Indications for ERCP

Patients with suspected choledocholithiasis can be stratified as having low, intermediate, or high probability for common bile duct (CBD) stones based on clinical criteria (bilirubin elevation, dilation of the CBD, presence of cholangitis). Patients with gallbladder in situ and low probability for CBD stones should directly undergo laparoscopic cholecystectomy with consideration for intraoperative cholangiogram (IOC). Patients in the intermediate probability group should undergo preoperative evaluation with endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP). Finally, patients in the high-probability group should undergo preoperative ERCP.

ERCP is the primary tool for treatment of documented choledocholithiasis if the stones are detected before or after laparoscopic cholecystectomy. Some controversy exists on the possible management strategies of bile duct stones detected at the time of laparoscopic cholecystectomy. Systematic review of randomized controlled studies showed that there was no significant difference between laparoscopic and ERCP clearance of CBD stones. Nevertheless, postoperative ERCP is the preferred method for treatment of CBD stones detected on IOC in the United States, because of its wide availability on the backdrop of relatively sparse surgical expertise in laparoscopic CBD exploration.

Instrumentation

Approximately 90% to 95% of CBD stones can usually be removed after endoscopic sphincterotomy by using balloon-tipped catheters or standard baskets. Larger stones are that difficult to remove may require specialized devices and techniques. If the main problem is that the stone is difficult to capture in the basket then a wire-guided, rotating, or multiwire basket can be applied. For large stones, mechanical lithotripsy with a basket-type device has been traditionally used. More recently the technique of using large (>12 mm) balloon dilation of the ampullary orifice after biliary sphincterotomy has gained popularity because of its simplicity, immediate availability, and high success rate. Of note, no increase in incidence of post-ERCP pancreatitis was observed. Although cholangioscopy-based lithotripsy with electrohydraulic lithotripsy (EHL) or laser has been available for more than 30 years, it just recently became feasible to use on a routine basis in everyday practice with the introduction of the SpyGlass Direct Visualization System (Boston Scientific Corporation, Natick, MA, USA) ( Fig. 1 ). SpyGlass-guided lithotripsy for bile duct stones that are difficult to remove has been shown to provide a high rate of stone clearance and low incidence of complications. The cumbersome technique of mechanical lithotripsy can be avoided in most cases.

Boston Scientific SpyGlass cholangioscope attached to the standard duodenoscope.

( Courtesy of Boston Scientific Corporation, Marlborough, MA; with permission.)

Indications for ERCP

ERCP is routinely done for evaluation of both benign and malignant biliary strictures because it can establish definitive tissue diagnosis and at the same time provide biliary drainage. The most common causes of benign biliary strictures are postoperative defect, chronic pancreatitis, trauma, and cholangiopathy (eg, primary or secondary sclerosing cholangitis). Malignant strictures are most frequently due to pancreatic cancer, ampullary cancer, cholangiocarcinoma, gallbladder cancer, and metastatic malignant lymphadenopathy.

Instrumentation

Various ERCP-based sampling modalities are available to establish the specific etiology of the stricture. More recently, the use of cholangioscopy-guided mini-forceps biopsy has been shown to increase the yield of ERCP-based sampling.

A multitude of stents for ERCP-based biliary drainage is commercially available. The choice of stent is determined by several factors including the etiology of the stricture, location of the lesion in the biliary tree (eg, distal versus proximal), patient prognosis, and the availability and cost of the specific device.

For benign biliary strictures, the standard endoscopic strategy for years has been to insert multiple plastic 10F stents over a period of 1 year with stent exchanges every 3 months. This strategy is highly effective for postoperative strictures with results in the range of 70% to 80%, but has been shown to have a relatively lower success rate for chronic pancreatitis–associated CBD stenosis (20%–30%). The main limitation of the treatment with multiple plastic stents is the need for multiple procedures over a long period of time and the relatively high incidence of cholangitis owing to stent occlusion. More recently, the use of fully covered metal stents has shown promising short-term results for the treatment of benign biliary strictures. The results of the long-term outcome studies that are currently under way are eagerly awaited.

