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 27 May 2018

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Editor: Peter B. Cotton

1. ERCP overview—A 30-year perspective

Peter B. Cotton

Top of page Historical background  Next section

Endoscopic cannulation of the papilla of Vater was first reported in 1968 [1]. However, it was really put on the map shortly afterwards by several Japanese groups, working with instrument manufacturers to develop appropriate long side-viewing instruments [2–5]. The technique (initially called ECPG—Endoscopic CholangioPancreatoGraphy—in Japan) spread throughout Europe in the early 1970s [6–13]. Early efforts were much helped by a multinational workshop at the European Congress in Paris in 1972, organized by the Olympus company. ERCP rapidly became established worldwide as a valuable diagnostic technique, although doubts were expressed in the USA about its feasibility and role [14], and the potential for serious complications soon became clear [15–18]. ERCP was given a tremendous boost by the development of its therapeutic applications, notably biliary sphincterotomy in 1974 [19–21], and biliary stenting 5 years later [22,23].

It is difficult for most gastroenterologists today to imagine the diagnostic and therapeutic situation 30 years ago. There were no scans. Biliary obstruction was diagnosed and treated surgically, with substantial operative mortality. Nonoperative documentation of biliary pathology by ERCP was a huge step forward. Likewise, ERCP was an amazing development in pancreatic investigation at a time when the only available test was laparotomy. The ability to 'see into' the pancreas, and to collect pure pancreatic juice [24] seemed like a miracle. We assumed that ERCP would have a dramatic impact on chronic pancreatitis and pancreatic cancer. Sadly, these expectations are not yet realized, but endoscopic management of biliary obstruction was clearly a major clinical advance, especially in the sick and elderly. The period of 15 or so years from the mid 1970s really constituted a 'golden age' for ERCP. Despite significant risks [25], it was quite obvious to everyone that ERCP management of duct stones and tumours was easier, cheaper, and safer than available surgical alternatives. Large series were published, including some randomized trials [26–31]. Percutaneous transhepatic cholangiography (PTC) and its drainage applications were also developed during this time, but were used (with the exception of a few units) only when ERCP failed or was not available. The 'combined procedure'—endoscopic cannulation over a guidewire placed at PTC [32,33]—became popular for a while, but was needed less as both endoscopic and interventional techniques improved.

Top of page The changing world of pancreatic–biliary medicine  Previous section Next section

The situation has changed in many ways during the last two decades. ERCP has evolved significantly, but so have many other relevant techniques.

The impact of scanning radiology  Previous section Next section

Imaging modalities for the biliary tree and pancreas have proliferated. High quality ultrasound, computed tomography, endoscopic ultrasonography, and MR scanning (with MRCP) have greatly facilitated the non-invasive evaluation of patients with known and suspected biliary and pancreatic disease. The proportion of ERCP examinations now done purely for diagnosis has diminished dramatically.

Extending the indications for therapeutic ERCP  Previous section Next section

The second major change has been the attempt of ERCP practitioners to extend their therapeutic territory into more complex areas like pancreatitis and suspected sphincter of Oddi dysfunction. The value of ERCP in these contexts remains controversial.

Improvements in surgery  Previous section Next section

The third major change is the substantial and progressive reduction in risk associated with conventional surgery (due to excellent perioperative and anaesthesia care) and the increasing use of less invasive laparoscopic techniques [34]. It is no longer correct to assume that ERCP is always safer than surgery. Sadly, bad complications of ERCP (especially pancreatitis and perforation) continue to occur, especially during speculative procedures done by inexperienced practitioners, often using the needle knife for lack of standard expertise [35]. These facts are forcing the ERCP community to search for ways to reduce the risks. Important examples of this preoccupation are the focus on refining indications [36], prospective studies of predictors of adverse outcomes [37], and attempts to remove stones from the bile duct without sphincterotomy, at least in younger patients with relatively small stones and normal sized ducts, which we see much more often in the era of laparoscopic cholecystectomy [38]. Equally important is the increasing focus on who should be trained, and to what level of expertise. How many ERCPists are really needed?

Patient empowerment  Previous section Next section

The fourth major development in this field is the increased participation of patients in decisions about their care. Patients are rightly demanding the data on the potential benefits, risks, and limitations of ERCP, and the same data about the alternatives [39].

Current focus  Previous section Next section

The focus in the early twenty-first century is on careful evaluation of what ERCP can offer (in comparison with available alternatives), and on attempts to improve the overall quality of ERCP practice. These issues are important in all clinical contexts, but come into clearest focus where ERCP is still considered somewhat speculative, e.g. in the management of chronic pancreatitis and of possible sphincter of Oddi dysfunction [36,40].

