6/17/2016. ERCP in June 26, Kenneth M. Sigman, M.D. Birmingham Gastroenterology Associates

Transcription

1 ERCP in 2016 June 26, 2016 Kenneth M. Sigman, M.D. Birmingham Gastroenterology Associates 1

2 2

3 3

4 Diagnostic/Therapeutic ERCP Biliary Obstruction Benign stricture Malignant Stones Ductal injuries Cholangitis Ampullary Adenoma Suspected PSC Suspected SOD Choledochal cysts Pancreatic Acute pancreatitis Relapsing pancreatitis Microlithiasis Pancreas divisum Suspected SOD Suspected pancreatic ca IPMN Chronic pancreatitis Ductal injuries Cystic lesions Indicatons for Biliary Therapeutics Obstruction Benign Malignant Stones Duct Leak SOD Cholangitis Acute cholecystitis Ampullary adenoma Indications for Pancreatic Therapy Stricture/obstruction Benign Malignant +/- Stones Ductal Injury Pseudocyst Drainage Pancreas Divisum Recurrent Pancreatitis- SOD or Microlithiasis 4

5 Sphincterotomy Stricture Dilation Therapies Stent Placement (biliary & pancreatic) Plastic Metal Stone Removal +/- lithotripsy Pseudocyst Drainage Ampullectomy Other Diagnostic Methods US CT MRI/MRCP EUS Lab Data It all starts with: Cannulation Deep & selective cannulation of the DOC Many ways to get there Know the ampullary anatomy & instruments 2 Methods- catheter insertion/contrast injection primary guidewire cannulation 5

6 Cannulation Instruments: Diagnostic catheters Various shapes and tips Sphincterotomes Various tip size, cutting wire length, rotateable Guidewires Many types / hydrophyllic Short-wire or Long-wire Needle Knife Pre-cut / access sphincterotomy Abraham Vater ( ) ampulla 6

7 Pancreatic Anatomy Ruggero Ferdinando Antonio Guiseppe Vincenza Oddi Ampullary Sphintcer Anatomy 7

8 Ampulla Bile Duct 11:30 Pancreatic duct 5 oclock Complexity is increased Ampullary and intraduodenal ductal segments like flexible accordians Like two Swan-ganz catheter sheaths Will bunch and kink when probed Bile duct may have a sigmoid morphology Forceful pushing with catheter makes it worse 8

9 9

10 10

11 11

12 12

13 Why do we care about method of cannulation? Success rates of accessing the desired duct(s) Speed of cannulation Complication rates 13

14 Risk Factors for Post-ERCP Pancreatitis Patient Sphincter of Oddi Dysfunction Recurrent or post-ercp pancreatitis Endoscopy Precut sphincterotomy Excessive cannulation attempts Contrast injection into pancreatic duct Ampullary trauma/ submucosal injection Pancreatic sphincterotomy Techniques to Reduce Risk of Post ERCP Pancreatitis Don t do ERCP Double wire technique/avoid the Needle Knife Referral to tertiary center high risk pts unsuccessful ERCPs Stay away from the pancreas guidewire cannulation Pancreatic stents/ Rectal Indomethacin Cannulation Techniques Catheter insertion/contrast injection - standard method Primary guidewire cannulation 14

15 What is Guidewire Cannulation? Guidewire cannulation (GC): A set of techniques utilizing catheters/sphincterotomes and guidewires to access the biliary and pancreatic ducts without the use of contrast. Theoretical Advantages of GC Avoidance of unnecessary contrast injection of PD Reduces risk of pancreatic hydrostatic overpressure Reduces risk of post-ercp pancreatitis Less ampullary trauma More rapid deep cannulation of desired duct Reduces need for Needle Knife Single Wire Method Catheter or sphincterotome is preloaded with wire Catheter gently advanced into the ampulla in the direction of the desired duct Guidewire is gently advanced Direction of wire on fluoroscopy determines which duct cannulated 15

16 Double Wire Technique After the first duct is accessed Guidewire left in place and catheter is removed Catheter re-inserted next to first wire with a second wire (must have 4.2 channel scope) Direct 2 nd catheter & wire into ampulla in direction of desired duct Use fluoroscopy for confirmation Double Wire Cannulation Leave the pancreatic wire Lengthens, straightens, & stabilizes the ampullary segment Aids biliary cannulation GIE 2001;53:820 16

