The difficult ERCP: Some points for assistants

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The difficult ERCP Some points for assistants

• Klaus Gottlieb, MD, FACP, FACG

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Why are some ERCPs difficult?

• Patient factors
• Sedation
• ASA class, obesity
• Variant gastric anatomy
• Billroth II
• Roux-en-Y
• Periampullary diverticulum
• Physician factors
• Inexperienced Assistants

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Sedation Tip

• Consider giving Phenergan 25 mg iv 30 minutes
  prior to the procedure in a patient with a
  history of alcohol, benzodiazepine or narcotic
  use

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Have a plan

• What is the indication for the ERCP?
• What are we likely to encounter?
• What is the plan for access to the desired duct?
• Are there alternative procedures available if the
  ERCP is not successful?
• Is your inventory up-to-date?

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Roux-en-Y difficult to impossible
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Billroth II
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Bile duct anatomy
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Pancreas Divisum
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Pancreas divisum
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Getting In Papilla vs. Ampulla

• Papilla What you see on the outside
• Ampulla The inside, surrounded by the sphincter
  of Oddi

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A close-up of the ampulla
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Steerable sphincterotome with guide wire preloaded

• Cannulating sphincterotome easier bile duct
  access
• Can be bowed upward and to the right ideal bile
  duct cannulation position
• Preloaded guide wire assists in finding the right
  channel

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The Cannulotome in Action
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Once in, stay put!

• RX Compatible Biliary Catheters combine a
  closed, distal 5-20 cm end with an open proximal
  guidewire channel. This open proximal channel
  allows for the guidewire to be separated and
  locked into the attached RX Locking Device and
  secured during device advancement, withdrawal,
  and manipulation. The open channel also allows
  for biliary procedures to be performed over a
  260cm Jagwire High Performance Guidewire

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Cant get in?
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Pharmacological Adjuncts

• Glucagon to reduce intestinal motility
• Cholecystokinin (CKK) helpful for bile duct
  cannulation, especially when the gallbladder is
  present
• Secretin pancreatic duct cannulation, minor
  papilla cannulation

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The Needle Knife

• Precut biliary sphincteromy
• Papillary roof incision
• Requires experience and judgement
• Higher complication rate

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Retreat is not defeat

• Alternative procedures
• Reevaluation of clinical need
• Second ERCP in 1-2 weeks
• Different endoscopist

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EUS sensitive for bile duct stones
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Action plan

• Inventory needs to be up-to-date
• Consider switching to Rx system
• Stock secretin, cholecystokinin (CKK), glucagon
• Assign roles to assistants