Concomitant laparoscopic cholecystectomy and antegrade wire, rendezvous cannulation of the biliary tree may reduce post-ERCP pancreatitis events

Abstract

Introduction

For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both two-session endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP).

Methods

An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire.

Results

Thirty-seven patients (27 female, age 19–77, BMI 21–50 kg/m²) underwent intraoperative ERCP via AWRC technique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a postoperative subhepatic abscess requiring drainage.

Conclusion

AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post-sphincterotomy bleeding.