Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography

Abstract

Patients with altered anatomy who require endoscopic retrograde cholangiopancreatography (ERCP) present a challenge to the surgeon and require a specialized approach. In the past, most patients had altered anatomy secondary to duodenal ulcer operations, specifically a Billroth II reconstruction with afferent and efferent limbs. More common in the current era are patients with altered anatomy secondary to bariatric surgery, specifically laparoscopic Roux-en-Y gastric bypass (RYGB). Cholecystectomy in patients with altered anatomy can usually be performed laparoscopically, but access to the duodenum and the major papilla via transoral ERCP may be extremely difficult and frequently impossible. Even if one is able to access the duodenum using a transoral approach, impaired visualization of the papilla and scope instability can reduce the likelihood of deep biliary cannulation and technical success. Given the difficulty and poor success rate of transoral ERCP in RYGB patients, laparoscopic-assisted ERCP has developed as a safe and reliable way to allow ERCP.