anatomy

ERCP in patient with altered
Upper GI anatomy
Bariatric surgery
75 million Americans are obese, BMI > 30
15 million are morbidly obese, BMI >40
Total economic cost $147 this year, and rising
200,000 bariatric surgeries performed in 2012
– 1-2% are on patients less than 21 years old
– 39% are Lap band procedure
– 61% Roux en Y Gastric bypass or gastric sleeve
Bariatric surgery
• Success defined as 50% loss of excessive
• Success rate is higher with RYGB surgery
compared with Lap band
• Complications: GERD, Vomiting, Stricture,
anastamotic ulcers , anastamotic leak.
• 25% of gastric bands require additional
surgery for revision or removal
Gallstones in Bypass patients
• If Gallstones are present at the time of Gastric
bypass, elective cholecystectomy generally
done, otherwise prophylactic chole not done
Rapid wt loss is a risk factor for gallstone
Risk of stone formation
• 125 patients followed for at least 16 months
following RYGB, none had stones at time of
bypass surgery, none treated with urso:
– 100 female; 25 male subjects
– 10 developed symptomatic gallstones in 3-21
months following bypass, and required surgery;
– All 10 pts were female
– Treated with lap chole, or open chole
– Caruana et al Surg Obes Rel Dis 2005, Nov. 564
Gallstones in Bariatric surgery
• Estimated that 30% will form stones at some
point following gastric bypass
• Reduced to 2% by giving URSO for 6 months
post op.
• Gallstones migrating into the common bile
duct can cause pancreatitis , jaundice,
ERCP after bypass or Whipple
• Standard transoral ERCP is difficult or
impossible following Bypass
• The Roux limb is 50-100 cm long.
• The Limb passes thru the mesentery at the
distal anastamosis.
• The endoscope approaches the ampulla
backwards, making cannulation, and
sphincterotomy difficult.
Treating common duct stones should
be done before gallbladder is removed
• Percutaneous cholangiogram, with basket
lithotripsy, and balloon dilation of the ampulla
• Open gastric access to create stoma in gastric
reminant to pass duodenoscope to the
ampulla, then conventional sphincterotomy,
followed by balloon or basket stone removal
• Single or double balloon enteroscopy
• Operative common duct exploration
Open gastric access
• Done in OR, general anesthesia, laparotomy
with 4-5 inch midline incision.
• Sterile technique for Gastroenterologist, and
assisting Nurse
• Protocol approved by surgery department and
endoscopy unit is essential
• Surgical capability for common duct
exploration is essential
Start with the scope
• High level disinfection
– Duodenal scope
– Forward view diagnostic endoscope in case of
unexpected pathology, such as pyloric stenosis
that needs balloon dilation
– Extra air water, suction valves, and instrument
channel caps
– Sterile cautery cable that is compatible with your
• Operating Room tech will come to scope
washing facility to remove the scope from
washer, and transport to OR in sterile
container using sterile technique
• The OR scrub nurse will take instruments from
package and place on sterile field
– Contrast, syringes (consider full strength)
– Saline wash
– Sphincterotome, straight and curved guidewire
– Retrieval balloon
– Stone basket with lithotripsy capability
Back up instruments:
TTS CRE balloon for pylorus
Pancreatic stents 5 french, Wilson Cook
Biliary stents, 10 fr, 5 and 7 cm length
Fully coated biliary stent (Boston Scientific)
Patient preparation
Pre op antibiotics
Fluoroscopy table
DVT prophylaxis
Possible PEG tube placement if further
endoscopy is needed for stent removal
• Not currently using indomethacin suppository
for post ERCP procedure pancreatitis
Length of Procedure
• OR time 2-3 hours (longer if CBD exploration)
• ERCP time ; 30 minutes to set up equipment,
30-40 minutes of endoscopy time
• Fluoroscopy generally 5 minutes
• Recovery:
• 1-2 days in hospital, longer if pancreatitis or

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