Top of page Benefits and risks  Previous section Next section

Evaluation of ERCP is a complex topic [41]. Its role is very much dependent on the clinical context [Fig. 1], and colleagues contributing to this resource provide guidance about the current state of practice in their main topic areas. This discussion focuses on the general difficulties in defining the role and value of ERCP [36]. Figure 2 attempts to illustrate all of the elements of the 'intervention equation'. There is much talk about 'outcomes studies', but 'outcomes' cannot be assessed without detailed knowledge of the precise 'incomes'. Thus, a patient with certain demographics, disease type, size, and severity causing a specific level of symptoms, disability, and life disruption is offered an ERCP intervention by a certain individual with a particular experience and skill level, with certain expected, planned, burdens (i.e. pain, distress, disruption, and costs). All of these metrics need clear and agreed definitions if we are to make any sense of the evaluation [36]. The conjunction of the patient and that intervention result in the 'outcomes'[Fig. 2]. Ultimately, we are most interested in the clinical outcome (reduced burden of symptoms and disease), but there are many factors along the way, including the technical results (influenced by the 'degree of difficulty') and the occurrence of unplanned events (or complications), which add to the actual burden.

Degree of difficulty and expertise  Previous section Next section

Some ERCP procedures are more technically challenging than others. Most can be predicted beforehand (e.g. known Billroth 2 resection, hilar tumour). A five-level scoring system for degree of difficulty was developed [42] and later simplified to three grades (Fig. 3[36]). Grade 1 procedures are those (mainly biliary) interventions which anyone offering ERCP should be able to achieve to a reasonable level of expertise. Grade 3 procedures are the most difficult, and are performed mainly in tertiary referral centres.

It is clear that some ERCP practitioners are more skilled than others. Some, like most of those just emerging from standard training programs, will be comfortable only with Grade 1 cases, where they should be technically successful in about 90 per cent of attempts. Endoscopists with more training (e.g. a dedicated 4th year in the USA), and those who have honed their skills in practice with the aid of community and academic colleagues, will attempt more complex cases. So-called experts, working in referral centres, will tackle all comers, but will also have very high success rates in the easier cases. These concepts of case difficulty and individual expertise can usefully be combined [Fig. 4]. A key and sensitive issue is whether and how widely these variations in expertise should be advertized.

Report cards  Previous section Next section

We are becoming accustomed to seeing 'league tables' of hospitals according to outcomes of major procedures, such as cardiovascular surgery and pancreatico-duodenectomy. Increasingly there is interest in drilling down further to the individual practitioner. The American Society for Gastrointestinal Endoscopy has recommended the use of 'report cards', i.e. summaries of the practice of individual endoscopists [43]. An example of a report card for one ERCP expert is shown in Fig. 5. Report cards are unlikely to become mandatory. What is the motivation for less expert endoscopists to provide data? Patients are increasingly advised to ask their potential interventionists about their experience. Some patients will certainly hesitate if their practitioners are not able to provide benchmark data. Well-trained and skilful practitioners should wear their data as badges of quality [39].

Unplanned events  Previous section Next section

The word 'complication' is emotive, raising issues of medical error and legal liability. We prefer to discuss 'unplanned events', since they are best described simply as deviations from the plan which had been agreed with the patient [36]. The phrase 'adverse events' has been used also, but not all unplanned events are negative. A patient with suspected cancer may be delighted to wake up from a procedure with an unexpected cure (sphincterotomy and stone removal). All unplanned events should be documented in a standard format [36], as an aid to efforts at quality improvement. Some events relatively trivial, such as transient hypotension or self-limited bleeding. At what level of severity do the events become 'complications'? An influential consensus conference [44] set the threshold at the need for hospital admission and defined levels of severity by the length of stay, as well as the need for surgery or intensive care [36,44]. Details of complications, their avoidance and management, are addressed in detail elsewhere in this Advanced Endoscopy e-book series.

