Vol.:(0123456789) 1 3 Surgical Endoscopy https://doi.org/10.1007/s00464-019-07074-5 2019 SAGES ORAL DYNAMIC Concomitant laparoscopic cholecystectomy and antegrade wire, rendezvous cannulation of the biliary tree may reduce post‑ERCP pancreatitis events Joshua S. Winder 1  · Ryan M. Juza 1  · Vamsi V. Alli 1  · Ann M. Rogers 1  · Randy S. Haluck 1  · Eric M. Pauli 1 Received: 25 April 2019 / Accepted: 16 August 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Introduction For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both two- session endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP). Methods An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis dur- ing CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without pre- operative biliary pancreatitis or cholangitis. Following confrmatory intraoperative cholangiogram, a fexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire. Results Thirty-seven patients (27 female, age 19–77, BMI 21–50 kg/m 2 ) underwent intraoperative ERCP via AWRC tech- nique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a post- operative subhepatic abscess requiring drainage. Conclusion AWRC is a useful technique for safe and efcient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post- sphincterotomy bleeding. Keywords ERCP · Rendezvous · Cholecystectomy · Choledocholithiasis Choledocholithiasis remains a challenging surgical diagno- sis requiring multimodality treatment which often results in a prolonged hospital course. Standard management rec- ommendations often involve sequential therapy beginning with preoperative endoscopic retrograde cholangiopancrea- tography (ERCP) followed by defnitive cholecystectomy (CCY) [1]. Common practice is to delay surgical interven- tion several days after endoscopic intervention to moni- tor for the development of post-ERCP pancreatitis (PEP), which complicates 10% of all ERCPs and carries with it a serious morbidity and mortality risk [2–4]. The sequential treatment strategy for choledocholithiasis increases length of stay, requires a second anesthetic, and risks the patient passing subsequent stones in the interval before defnitive surgery [5–7]. and Other Interventional Techniques Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00464-019-07074-5) contains supplementary material, which is available to authorized users. * Eric M. Pauli epauli@pennstatehealth.psu.edu 1 Division of Minimally Invasive and Bariatric Surgery, Department of General Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, H149, Hershey, PA 17033, USA