Laparoscopic Assisted Trans Gastric Endoscopic Retrograde Cholangiopancreatography (ERCP) - A District Hospital Experience

Background: Traditional ERCP approach for choledocholithiasis becomes very challenging in patients with previous Roux-en-Y gastric bypass (RYGB) and cholecystectomy [1, 2]. Various techniques like Double Balloon Enteroscopy and Spiral Enteroscopy were developed to manage these patients. The use of pediatric colonoscope and enteroscope in long limb bypass patients was also reported. Laparoscopic assisted ERCP (LA-ERCP) is a simple procedure that does not require special equipment. We describe using this method in a district hospital. Presentation of Cases: Three cases had LA-ERCP for CBD stones. They all had previous laparoscopic cholecystectomy and RYGB. In 2 cases two stay sutures was used to bring the stomach to the abdominal wall. Then 15 mm port was inserted into a gastrostomy and ERCP performed. Both patients were discharged within 2 days. Third patient had high BMI of 48. Adhesions prevented bringing the stomach to the abdominal wall. Endoscope was inserted via 15mm port into abdominal cavity and guided to the gastrostomy site. Patient stayed in hospital for 2 weeks due to COVID. Conclusion: LA trans-gastric ERCP is a feasible procedure. it is safe and reliable, with low complication and good recovery and can be performed in district hospital avoiding transfer to tertiary centers.