Clinical success and value  Previous section Next section

Clinical success may sometimes be relatively obvious, e.g. removal of a stone, or relief of jaundice with a stent. However, in many cases (e.g. chronic pancreatitis, sphincter dysfunction), the judgement can be made only after long periods of follow-up. This greatly complicates evaluation studies in just the clinical circumstances where the knowledge is needed most. Patient satisfaction is another important parameter. It is determined partly by the clinical results (and how that compares with the patient's expectation), but also by the patient's perception of the process (accessibility, courtesy, etc.). The cost (burden) of the intervention is obviously a key consideration. This consists of the planned burden, plus the result of any unplanned events. The ratio between the clinical impact (benefit) and the burden (cost) determines the 'value' of the procedure in that individual patient [45]. Attempts to provide definitions for all of these metrics are advancing slowly. Their incorporation in endoscopy reporting databases will allow on-going useful outcomes evaluations to guide further decisions. If the same or similar metrics are used also by those performing alternative interventions such as surgery, we will get a clearer idea of the relative roles of these different procedures [46]. In some cases randomization will be necessary to make a final judgement. However, the issue of 'operator dependence' will always exist. A randomized trial of two techniques performed by experts may not be the best guide to the choice of intervention in everyday community practice.

Top of page The future  Previous section Next section

The trends which we have outlined are likely to continue and to accelerate in the coming years. Quality is the big issue. That means making sure that we are doing the right things, and doing them right. It has been clear for a long time (but only now becoming generally accepted) that ERCP is a procedure that should be undertaken only by a minority of gastroenterologists. The amount of training and continuing dedication in practice needed to attain and maintain high levels of competence, and to improve, means that the procedures should be focused in relatively few hands. The increasing variety and safety of alternative procedures, and the vigilance of our customers, will drive that agenda. The other imperative is to pursue the research studies necessary to improve current methods and to evaluate all of them rigorously. This is best done in collaboration with colleagues in surgery and radiology to establish the best methods for approaching patients with known or suspected biliary and pancreatic disease. The dynamics between specialists will change with time, which is one excellent reason for organizing care to be patient-focused, rather than in traditional technical silos. Multidisciplinary organizations, like our Digestive Disease Center at the Medical University of South Carolina, attempt to provide that perspective and a platform for the unbiased research and education aimed at improving the quality of service [47].

Top of page References  Previous section

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18 Bilbao, MK, Dotter, CT, Lee, TG & Katon, RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology 1976; 70: 314–20. PubMed

19 Classen, M & Demling, L. Endoskopische sphinkterotomie der papilla Vateri und steinextraktion aus dem ductus choledochus. Deutsche Med Wochenschrift 1974; 99: 496–7.

20 Kawai, K, Akasaka, Y, Murakami, K, Tada, M, Kohill, Y & Nakajima, M. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974; 20: 148–51. PubMed

21 Cotton, PB, Chapman, M, Whiteside, CG & LeQuesne, LP. Duodenoscopic papillotomy and gallstone removal. Br J Surg 1976; 63: 709–14. PubMed

22 Soehendra, N & Reijnders-Frederix, V. Palliative bile duct drainage. A new endoscopic method of introducing a transpapillary drain. Endoscopy 1980; 12: 8–11. PubMed

23 Laurence, BH & Cotton, PB. Decompression of malignant biliary obstruction by duodenoscope intubation of the bile duct. Br Med J 1980; 280 (6213) 522–3. PubMed

24 Robberrecht, P, Cremer, M, Vandermers, A, Vandermers-Piret, M-C, Cotton, PB & de Neef, P et al. Pancreatic secretion of total protein and three hydrolases collected in healthy subjects via duodenoscopic cannulation. Effects of secretin, pancreozymin and caerulein. Gastroenterology 1975; 69: 374–9. PubMed

25 Byrne, P, Leung, JWC & Cotton, PB. Retroperitoneal perforation during duodenoscopic sphincterotomy. Radiology 1984; 150: 383–4. PubMed

26 Vaira, D, Ainley, C, Williams, S, Caines, S, Salmon, P & Russell, C et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989; 2: 431–4. PubMed

27 Cotton, PB. Endoscopic management of bile duct stones (apples and oranges). Gut 1984; 25: 587–97. PubMed

28 Leung, JWC, Emery, R, Cotton, PB, Russell, RCG, Vallon, AG & Mason, RR. Management of malignant obstructive jaundice at The Middlesex Hospital. Br J Surg 1983; 70: 584–6. PubMed

29 Cotton, PB. Endoscopic methods for relief of malignant obstructive jaundice. World J Surg 1984; 8: 854–61. PubMed

30 Speer, AG, Cotton, PB, Russell, RCG, Mason, RR, Hatfield, ARW & Leung, JWC et al. Randomized trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987; 2: 57–62. PubMed

31 Smith, AC, Dowsett, JF, Russell, RCG, Hatfield, ARW & Cotton, PB. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet 1994; 344: 1655–60. PubMed

32 Shorvon, PJ, Cotton, PB, Mason, RR, Siegel, HJ & Hatfield, ARW. Percutaneous transhepatic assistance for duodenoscopic sphincterotomy. Gut 1985; 26: 1373–6. PubMed

