Ercp in patient with altered upper gi anatomy
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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

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ERCP in patient with altered Upper GI anatomy

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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 weight.

  • 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 formation.


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 SurgObesRel 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, cholangitis.


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 equipment


scope

  • 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


Instruments

  • 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 cholangitis


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