Samer AlMasri1, Mazen S Zenati2, Georgios I Papachristou3, Adam Slivka4, Michael Sanders4, Jennifer Chennat4, Mordechai Rabinowitz4, Asif Khalid4, Andres Gelrud5, John Nasr4, Savreet Sarkaria4, Rohit Das4, Kenneth K Lee1, Wolfgang Schraut1, Steve J Hughes6, A James Moser7, Alessandro Paniccia1, Melissa E Hogg8, Herbert J Zeh9, Amer H Zureikat10. 1. Department of Surgery, University of Pittsburgh Medical Center, 5150 Center Ave., Suite 421, Pittsburgh, PA, 15232, USA. 2. Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA. 3. Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA. 4. Department of Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA. 5. Department of Internal Medicine, Miami Cancer Institute, Gastro Health, Miami, FL, USA. 6. Department of Surgery, University of Florida, Gainesville, FL, USA. 7. Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA. 8. Department of Surgery, NorthShore Hospital System, Chicago, IL, USA. 9. Department of Surgery, University of Texas Southwestern, Dallas, TX, USA. 10. Department of Surgery, University of Pittsburgh Medical Center, 5150 Center Ave., Suite 421, Pittsburgh, PA, 15232, USA. zureikatah@upmc.edu.
Abstract
INTRODUCTION: Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP. METHODS: A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed. RESULTS: 131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48 min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics. CONCLUSION: LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.
INTRODUCTION: Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP. METHODS: A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed. RESULTS: 131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48 min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics. CONCLUSION: LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.