1. ERCP in patient with altered Upper GI anatomy

2. 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

3. 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

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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