33 Dowsett, JF, Vaira, D, Hatfield, AR, Cairns, SR, Polydorou, A & Frost, R et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989; 96: 1180–6. PubMed

34 Cotton, PB, Chung, SC, Davis, WZ, Gibson, RM, Ransohoff, DF & Strasberg, SM. Issues in cholecystectomy and management of duct stones. Am J Gastroenterol 1994; 89: S169–76. PubMed

35 Cotton, PB. ERCP is most dangerous for people who need it least. Gastrointest Endosc, 2001; 54(4) 535–6. PubMed

36 Cotton, PB. Income and outcome metrics for objective evaluation of ERCP and alternative methods. Gastrointest Endosc 2002; 56(6 suppl):S283–90. PubMed

37 Freeman, ML, DiSario, JA, Nelson, DB, Fennerty, MB, Lee, JG & Bjorkman, DJ et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001; 54: 425–34. PubMed

38 Huibregtse, K. Endoscopic balloon dilation for removal of bile duct stones: special indications only. Endoscopy 2001; 33 (7): 620–2. PubMed

39 Cotton, PB. How many times have you done this procedure, Doctor? Am J Gastroenterol 2002; 97: 522–3. PubMed

40 Lehman, GA & Sherman, S. Sphincter of Oddi dysfunction. Int J Pancreatol 1996; 20: 11–25. PubMed

41 Cotton, PB. Therapeutic gastrointestinal endoscopy. Problems in proving efficacy. N Engl J Med 1992; 326: 1626–8. PubMed

42 Schutz, SM & Abbott, RM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc 2000; 51: 535–9. PubMed

43 American Society for Gastrointestinal Endoscopy. Quality and outcome assessment in gastrointestinal endoscopy. Gastrointest Endosc 2000; 52(6): 827–30.

44 Cotton, PB, Lehman, G, Vennes, J, Geenen, JE, Russell, RCG & Meyers, WC et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383–93. PubMed

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46 Cotton, PB. Randomization is not the (only) answer: a plea for structured objective evaluation of endoscopic therapy. Endoscopy 2000; 32: 402–5. PubMed

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Copyright © Blackwell Publishing, 2003

