Sterile laparoscopic transgastric ERCP with single-use disposable duodenoscope

Laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) is a common interventional procedure in patients with biliary disease and altered anatomy due to Roux-en-Y gastric bypass [1] [2] [3]. After access to the stomach, the operation field needs to be widely redraped to proceed with nonsterile ERCP. However, converting from the sterile to a nonsterile setting has become unnecessary with the introduction of single-use disposable duodenoscopes [4] [5]. The entire procedure can now be performed in a sterile manner.

A 66-year-old woman with mild hypertension and diabetes presented with a history of repeated right upper quadrant abdominal pain. She had undergone cholecystectomy 30 years earlier for gallstone with biliary colic. In addition, she had a laparoscopic Roux-en-Y gastric bypass performed 13 years earlier, with successful weight loss and no postoperative complications. Magnetic resonance cholangiopancreatography revealed an 8-mm calculus in the common bile duct (CBD) ([Fig. 1]).

Fig. 1 Magnetic resonance cholangiopancreatography shows the stone in the common bile duct.

An elective laparoscopic transgastric ERCP using the single-use/disposable duodenoscope (Exalt Model D; Boston Scientific Corporation, Marlborough, Massachusetts, USA) was planned. The operation was performed with the patient under general anesthesia. Laparoscopically, a 15-mm trocar was placed under the left costal arch and into the bypassed stomach and fixed with sutures ([Fig. 2]). Seamlessly, the procedure continued in the sterile setting with unpacking of the sterile duodenoscope ([Fig. 3]). The duodenoscope was introduced through the port ([Fig. 4]) and advanced to the duodenum. The CBD was cannulated, and the cholangiogram confirmed the presence in it of a bile stone. A sphincterotomy was performed, and the stone was extracted with a balloon catheter ([Video 1]). After the ERCP, the 15-mm port was removed and the gastrotomy sutured. Operative time was less than 1 h. The postoperative course was uneventful, and the patient was discharged after 24 h.

Fig. 2 A 15-mm trocar was placed under the left costal arch to enter the stomach.

Fig. 3 Unpacking the sterile duodenoscope.

Fig. 4 The EXALT duodenoscope is inserted through the port and advanced to the duodenum.

Video 1 Transgastric endoscopic retrograde cholangiopancreatography performed using the single-use EXALT duodenoscope. The endoscope is introduced through the port, followed by cannulation, sphincterotomy, and stone removal with a balloon catheter.

Our case demonstrates a successful transgastric ERCP procedure using the new single-use/disposable duodenoscope, thus introducing the possibility of performing this type of procedure in a completely sterile manner, reducing the risk of contamination and infection. This opens up new prospects in the use of single-use endoscopes, where the sterility of the scopes becomes a substantial asset.

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• References

• 1 Tonnesen CJ, Young J, Glomsaker T. et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass. Endoscopy 2020; 52: 654-661
• 2 Peters M, Papasavas PK, Caushaj PF. et al. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography for benign common bile duct stricture after Roux-en-Y gastric bypass. Surg Endosc 2002; 16: 1106
• 3 Banerjee N, Parepally M, Byrne TK. et al. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2017; 13: 1236-1242
• 4 Muthusamy VR, Bruno MJ, Kozarek RA. et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2020; 18: 2108-2117.e3
• 5 Ross AS, Bruno MJ, Kozarek RA. et al. Novel single-use duodenoscope compared with 3 models of reusable duodenoscopes for ERCP: a randomized bench-model comparison. Gastrointest Endosc 2020; 91: 396-403