Making ERCP Easy: Tips From A Master

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1 Making ERCP Easy: Tips From A Master Raj J. Shah, M.D., FASGE Associate Professor of Medicine University of Colorado School of Medicine Co-Director, Endoscopy Director, Pancreaticobiliary Endoscopy Services University of Colorado Anschutz Medical Campus

2 The ABC S of ERCP ACCESS BILIARY SPHINCTEROTOMY CALCULI STRICTURES

3 Pearls of Wisdom Avoid diagnostic ERCP

4 Pearls of Wisdom Avoid diagnostic ERCP SELECTIVE Therapeutic ERCP Selective Endoscopists within your group

5 Pearls of Wisdom Avoid diagnostic ERCP SELECTIVE Therapeutic ERCP Selective Endoscopists within your group Selective Risk (yours and the patient s!)

6 Pearls of Wisdom Avoid diagnostic ERCP SELECTIVE Therapeutic ERCP Selective Endoscopists within your group Selective Risk (yours and the patient s!) Selective Cannulation

7 Pearls of Wisdom Avoid diagnostic ERCP SELECTIVE Therapeutic ERCP Selective Endoscopists within your group Selective Risk (yours and the patient s!) Selective Cannulation Selective Patients

8 Modified Bismuth-Corlette Classification

9 NIH 2002 Consensus Conference on ERCP Choledocholithiasis High-index of suspicion Low suspicion - less invasive modalities U/S 50% sensitivity MRCP less than 5mm and/or distal stones may be missed EUS may be better than cholangiography Pre-operatively vs. Post-operatively

10 NIH 2002 Consensus Conference on ERCP Acute Biliary Pancreatitis When biliary obstruction is present Pancreaticobiliary abdominal pain Depends on objective evidence (elevated LFT s AND dilated bile duct emperic sphincterotomy)

11 Access

12 Position, Position, Position

13 Position, Position, Position

14

15

16 Improve Biliary Cannulation Guidewire physician controlled Double Wire Technique Pancreatic duct stent Transpancreatic septotomy Needle-knife pre-cut (expert)

17

18 Biliary Sphincterotomy 11 o clock position One-third of cutting wire in the duct Extent of sphincterotomy depends on pathology Base it on size of stone and/or distal bile duct diameter For maximal extent, consider the intraduodenal portion of the bile duct

19 Calculi (Biliary)

20 Extraction Balloons and Baskets

21 Stone Extraction Algorithm Deep cannulation Adequate sphincterotomy 90% of all Equipment stones Balloons (extraction and dilating) Baskets Mechanical Lithotripsy Electrohydraulic Lithotripsy (cholangioscopy) Stent (not as sole therapy)

22 Difficult Biliary Stones Size greater than downstream bile duct Balloon dilation Mechanical lithotripsy Acutely impacted and not stentable Consider PTC to decompress and percutaneous cholangioscopy with EHL as an alternative to surgery Emergent referral Treat downstream strictures Multiple and/or cuboidal

23 Billroth II

24 Lehman et al. Large diameter biliary orifice dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointestinal Endoscopy 2008 June. Sphincterotomy and Papillary Balloon Dilation N=103 (5 U.S. Referral Centers) ES (initial or extension) and EBD (12mm or greater) Median stone and balloon size = 13mm Fluoroscopic waist 95% success in one session (1/4 th required lithotripsy) Complications (5.4%) Cystic duct perforation required 2 month hospitalization (N=1) Bleeding requiring embolization of GDA (N=1) Broken basket requiring open BDE (N=1) No pancreatitis reported

25

26 Lithotriptors

27

28 Enhancing Ductal Clearance: The ABC s Assess opening: cautiously consider papillary balloon dilation Bust the stone: lithotripsy Cut: extend the sphincterotomy maximally Strictures: recognize downstream strictures and dilate prior to attempting extraction

29 Strictures

30 The Importance of Confirming Malignancy Surgical morbidity/mortality Low rate of resectability Expands and expedite treatment Tumor markers do not diagnose cancer

31 Yield of Sampling Depends on Etiology Forceps biopsy: Ampullary CA 80% - 90% Cholangio 33% - 50% Pancreatic 33% - 70% Brush cytology: Cholangio 40% - 80% Pancreatic 15% - 65% De Bellis M, Sherman S, Fogel EL, et al. Tissue sampling at ERCP in suspected malignant biliary strictures. GI Endosc 2002, 56

32 Improving Tissue Sampling Yield Use two modalities, even two brushes Stricture dilation prior to brush cytology has mixed yield Clip the brush and flush the cathete

33

34 EUS or ERCP to diagnose Pancreatic Adenocarcinoma? Prospective, comparative study ERCP biopsy and brush X 2 EUS-FNA (at least two passes) Sensitivities (ERCP better for biliary tumors, EUS better for pancreatic tumors) ERCP biopsy 36% ERCP cytology 46% EUS-FNA 75% Rosch T, Hofrichter, et al. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective, comparative study. Gastrointest Endosc 2004 September

35 Conclusions: The ABC S Access: Understand multiple techniques If failed, do you retry? Biliary Sphincterotomy: Tailor to indication Calculi: recognize features of stone location and downstream duct to improve success Strictures: exclude malignancy with multiple modalities

36 Making ERCP Easy: Tips From A Master Raj J. Shah, M.D., FASGE Associate Professor of Medicine University of Colorado School of Medicine Co-Director, Endoscopy Director, Pancreaticobiliary Endoscopy Services University of Colorado Anschutz Medical Campus

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