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Historical background
The changing world of pancreatic–biliary medicine
  The impact of scanning radiology
  Extending the indications for therapeutic ERCP
  Improvements in surgery
  Patient empowerment
  Current focus
Benefits and risks
  Degree of difficulty and expertise
  Report cards
  Unplanned events
  Clinical success and value
The future
  Imaging of the pancreatico-biliary system
   ERCP vs. PTC
Section I: Preparation for ERCP
  Room set-up and floor plan (Figs 1, 2)
   Position of monitors and endoscopy cart (Fig. 2)
  Essential equipment for ERCP
   Side-viewing duodenoscopes
   Forward-viewing scopes
   Sedatives and analgesics
   Smooth muscle relaxants
   Reversal agents
  Monitoring during conscious sedation
  Contrast agents
   Syringes for aspiration and irrigation
  Organization and storage of accessories (Fig. 4)
  Organization of the worktop (Fig. 5)
  Fluoroscopy for ERCP
   Fluoroscopy units (Fig. 6)
   KV and mA
   Split screen
   Magnified view
   Orientation of fluoroscopic images
   Personnel protection (Fig. 8)
   Other protective gear
   Positioning of the patient
  Radiological interpretation
   Scout film (Fig. 7)
   Contrast studies
   Drainage films
   The pancreatogram
   Normal anatomy
   Pathological changes
   Congenital anomalies
   The cholangiogram
   Normal anatomy
   Pathological strictures
   Bile duct stones (Fig. 11)
   Underfilling and delayed drainage
Section II: Diagnostic and therapeutic ERCP
  Diagnostic ERCP
   Accessories (Fig. 13)
   Preparation of patient
   Informed consent
  ERCP procedure
   Intubation and examination of the stomach
   Approaching the main papilla
   Cannulation of the papilla
   Ease and success in cannulation
   Minor papilla cannulation
  Complications of diagnostic ERCP
   Respiratory depression and other complications
  Failed cannulation and special situations
   What to do with a difficult intubation
   Failure to insert the duodenoscope
   Lost in the stomach
   Failure to identify the papilla
   Tip of endoscope is too proximal
   Tip of scope is too distal
   Obscured papilla
   What to do if cannulation is difficult
   Abnormal papilla
   Failed common duct cannulation
   Failed pancreatic duct cannulation
   Failed accessory (minor) papilla cannulation
   Failure to obtain get deep CBD cannulation
   Precut sphincterotomy to assist in CBD cannulation
   Needle-knife precut technique
   Selective cannulation of the intrahepatic system (IHBD)
   Cannulation of the papilla in a Billroth II situation(Fig. 17)
  Therapeutic ERCP
   Standard endoscopic sphincterotomy or papillotomy (Fig. 18)
   Preparation of patients
   Laboratory tests
   The sphincterotome (or papillotome)
   Electrosurgical unit
   Adequacy of sphincterotomy
   Wire-guided sphincterotomes
   Periampullary diverticula and sphincterotomy
   Distorted anatomy
   Precut sphincterotomy for impacted stone
   Indications for sphincterotomy and results
   Complications of sphincterotomy
   Post sphincterotomy bleeding
   What to do if the sphincterotomy fails to cut
   The risk of a half cut
   What to do with a deviated cut
   Sphincterotomy in Billroth II cases
   Stone extraction (Figs 19, 20)
   Endoscopic nasobiliary catheter drainage for bile duct obstruction (Fig. 24)
   Endoscopic plastic stent insertion for malignant biliary obstruction (Fig. 26)
   Preparation of patient
   One-step introducer system
   Bilateral stenting for hilar obstruction
   Brushing cytology for bile duct strictures (Fig. 27)
   Single-lumen system
   Double-lumen system
   Assessment of response to biliary stenting
   Results of biliary stenting
   Complications of stenting
   Early complications
   Late complications
   Self-expandable metal stents
   Stent configurations
   Lengths of stents
   Introducer system for SEMS
   Balloon dilation of biliary strictures (Fig. 28)
   Endoscopic management of bile leaks
Outstanding issues and future trends
  Incidence of CBD stones
  Traditional management
  Non-operative approach to CBD stones
  Classification of CBD stones
   Primary CBD stones
   Bacteriology of primary CBD stones
   Secondary CBD stones
Clinical presentations
  Asymptomatic biliary stones
  Symptomatic biliary stones
   Obstructive jaundice
   Clinical cholangitis
   Biliary pancreatitis
   Oriental cholangitis or recurrent pyogenic cholangitis
  Clinical diagnosis
   Abdominal ultrasound scan
   Endoscopic retrograde cholangiopancreatography (ERCP)
   Magnetic resonance cholangiogram (MRC) for CBD stones
   Endoscopic ultrasonography (EUS) for CBD stones
Management for CBD stones
  ERCP, sphincterotomy, and stone extraction
   Endoscopic sphincterotomy
   Choice of endoscopes
   Cannulation with sphincterotome
   Stone extraction
   Basket stone extraction
   Balloon stone extraction
  Acute pancreatitis
  Sphincterotomy vs. balloon sphincteroplasty