Placement of a biliary stent in malignant obstruction is mostly palliative. For palliation purposes metal stents have been shown to be superior to plastic stents, because of their lower occlusion rate with the resulting lower incidence of cholangitis and need for stent exchanges. Although no uniform consensus exists, in general partially covered or fully covered stents are preferred for distal biliary obstruction, whereas uncovered metal stents are used for proximal lesions. In the past, insertion of plastic stents was routinely done as a bridge to surgery in resectable patients with jaundice. The main rationale for the procedure was that the insertion of the stent would lead to resolution of the jaundice and provide for improvement in nutritional status of the patient, which may ultimately enhance surgical outcomes. Surprisingly a recent randomized study demonstrated worse outcomes in patients with pancreatic cancer who underwent preoperative ERCP biliary drainage with plastic stent compared with patients who went directly to surgery. At present, one can consider sending patients directly to surgery without preoperative ERCP biliary drainage if the surgery can be done in a timely fashion (7–10 days from presentation) and the patient has a moderate degree of jaundice (total bilirubin <15 mg/dL).

Because bare and partially covered metal stents are very difficult and more frequently impossible to remove, until recently their deployment was reserved for patients with established tissue diagnosis of malignancy who were not considered to be surgical candidates. With the recent availability of fully covered metal stents, a new paradigm is emerging for the management of distal biliary strictures that appear to be malignant but without definitive tissue diagnosis available. The main premise is to insert a fully covered stent at the index ERCP. If the patient is later determined to have malignancy and is a surgical candidate, the stent can be easily removed at the time of surgery. Alternatively, the patients who have malignant biliary obstruction and are not surgical candidates can be followed clinically with no further interventions because the majority will be effectively palliated with the fully covered metal stent. Finally, in patients with benign disease the metal stent can be removed endoscopically at a later date and the stricture reevaluated at that time. The viability of the described strategy has to be validated by further studies.

Indications for ERCP

Patients with suspected choledocholithiasis can be stratified as having low, intermediate, or high probability for common bile duct (CBD) stones based on clinical criteria (bilirubin elevation, dilation of the CBD, presence of cholangitis). Patients with gallbladder in situ and low probability for CBD stones should directly undergo laparoscopic cholecystectomy with consideration for intraoperative cholangiogram (IOC). Patients in the intermediate probability group should undergo preoperative evaluation with endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP). Finally, patients in the high-probability group should undergo preoperative ERCP.

ERCP is the primary tool for treatment of documented choledocholithiasis if the stones are detected before or after laparoscopic cholecystectomy. Some controversy exists on the possible management strategies of bile duct stones detected at the time of laparoscopic cholecystectomy. Systematic review of randomized controlled studies showed that there was no significant difference between laparoscopic and ERCP clearance of CBD stones. Nevertheless, postoperative ERCP is the preferred method for treatment of CBD stones detected on IOC in the United States, because of its wide availability on the backdrop of relatively sparse surgical expertise in laparoscopic CBD exploration.

Instrumentation

Approximately 90% to 95% of CBD stones can usually be removed after endoscopic sphincterotomy by using balloon-tipped catheters or standard baskets. Larger stones are that difficult to remove may require specialized devices and techniques. If the main problem is that the stone is difficult to capture in the basket then a wire-guided, rotating, or multiwire basket can be applied. For large stones, mechanical lithotripsy with a basket-type device has been traditionally used. More recently the technique of using large (>12 mm) balloon dilation of the ampullary orifice after biliary sphincterotomy has gained popularity because of its simplicity, immediate availability, and high success rate. Of note, no increase in incidence of post-ERCP pancreatitis was observed. Although cholangioscopy-based lithotripsy with electrohydraulic lithotripsy (EHL) or laser has been available for more than 30 years, it just recently became feasible to use on a routine basis in everyday practice with the introduction of the SpyGlass Direct Visualization System (Boston Scientific Corporation, Natick, MA, USA) ( Fig. 1 ). SpyGlass-guided lithotripsy for bile duct stones that are difficult to remove has been shown to provide a high rate of stone clearance and low incidence of complications. The cumbersome technique of mechanical lithotripsy can be avoided in most cases.

