Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Challenges in ERCP:Challenges in ERCP:

Richard A. Richard A. KozarekKozarek, MD, MD

DDifficult ifficult CannulationCannulationLarge StonesLarge Stones

SODSOD

ERCP PresentERCP PresentEstimated Procedural Volume Estimated Procedural Volume

United States: 445,000 cases per yearUnited States: 445,000 cases per year

Worldwide: 1.1 Worldwide: 1.1 –– 1.3 million cases per 1.3 million cases per yearyear

Diagnostic Diagnostic ERCPsERCPs: 69,000: 69,000

•• Decreasing ~4% per yearDecreasing ~4% per year

Therapeutic Therapeutic ERCPsERCPs: 376,000: 376,000

•• Increasing ~12% per yearIncreasing ~12% per year

Difficult Difficult CannulationCannulation What makes What makes cannulationcannulation difficult?difficult?

•• Training/ExperienceTraining/Experience•• Poorly sedated patientPoorly sedated patient•• Difficult local anatomyDifficult local anatomy

JuxtaJuxta--ampullaryampullary tic/tight papillary tic/tight papillary stenosisstenosis

CC--loop/papilla infiltration with loop/papilla infiltration with neoplasmneoplasm

Variant anatomyVariant anatomy−− BI/II RouxBI/II Roux--enen--YY

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Training and Experience: Training and Experience: Quantitative Assessment of ERCP Quantitative Assessment of ERCP

CompetenceCompetence

JowellJowell PS, et al. PS, et al. Ann Intern MedAnn Intern Med1996;125:983.1996;125:983.•• Prospective studyProspective study•• 17 GI fellows17 GI fellows•• 1450 1450 ERCPsERCPs•• Average number of Average number of ERCPsERCPs required required

for competency: 180for competency: 180--200200

Assessment of Assessment of Endoscopic CompetenceEndoscopic Competence

VermaVerma et al. et al. GIEGIE 2007;65:394.2007;65:394.

Retrospective review 1047 ERCP proceduresRetrospective review 1047 ERCP procedures•• Main outcomes measurement = successful Main outcomes measurement = successful

deep deep biliarybiliary cannulationcannulation CannulationCannulation rate 43% at training onsetrate 43% at training onset ≥≥80% after 35080% after 350--400 procedures400 procedures

Conclusion: Conclusion: ≥≥80% 80% biliarybiliary cannulationcannulation rate rate should become the standard for advanced should become the standard for advanced endoscopy fellowship programsendoscopy fellowship programs

Poorly Sedated PatientPoorly Sedated Patient Factors associated with suboptimal sedationFactors associated with suboptimal sedation

•• YouthYouth

•• AnxietyAnxiety

•• Narcotic habituationNarcotic habituation

•• Procedural discomfortProcedural discomfort

SolutionsSolutions

•• AdditionalAdditional--diphenhydraminediphenhydramine, , promethazinepromethazine, , inapsineinapsine

•• Anesthesia assistanceAnesthesia assistance

•• 44--point restraintpoint restraint

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Difficult Anatomy: Difficult Anatomy: Tight Papillary Tight Papillary StenosisStenosis

6??

Difficult Anatomy: Juxta-Ampullary Strix

Difficult Anatomy: Impacted StoneDifficult Anatomy: Impacted Stone

8?

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Difficult Anatomy: Large Stone/BIIDifficult Anatomy: Large Stone/BII

9?

Difficult Anatomy: Roux LimbDifficult Anatomy: Roux Limb

AmpullaryAmpullary NeoplasiaNeoplasia

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

BII AnatomyBII Anatomy

Large StonesLarge Stones

What defines a What defines a ““largelarge”” stone?stone?