17 17

18 Short Wire Technique Shorter wire gives physician better control Direct guidewire cannulation is faster and less traumatic Exchanges are faster and more assured Directing the wire through strictures or into specific ducts is easier Wire locking device keeps wire in place Brings the nurse/tech back into the room 18

19 The Wires Hydrophilic end facilitates atraumatic cannulation & deep ductal insertion (Jagwire or Metrowire) Back end facilitates back-loading of other accessories Theoretical Disadvantages of GC Guidewire perforation Guidewire induced pancreatitis Guidewire induced pancreatic duct trauma The Data Vandervoot et al GIE 2002 retrospective 1200pts Lella et al GIE 2004 prospective/randomized 400pts Lee et al GIE 2009 prospective/randomized 300pts Artifon et al AJG 2007 prospective/randomized 300pts Adler et al JCG 2009 retrospective 822pts Bailey et al END 2008 prospective/randomized 430pts Katsinelos et al END 2008 prospective/randomized 332pts *some variability in pt pop.,catheter or guidewire, therapeutics, & panc. stents 19

20 Cannulation rates sm/gc% Pancreatitis sm/gc% Vandervoot et al 6.1/10.2 Lella et al 97.5/ /0 Lee et al 97/ /2 Artifon et al 94/ /8.6 Adler et al /97.4 /1.3 Bailey et al 94.9/92 Katsinelos et al 78.2/84 Summary of Cannulation Techniques Know the anatomy Good endoscopic position Have a selection of catheters and wires Hydrophyllic wires are less traumatic Physician controlled wireguide cannulation Double wire technique Avoid the needle knife if possible Have a plan B Surgically Altered Anatomy Know the anatomy Choose the right scope SCOPE LENGTH CHANNEL SIZE May need special instruments Plan a little extra time Have a plan B 20

21 Billroth I Billroth II Roux-en-y GJ Whipple Hepatico-jejunostomy RYGJByp 21

22 J-J Anastamosis Biliary-enteric anastamosis ERCP for Strictures Imaging of both ducts Brush cytology & biopsies Direct visualization with Spyglass Balloon dilation Stent placement Polyethylene/plastic Metal mesh Benign Strictures Post cholecyst Chronic pancreatitis PSC Autoimmune pancreatitis/cholangitis Benign polyps and nodules 22

23 Malignant Strictures Pancreatic Ca Cholangio Ca Metastatic Ca Ampullary Ca Primary Duodenal Ca Klatskin 23

24 Stricture Diagnosis ERCP Brush cytology % sensitivity Duct biopsy % sensitivity Direct Cholangioscopy/ targeted biopsy % sens EUS/FNA Pancreatic mass % sensitivity Biliary strictures % sensitivity *- other modalities- intraductal US, CLE Plastic Biliary Stent 24

25 Charles Thomas Stent( ) Plastic or Metal Polyethylene Stents Good short-term relief of bile duct obstruction Easily placed and removed Inexpensive Effective in healing bile leaks and benign strictures 25

26 Polyethylene Stents Limited diameter 11.5 French Occlude easily Additional ERCP s drive up cost Plastic Stent Randomized Study Occlusion Rates Prat Schmassann Knyrim Davids n - 33 n - 70 n - 28 n - 56 P<.001 P=.006 Metal Stents Good long-term relief of bile duct obstruction Easily placed Large diameter (30 French) prolongs patency Fewer repeat ERCP s lower cost 26

27 Metal Stents Malignant obstruction Chronic pancreatitis Some benign post-op strictures Covered or Uncovered Covered Less tissue ingrowth Migration (3-13%) No advantage patency time No significant increase of pancreatitis/cholecystitis Removable More expensive Uncovered More tissue ingrowth No migration Patency time equvalent Not removable Less expensive Difficult Stones Large Multiple Intrahepatic Prox to stricture Cystic duct 27

28 Post Balloon Dilitation BAS in BABDS DASE (Dilation Assisted Stone Extraction) Large & multiple stones CRE wireguided balloon (12-18mm) Reduces risk & time Reduces need for large sphincterotomy Reduces need for lithotripsy Reduces need for stents and mult procedures Spyglass Digital format is superior Most useful for: Indeterminant strictures Large stones/ehl Staging cholangioca 28

29 What to expect from your ERCP endoscopist Kind, courteous, friendly Rapid response Always on time > 95% successful pancreatic and bile duct cannulation Low complication rates > 90% Relief of obstruction Successful stone extraction Diagnosing malignant vs benign lesions & appropriate tx * Always have a plan B & sometimes C,D,E 29