Basics of ERCP



Basics of ERCP


Larissa Fujii-Lau, MD



Since endoscopic retrograde cholangiopancreatography (ERCP) was first introduced in 1968 and endoscopic sphincterotomy in 1974, it has become the standard of care in the therapeutic management of many pancreaticobiliary diseases.1,2 ERCP remains one of the most technically challenging of all procedures performed by gastroenterologists and typically requires an additional year of training to become comfortable with its nuances. This chapter reviews the basics of ERCP through the periprocedural period but does not focus on the interventional aspect of this procedure as that is covered in later chapters.


PREPROCEDURAL CONSIDERATIONS




Periprocedural Administration of Antibiotics



  • Routine use of periprocedural administration of antibiotics (typically a fluoroquinolone, beta-lactam, or third-generation cephalosporin) does not decrease the risk of infectious complications.4,5


  • Judicious use of antibiotics in certain situations does have benefit in certain patients:



    • Complex strictures where there is a risk of retained contrast (i.e., hilar strictures, primary sclerosing cholangitis).


    • Immunosuppressed patients.


    • Contrast is injected during failed cannulation attempts.



INTRAPROCEDURAL CONSIDERATIONS


Sedation

Each institution differs in regard to preference for the type of sedation administered during an ERCP. Most institutions use an anesthesiologist or nurse anesthetist to provide sedation for ERCP cases, but some also provide nurse-administered sedation under the guidance of the endoscopist.

It is important to take into account the patient’s inherent risk of sedation based on cardiopulmonary status, physical examination (including the body measurement index [BMI] and Mallampati score), and presence of cervical spine disease when determining the level of sedation. In addition, the anticipated length and complexity of the planned procedure should
be considered when deciding how to sedate the patient. If the indication is for stent removal, a lower level of sedation may be required than for an ERCP planned in a patient with a hilar stricture. Furthermore, patient positioning may dictate the type of sedation given. In the prone position, airway patency and assessment of respirations are more difficult than in the left lateral or supine position. Therefore, general anesthesia is often preferred, but not required, if the patient is prone.


Patient Positioning

Typically patients are positioned either left lateral or prone during ERCP. Patient positioning is determined by endoscopist preference, anesthesiologist concerns (airway, respiratory stability), and patient factors (BMI, neck flexibility, abdominal wounds, abdominal distention). The prone position typically allows for better fluoroscopic imaging of the distal bile and pancreatic duct systems (easier to determine what duct is being cannulated) and the intrahepatic system. In addition, secretions tend to obscure duodenoscope visualization less in the prone position. Despite these theoretical advantages, studies have not shown a significant difference in technical success or adverse events between the two positions.8,9,10


Technique


Duodenoscope Insertion

Duodenoscope insertion is often the first step to learn during ERCP training. As compared to the standard gastroscope, the duodenoscope is side-viewing and has stiffer tip. With this side view, to gain passage through any opening (i.e., upper esophagus, lower esophagus, pylorus), the orifice needs to be positioned below the view of the scope. If the endoscopist can see the opening, the scope is not positioned correctly and will not advance through it. It is important not to push with significant force while advancing the duodenoscope to decrease the risk of perforation.

Tips to advance the duodenoscope to the papilla:



  • When inserting into the mouth, slightly reflect the up/down knob downward toward you in a counterclockwise fashion (tip up) until you pass the tongue.


  • Then reflect the up/down knob upward away from you in a clockwise fashion (tip down) to advance the scope to the back of the throat.


  • Use your right hand to make small right/left motions of the scope while gently advancing the duodenoscope to pass the cricopharyngeus and enter into the esophagus.



  • Passing through the esophagus should be relatively straightforward, continuing with the small right/let torquing movements of the duodenoscope shaft using your right hand while advancing the duodenoscope.


  • In the esophagus, be cautious in older patients or those with esophageal disorders who may have a tortuous esophagus.


  • At the lower esophageal sphincter, make sure you do not see the opening of the gastroesophageal junction in direct view. If you see the gastroesophageal opening in view, then reflect the up/down knob downward toward you in the counterclockwise direction (tip up) to put the opening at the 6-o’clock position, then gently advance the duodenoscope into the stomach.


  • In the stomach, similar to an upper endoscopy, torque the duodenoscope shaft to the right (clockwise) using your right hand while advancing the duodenoscope.


  • When you reach the antrum, reflect the up/down knob downward toward you in the counterclockwise direction (tip up) until you reach the pylorus.


  • Often when advancing the duodenoscope in the antrum, the pylorus can often be seen en face. Position the pylorus so it is lying in the 6-o’clock position below the duodenoscope and your view of the pyloric opening is lower and lower (similar to a “setting sun”) by reflecting the up/down knob downward toward you (tip up).


  • Once the duodenoscope enters the posterior duodenal bulb, rotate the duodenoscope shaft toward the right (clockwise), turn your body a little to the right, continue to hold the up/down knob a little downwards toward you (tip up) until you reach the descending duodenum


  • Shorten the scope by keeping the right torque of the duodenoscope shaft (some endoscopists lock it in this position), right torque of your body, then pull the duodenoscope back to allow it to naturally advance to the second/third portion of the duodenum. Continue to pull back on the scope until you see the papilla.


  • On fluoroscopy, the duodenoscope should look like a curved L in the short position, which is preferred in majority of cannulations (Fig. 25.3). Sometimes the long position is required for appropriate alignment of the papilla (Fig. 25.4). To move the scope into the long position, push the scope in with a right torque. Using fluoroscopy often helps to ensure that the scope is moving appropriately and it is important not to push against too much resistance as this is a technique that can rarely lead to a perforation.

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May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Basics of ERCP
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