>1.5 cm>1.5 cm

Larger than downstream ductLarger than downstream duct

Stone significantly larger than Stone significantly larger than anatomically safe ESanatomically safe ES

Options, Large StonesOptions, Large Stones

Mechanical lithotripsyMechanical lithotripsy

ES/Balloon ES/Balloon sphincteroplastysphincteroplasty

Direct Direct cholangioscopycholangioscopy

•• EHLEHL

•• Laser lithotripsyLaser lithotripsy

ESWLESWL

‡‡LongLong--term stent placementterm stent placement

SurgerySurgery

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Balloon Balloon sphincteroplastysphincteroplasty

Balloon Balloon SphincteroplastySphincteroplasty

Reference # CasesBalloon size

(mm)

% Lithotripsy

Use

Success

1st/final

Complications

%

Ersoz et al 58 12-20 7 (83) 100 17%

Maydeo et al 60 12-15 5 (95) 100 0

Attasaranya et al 107 12-18 27 (95) 95 3

Itoi et al 53 15-20 6 (96) 100 6

Selected Series Using Balloon Dilation Of The Sphincter In Conjunction With Sphincterotomy (ESLBD)

For Removal of Large Common Bile Duct Stones

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Direct Direct CholangioscopyCholangioscopy with with EHL/Laser LithotripsyEHL/Laser Lithotripsy

((PancreaticoPancreatico--) ) BiliaryBiliaryDyskinesiaDyskinesia/SOD/SOD

Original DescriptionOriginal Description•• Type I: Episodic Type I: Episodic biliarybiliary colic w/o stonescolic w/o stones•• >45 min CBD drainage>45 min CBD drainage•• CBD diameter CBD diameter ≥≥ 12 mm12 mm•• ↑↑ transaminasestransaminases 22--fold x 2fold x 2•• Subsequent Subsequent modifixmodifix: CBD : CBD ≥≥ 10 mm, PD 10 mm, PD ≥≥

55--6 mm6 mm•• Addition: ARPAddition: ARP•• Elimination: Elimination: biliarybiliary drainagedrainage•• Presumption: Presumption: struxstrux lesion of papillalesion of papilla•• Results Results biliarybiliary ES 90% responseES 90% response

(P)B (P)B dyskinesiadyskinesia/SOD/SOD Original description:Original description:

•• Type II: 3 of 4 parameters (Type I) Type II: 3 of 4 parameters (Type I) SODSOD Modifications: ARPModifications: ARP

−− 2 of 3 Type I parameters2 of 3 Type I parameters Presumption: Presumption: StruxStrux or or fuxfux lesions of lesions of

papillapapilla•• Results of Results of biliarybiliary ES: 80% response if ES: 80% response if ↑↑ SOPSOP

•• 30% response if SOP normal30% response if SOP normal

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

(P)B SOD(P)B SOD

Type III: (Type III: (Pancreatico)BiliaryPancreatico)Biliary pain pain without objective lab/imaging without objective lab/imaging abnormalitiesabnormalities

Response to CBD/PD/dual ES Response to CBD/PD/dual ES unknownunknown

Learning Luncheon 11: Challenges in ERCP: Difficult Cannulation, Large Stones, SOM

Match the Patient to SOD Match the Patient to SOD ClassificationClassification

A 59 male with previous A 59 male with previous cholecystectomycholecystectomy has severe episodic has severe episodic RUQ pain, normal RUQ pain, normal LFTsLFTs, and a 19 mm CBD on MRCP, and a 19 mm CBD on MRCP

An 82 year old lady has had 2 episodes of pancreatitis, 2 An 82 year old lady has had 2 episodes of pancreatitis, 2 years apart. CT scan demonstrates a 5 mm CBD, and a years apart. CT scan demonstrates a 5 mm CBD, and a normal pancreas and gallbladder.normal pancreas and gallbladder.

A 32 year old female had A 32 year old female had cholecystectomycholecystectomy for chronic RUQ for chronic RUQ and an abnormal HIDA scan. There were no stones in the and an abnormal HIDA scan. There were no stones in the gallbladder and IOC demonstrated an 8 mm CBD without gallbladder and IOC demonstrated an 8 mm CBD without stones. Her pain persists. stones. Her pain persists. TransaminasesTransaminases and/or amylase and and/or amylase and lipase increase by 10% during attacks. Or: are normal. Or: lipase increase by 10% during attacks. Or: are normal. Or: stay elevated between pain attacks. Or: her pain is chronic, stay elevated between pain attacks. Or: her pain is chronic, not intermittent. not intermittent.