   Balloon sphincteroplasty
   Balloon sphincteroplasty for CBD stones
   Sphincterotomy for CBD stones
   Long-term complications of sphincterotomy
  ERCP vs. laparoscopic common duct exploration for retained CBD stones
   Preoperative ERCP
   Operative removal of CBD stones
   Factors that predict CBD stones
   MRC for detection of CBD stones
   Risk scores for prediction of CBD stones
Alternative approaches to CBD stones
  Precut sphincterotomy for failed deep cannulation
   Complications of precut sphincterotomy
  Percutaneous transhepatic cholangiogram and drainage
   Rendezvous procedure (two-hands technique)
   Percutaneous stone extraction
The challenge: giant CBD stones
  Basket mechanical lithotripsy (BML)
  Through-the-scope BML using a metal sheath
   Results of BML
  Mother and baby choledochoscopy and intraductal lithotripsy
   Electrohydraulic lithotripsy (EHL)
   Intraductal laser lithotripsy
  Stenting and interval endoscopic lithotripsy
   Effects of stenting on CBD stones
   The need for stone extraction after stenting
  Extracorporeal shock-wave lithotripsy (ESWL)
   Results of ESWL for CBD stones
  Open surgery
Intrahepatic duct stones
  ERCP and basket removal
  Wire-guided basket
  Percutaneous transhepatic cholangioscopy (PTC)
   Results of percutaneous treatment of intrahepatic stones
ERCP and sphincterotomy in Billroth II gastrectomy
  Precaution and alternatives for Billroth II gastrectomy
  Side-viewing vs. forward-viewing scope for ERCP in Billroth II gastrectomy
   Effect of biliary obstruction on the reticuloendothelial system
   Bacteriology of cholangitis
   Effect of raised intrabiliary pressure and cholangiovenous reflux
  Clinical presentation
   Simple cholangitis: Charcot's triad
   Suppurative cholangitis: Reynold's pentad
  Clinical management
   Initial conservative management
   Urgent biliary decompression
   Role of ERCP
   Endoscopic drainage vs. surgery
   ERCP vs. PTBD
   Nasobiliary catheter drainage vs. stenting in acute cholangitis
   Surgery to prevent recurrent cholangitis
   Types of operation
Outstanding issues and future trends
ERCP in diagnosis of pancreatico-biliary malignancies
  Radiological diagnosis
   Significance of 'double duct stricture' sign
  Tissue diagnosis
   Brush cytology, biopsy, and FNA
  Tumor markers in bile or pancreatic juice
Direct endoscopic examination of pancreatico-biliary malignancies
Intraductal ultrasound [IDUS]
Magnetic resonance cholangiopancreatography
Palliation of inoperable pancreatico-biliary malignancies
  Endoscopic stenting for malignant jaundice
   Technique of endoscopic stent insertion
   Types of stents
   Plastic stents
   Metal stents
   Metal vs. plastic stents
   Covered and uncovered metal stents
   Biodegradable stents
   Endoscopic stenting for hilar strictures
   Bismuth classification for hilar obstruction
   Unilateral vs bilateral drainage for hilar obstruction
  Other techniques of endoscopic palliation
   Intraductal photodynamic therapy
ERCP in management of ampullary neoplasms
  Benign tumors
   Ampullary carcinoma
Outstanding issues and future trends
Classification of bile duct injuries
Diagnostic protocol
Management of bile duct leakage after cholecystectomy
  Type A injury (peripheral leaks)
  Type B injury (main duct leaks)
  Type C injuries (postoperative biliary strictures)
  Type D injury (transections)
   Delayed reconstruction
Surgical treatment of postoperative biliary strictures
Percutaneous treatment of postoperative strictures
Endoscopic treatment of postoperative biliary strictures
  Reported results
  Phases of endoscopic treatment
   Stent insertion phase
   Stenting phase
   Follow-up phase
Postoperative biliary strictures: surgery or endoscopy [43]?
  Recurrent strictures after surgery
Metal stents for benign strictures
A more aggressive treatment protocol?
Outstanding issues and future trends
  Sphincter of Oddi dysfunction
  Sphincter of Oddi stenosis
Classification of SOD
  SOD in patients with gallbladder disease
  SOD after cholecystectomy
  SOD in the biliary or pancreatic sphincter, or both
  SOD and pancreatitis
Clinical presentation
  The Rome criteria
Initial evaluation
  Serum chemistries
  Standard imaging
Non-invasive diagnostic methods for SOD
  Morphine–prostigmin provocative test (Nardi test)
  Radiographic assessment of extrahepatic bile duct and main pancreatic duct diameter after secretory stimulation
   Ultrasound provocation testing
   Endoscopic ultrasound monitoring
   MRCP monitoring
  Quantitative hepatobiliary scintigraphy
   Adding morphine provocation
  Comparing non-invasive tests
  Current status of non-invasive methods
Invasive diagnostic methods for SOD
  Intraductal ultrasonography (IDUS)
Sphincter of Oddi manometry
  Sphincter of Oddi manometry: technique and indications
   Drug interactions
   Manometry catheters
   Cannulation techniques
   Study both sphincters
