Advanced Cannulation Techniques

Transcription

1 Advanced Cannulation Techniques Priya A. Jamidar, M.D., FASGE Professor of Medicine, Director of Endoscopy Yale School

2 Disclosures Consultant to Boston Scientific and Olympus America

3 Cannulation at ERCP Competent endoscopist % technical success rate Expert 95%-100% success rate Confounding anatomic variables Papilla adjacent to or within diverticulum Tumor infiltration B2 gastrectomy or Bariatric surgery

4 Cannulation at ERCP Competent endoscopist % technical success rate Expert 95%-100% success rate Confounding anatomic variables Papilla adjacent to or within diverticulum Tumor infiltration B2 gastrectomy or Bariatric surgery

5 Biliary Cannulation Techniques Freeman M, Guda N, GIE 2005;61:1,

6 Guidewire Assisted Cannulation Freeman M, Guda N, GIE 2005;61:1,

7 Guidewire Assisted Cannulation Gentle probing of a guidewire in a preloaded papillotome Advance guidewire out of papillotime a few mm or engage tip of papillotome into the papillary orifice before advancing the guidewire Wire manipulation by endoscopist or assistant

8 Guidewire (GW) Assisted Cannulation Early studies & metaanalysis of non randomized trials found GW cannulation increased successful cannulations and decreased PEP Recent prospective studies have not substantiated results of earlier trials GW can cause false passage, intramural dissection, pancreatic duct injury and perforation

9 Guidewire Assisted Cannulation Testoni P, et al., DDS 2011;43:

10 Double Guidewire Technique Testoni P, et al., DDS 2011;43:

11 Guidewire Assisted Cannulation: Pancreatic Duct technique GW in PD can be very helpful Stabilizes scope position Anchor and straighten PD and common channel and opens stenotic orifice Separate biliary and pancreatic orifice and deflect GW into CBD Stent in PD Allows better identification of pancreatic axis and total occlusion of PD

12 Guidewire Assisted Cannulation; Stent in PD Testoni P, et al., DDS 2011;43:

13 Precut Sphincterotomy Precut Papillotomy Incision from upper rim of papillary orifice extending cut cephalad Usually performed freehand with needle knife Precut Fistulotomy Create incision at apex of bulge and cutting downward into a dilated duct or onto the surface of an impacted stone

14 Precut (Access Sphincteromy) Freeman M, Guda N, GIE 2005;61:1,

15 Precut Considerations Freeman NEJM 1996

16 Precut Sphincterotomy I am on record as stating that precut sphincterotomy is a risky technique for experts only and still continue to receive invitations for lawsuits where the outcome has been disastrous PB Cotton, Endoscopy 1996

17 Precut Sphincterotomy Was considered a high risk technique with high rates of pancreatitis, bleeding and perforation. Incidence of severe pancreatitis and overall complications decreased with prophylactic PD stent placement Repeat ERCP following precut can be successful (once inflammation and edema resolves)

18 Needle Knife Sphincterotomy Bailey J, Gastrointest Endosc 2014,

19 NKES

20 Needle Knife Fistulotomy Parsi M, Gastrointest Endosc 79, 5, 2014

21 S/P NKES Bailey J, Gastrointest Endosc 2014,

22 Transpancreatic septotomy First described by Goff in 1995 Cutting through septum seperating the terminal end of the CBD from the PD Sphincterotome introduced into the PD oriented in the 11 O Clock position and incision made to expose the biiary orifice. Comparable to NKS and Double guidewire technique. Use PD stent

23 Transpancreatic Precut Freeman M, Guda N, GIE 2005;61:1,

24 Intradiverticular Papilla Papilla may be around rim or inside a diverticulum Various techniques utilized including injecting saline, cap assisted scope, clipping of diverticular or peripapillary folds. Dual accessory approach also used Use precut cautiously as wall is thinner

25 Intradiverticular Papilla Freeman M, Guda N, GIE 2005;61:1,

26 Billroth 11 Cannulation Freeman M, Guda N, GIE 2005;61:1,

27 What to do when Cannulation fails Repeat ERCP by same/another MD Refer to specialized center Consider alternate approach Percutaneous Increased risks of complication Laparoscopic Transpapillary GW placement during cholecystectomy EUS guided Rendezvous

28 Summary Wire guided cannulation with sphincterome standard technique Pancreatic wire/stent placement aids cannulation Low threshold for pancreatic stent placement and indomethacin Little to no role for diagnostic ERCP Consider referring difficult /complex cannulations to referral centers