Boston Scientific SpyGlass cholangioscope attached to the standard duodenoscope.

( Courtesy of Boston Scientific Corporation, Marlborough, MA; with permission.)

Indications for ERCP

ERCP is routinely done for evaluation of both benign and malignant biliary strictures because it can establish definitive tissue diagnosis and at the same time provide biliary drainage. The most common causes of benign biliary strictures are postoperative defect, chronic pancreatitis, trauma, and cholangiopathy (eg, primary or secondary sclerosing cholangitis). Malignant strictures are most frequently due to pancreatic cancer, ampullary cancer, cholangiocarcinoma, gallbladder cancer, and metastatic malignant lymphadenopathy.

Instrumentation

Various ERCP-based sampling modalities are available to establish the specific etiology of the stricture. More recently, the use of cholangioscopy-guided mini-forceps biopsy has been shown to increase the yield of ERCP-based sampling.

A multitude of stents for ERCP-based biliary drainage is commercially available. The choice of stent is determined by several factors including the etiology of the stricture, location of the lesion in the biliary tree (eg, distal versus proximal), patient prognosis, and the availability and cost of the specific device.

For benign biliary strictures, the standard endoscopic strategy for years has been to insert multiple plastic 10F stents over a period of 1 year with stent exchanges every 3 months. This strategy is highly effective for postoperative strictures with results in the range of 70% to 80%, but has been shown to have a relatively lower success rate for chronic pancreatitis–associated CBD stenosis (20%–30%). The main limitation of the treatment with multiple plastic stents is the need for multiple procedures over a long period of time and the relatively high incidence of cholangitis owing to stent occlusion. More recently, the use of fully covered metal stents has shown promising short-term results for the treatment of benign biliary strictures. The results of the long-term outcome studies that are currently under way are eagerly awaited.

Placement of a biliary stent in malignant obstruction is mostly palliative. For palliation purposes metal stents have been shown to be superior to plastic stents, because of their lower occlusion rate with the resulting lower incidence of cholangitis and need for stent exchanges. Although no uniform consensus exists, in general partially covered or fully covered stents are preferred for distal biliary obstruction, whereas uncovered metal stents are used for proximal lesions. In the past, insertion of plastic stents was routinely done as a bridge to surgery in resectable patients with jaundice. The main rationale for the procedure was that the insertion of the stent would lead to resolution of the jaundice and provide for improvement in nutritional status of the patient, which may ultimately enhance surgical outcomes. Surprisingly a recent randomized study demonstrated worse outcomes in patients with pancreatic cancer who underwent preoperative ERCP biliary drainage with plastic stent compared with patients who went directly to surgery. At present, one can consider sending patients directly to surgery without preoperative ERCP biliary drainage if the surgery can be done in a timely fashion (7–10 days from presentation) and the patient has a moderate degree of jaundice (total bilirubin <15 mg/dL).

Because bare and partially covered metal stents are very difficult and more frequently impossible to remove, until recently their deployment was reserved for patients with established tissue diagnosis of malignancy who were not considered to be surgical candidates. With the recent availability of fully covered metal stents, a new paradigm is emerging for the management of distal biliary strictures that appear to be malignant but without definitive tissue diagnosis available. The main premise is to insert a fully covered stent at the index ERCP. If the patient is later determined to have malignancy and is a surgical candidate, the stent can be easily removed at the time of surgery. Alternatively, the patients who have malignant biliary obstruction and are not surgical candidates can be followed clinically with no further interventions because the majority will be effectively palliated with the fully covered metal stent. Finally, in patients with benign disease the metal stent can be removed endoscopically at a later date and the stricture reevaluated at that time. The viability of the described strategy has to be validated by further studies.