  Interpretation of manometry traces
   Normal values
  Complications of SOM
   Methods to reduce complications
   Aspirating catheter system
   Prophylactic stenting
  Sphincter of Oddi manometry; conclusion
   Type I patients
   Type II patients
   Type III patients
Therapy for sphincter of Oddi dysfunction
  Medical therapy
   Electrical nerve stimulation
  Surgical therapy
  Endoscopic balloon dilation and biliary stent trials
  Endoscopic sphincterotomy
   Randomized controlled trials of endoscopic sphincterotomy for SOD
   Is pancreatic sphincterotomy necessary?
  Risks and benefits of endoscopic treatment for SOD
  Botulinum toxin injection
Sphincter of Oddi dysfunction in recurrent pancreatitis
  Endoscopic sphincterotomy for SOD in pancreatitis
   Lans and colleagues
   Guelrud and colleagues
   Kaw and Brodmerkel
   Toouli and colleagues
   Okolo and colleagues
  Endoscopic sphincterotomy as a cause of pancreatic sphincter stenosis
  Endoscopic Botox injection
  SOD in recurrent pancreatitis: conclusion
Outstanding issues and future trends
Interdisciplinary management; complex ERCP
Acute gallstone pancreatitis
  Clinical diagnosis of acute gallstone pancreatitis
  Predicting severity of acute pancreatitis
  Acute treatment
  The role of early ERCP
   British study
   Hong Kong study
   Polish study
   German study
   Meta-analysis of studies of early ERCP, and current consensus
   ERCP is rarely indicated before cholecystectomy in patients with gallstone pancreatitis
   Acute pancreatitis postcholecystectomy
   Treatment by biliary sphincterotomy alone?
Pancreatic duct disruptions
  Stenting for duct disruption
Smoldering pancreatitis
Acute recurrent pancreatitis
  'Idiopathic' pancreatitis
  Microlithiasis and occult gallstones
   Detecting microlithiasis
   Bile crystals
   Empiric cholecystectomy?
  Sphincter of Oddi dysfunction (SOD)
   Diagnosis of SOD
   Endoscopic therapy for SOD
   Sphincterotomy without sphincter manometry?
   Is sphincter manometry dangerous?
   SOD in patients with intact gallbladders
  Pancreas divisum
   Does pancreas divisum cause pancreatitis?
   Endoscopic treatment for pancreas divisum
   Stenting for pancreas divisum
   Problems with endoscopic therapy
  Chronic pancreatitis (idiopathic, alcohol, familial, other)
   Endoscopic therapy for chronic pancreatitis
  Pancreatitis due to neoplastic obstruction
   Endoscopic management of neoplastic obstruction
   Stenting for smoldering pancreatitis due to malignancy
  Other rare causes of pancreatitis
Overall approach to unexplained acute pancreatitis
  Concerns about ERCP and empiric sphincterotomy in recurrent acute pancreatitis
   Risks of ERCP
  Investigations other than ERCP
  Recommended approach to ERCP for acute recurrent pancreatitis
  Final diagnosis in recurrent acute pancreatitis after extensive investigation
   Our experience
   Occult neoplasms
   Endoscopic treatment and results
Outstanding issues and future trends
Chronic pancreatitis
Treatments for chronic pancreatitis
  Medical therapy
  Surgical therapy
  Endoscopic treatment for chronic pancreatitis
   Safety issues
   Indications for endoscopic treatment
   Results of endoscopic treatment
Pancreatic ductal strictures
  Pancreatic stent placement techniques
  Efficacy of pancreatic duct stenting
   Cremer and colleagues
   Ponchon and colleagues
   Smits and colleagues
   Ashby and Lo
   Hereditary and early onset pancreatitis
   Predicting the outcome
  Duration of stenting
  Does response to stenting predict the outcome of surgery?
  Long-term follow-up
  Complications associated with pancreatic stents
   Stent-induced duct changes
   Brief mini-stents
Pancreatic ductal stones
  Causes of pancreatic ductal stones
  Stones cause obstruction
  Endoscopic techniques for stone extraction
   Pancreatic sphincterotomy
   Biliary sphincterotomy also?
   Pancreas divisum
   Stone removal
   Results of endoscopic treatment for stones
   Sherman and colleagues
   Smits and colleagues
   Cremer and colleagues
   Summary results
   Endoscopic therapy with ESWL
   Sauerbruch and colleagues
   The Brussels group
   Kozarek and colleagues
   Farbacher and colleagues
   Intraductal lithotripsy
   Medical treatment for stones
   Overall results for stone treatment
Pancreatic pseudocysts
  Endoscopic treatment for pseudocysts
Biliary obstruction in chronic pancreatitis
  Standard biliary stents
   Deviere and colleagues
   The Amsterdam group
   Barthet and colleagues
  Metal stents for biliary obstruction?
  Biodegradable stents
  Stenting for biliary strictures and chronic pancreatitis: conclusion
Sphincter of Oddi dysfunction in chronic pancreatitis
  Pathogenesis of SOD in chronic pancreatitis
  Frequency of SOD in chronic pancreatitis
  Surgical sphincter ablation
  Endoscopic pancreatic sphincterotomy
Pancreas divisum
  Pancreas divisum: a cause of pancreatitis?
  Minor papilla ablation
Outstanding issues and future trends
Toxic and metabolic complications
Pancreatic fluid collections
Pseudocysts and abscesses
Pancreatic necrosis
  Organizing necrosis
Miscellaneous complications
  Pancreatic fistulas
  Ductal disruption
  Vascular complications
   Venous thrombosis
Arterial complications
Outstanding issues and future trends
Patient preparation
  Sedation for ERCP in children
  Antibiotic prophylaxis
  Other medication
  Biliary indications
  Pancreatic indications
Success rates for ERCP in children
Biliary findings (Fig. 3)
  Biliary atresia vs. neonatal hepatitis
   ERCP findings
  Miscellaneous genetic cholestatic diseases
  Bile plug syndrome
  Choledochal cyst
   Pathogenesis of choledochal cyst
   Classification of anomalous ductal union
   Classification of choledochal cysts
   Type I
   Type II
   Type III
   Type IV
   Type V
   Treatment of choledochal cysts
   Fusiform choledochal dilatation and carcinoma
  Primary sclerosing cholangitis
  Parasitic infestation
   ERCP for stones
  Biliary strictures and leaks
   Primary stricture
   Malignant strictures
   Liver transplantation
   Bile leaks
Pancreatic findings (Fig. 17)
  Recurrent pancreatitis
   Choledochal cyst and anomalous pancreatico-biliary union
   Pancreas divisum
   Prevalence of pancreas divisum
   Significance of pancreas divisum
   ERCP diagnosis of pancreas divisum
   Treatment of pancreas divisum
   Other pancreatic congenital anomalies
   Duodenal duplication cyst
   Sphincter of Oddi dysfunction
   Pancreatic trauma
   Acquired immunodeficiency syndrome
  Chronic pancreatitis
   Endoscopic treatment of chronic pancreatitis in children
  Pancreatic pseudocysts
Outstanding issues and future trends
The risks of ERCP
  Risks for endoscopists and staff
  Technical failure
   Degree of difficulty scale for ERCP procedures (Fig. 1)
   Level 1
   Level 2
   Level 3
   Defining intent
   Risk consequences of technical failure
  Clinical failure
Unplanned adverse clinical events—complications
  When does an event become a complication?
   Complication definition
   Severity criteria
  Types of adverse clinical events
  Timing of events and attribution
  A dataset for unplanned events
Overall complication rates
  Accuracy of data collection
  Changes in complications over time
  Complication rates at MUSC
General risk issues
  Operator-related issues
  Patient-related issues; clinical status, indications, and comorbidities
   Illness and associated conditions
   Anatomical factors
   Complication-specific risk factors
  Procedure performed
   Diagnostic or therapeutic?
   Biliary sphincterotomy
   Pancreatic sphincterotomy
   Precut sphincterotomy
   Repeat sphincterotomy
   Balloon sphincter dilation
   Endoscopic papillectomy
   Pseudocyst drainage
Reducing the risks of ERCP: general issues
  The contract with the patient; informed consent
   Educational materials
  Care after ERCP
   Early refeeding?
Pancreatitis after ERCP
  Incidence of pancreatitis after ERCP
  Risk factors for pancreatitis
   Patient factors increasing the risk [114,115,122,123]
   Procedure factors increasing the risk
   Pancreatic manipulation
   Sphincter manometry
   Biliary sphincter dilation
   Biliary stenting
   Pancreatic stenting
   Combining patient- and procedure-related factors
  Prevention of pancreatitis after ERCP
   Avoiding ERCP, especially in high-risk patients
   Mechanical factors
   Contrast agents
   Pharmacological prophylaxis
   Pancreatic stenting to prevent pancreatitis
   Feeding and monitoring
  Post-ERCP pancreatitis, recognition, and management
  Post-ERCP pancreatitis, conclusion
  Duct and tumor 'penetrations'
  Sphincterotomy-related perforation
   Risk factors for sphincterotomy perforation
   Recognition of sphincterotomy perforation
   Reducing risks of sphincterotomy perforation
   Management of sphincterotomy perforation
  Perforation remote from the papilla
   Recognition and management of endoscopic perforation
  Stent migration perforation
Infection after ERCP
  Nosocomial infection
  Pancreatic sepsis
  Prophylactic antibiotics
  Delayed infection
Bleeding after ERCP
  Definition of bleeding, and incidence
  Risk factors for bleeding, and avoidance
  Management of sphincterotomy bleeding
   Delayed bleeding
Complications of stents
  Blockage of (plastic) biliary stents
  Stent migration
  Duct damage due to stents
Basket impaction
Cardiopulmonary complications and sedation issues
Rare complications
Deaths after ERCP
Late complications
  Diagnostic error
  Late infection
  Late effects of sphincterotomy
  Sphincterotomy with the gallbladder in place
  Pancreatic sphincterotomy
Managing adverse events
  Prompt recognition and action
  Professionalism and communication
Learning from lawsuits
  Financial concerns
  Standard of care practice
   The procedure
   Postprocedure care
Outstanding issues and future trends

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