10/4/2014

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Doctor, Why are we doing this ERCP?

Deepak Dath

Professor of Surgery, Liver and Pancreas Surgery

McMaster University

Saturday, October 4, 2014

Disclosure

Disclosure

• I am an ERCPist

• I am a liver and pancreas surgeon

• I work at the Juravinski Hospital in Hamilton

• I represent no companies

10/4/2014

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Objectives

• Answer your questions

• Review ERCP and techniques

• Consider the indications for ERCP

• Discuss common techniques to achieve outcomes

• Explore alternatives to ERCP

Questions from the floor

• Your opportunity to ask what you want

• Prize for the “best” question.

Dr., I’m new… what’s an ERCP?

• Endoscopic Retrograde Cholangio-Pancratiocogram

• A big word with lots of Latin, designed to confuse patients.

• Retrograde Against the natural flow of the bile

• Cholangio-Pancreaticogram – pictures of the CBD and pancreatic ducts

• ERCP – Essentially a Really Convoluted Procedure

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The side-viewing, operating scope

• Not used just for diagnosis

• Risks: 10% mild complication• Pancreatitis

• Perforation

• Infection

• Bleeding

• 90% uncomplicated

ERCP for Therapeutics!

• MRCP

• Gives a reasonable picture

• Patient has to lie still in a “pipe”

• Claustrophobia, implants etc

• Can’t fiddle with things

These are a few of my favourite things…

• Sphincterotome

• Balloon catheter

• Basket

• Stent

• Brush

• Needle Knife

• Balloon dilator

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Dr., what’s that beautiful music?

• Lucky music for ERCP• Faster cannulation

• Better stent placementNot evidence-based

• Not widely accepted

• OK, only I use it

• Putamayo, Coffee Lands

• Especially Guajira

Question from the floor.

Sphincterotomy? Dr., this is ERCP, not colonoscopy

• Sphincter of Oddi at the bottom end of the duct

• Hampers the passage of stones

• May obstruct the pancreas around a CBD stent

• So, cut it open using cautery on a tiny wire at the end of the catheter

• Watch out for diverticula – they don’t have a muscle lining and will cause a perforation

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Sphincterotome – the workhorse instrument

• Cannulation, cutting

Yesterday’s case -cholangitis

Yesterday’s case -cholangitis

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Tricky Sphincterotomy – the diverticulum

• Incision over the CBD only

• Risk of mucosal perforation

• High mortality with this perforation

What balloon? Are we having a party?

• Balloon cholangiogram• Blow up the balloon at the bottom of the duct and inject the dye

• Will distend the duct, show stones better, and give a better picture of the intrahepatic ducts

• Good for Primary Sclerosing Cholangitis

• Finds small leaks

• Balloon sweep• Insert the catheter high in the duct, inflate balloon, retract the catheter

• Good for removing stones

• Balloon dilatation• Open the sphincter without a cut (big stones/diverticulum)

Balloon Cholangiogram

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Question from the floor.

Doctor, did you say this was a basket case?

• A basket – a wire cage on a wire thread

• Insert the catheter, deploy the basket.• The stone may get caught inside the wires of the cage.

• Tighten the cage, pull out the stone.

• Watch for getting stuck!

• Crushing basket (Sohendra) – cringe!

Dr., what should I never do before the ERCP?

• Hide my lucky lead gown and lead collar

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Dr., how do you know if there are stones?

• Jaundice with pain• Blockage happens quickly, no time for physiologic adjustment

• Painless jaundice• Slow growth of a cancer--no pain, just jaundice when blockage is complete

• Ultrasound— only 50% sensitive at picking up stones• But: will see a dilated duct after about 2 days of blockage

• CT and MRI—better at seeing tumors and staging them

Dr., isn’t ERCP better than removing the stones at surgery?

• Well, yes and no.

• Timing: • Bigger stones don’t pass well, so do the ERCP before lap chole.

• Some patients have already had cholecystectomy and have recurrent stones

• Many patients will have passed their stones, and the intraoperative cholangiogram will show a clean CBD so, no ERCP necessary

• If the cholangiogram shows stones (small # of patients) – followup with ERCP

Question from the floor.

10/4/2014

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Dr., why stones now? Pt is 10 yrs post chole

• Stones in the cystic duct

• CBD dilates.

• Stones loosen and fall

• Block the CBD later

Dr., why elective vs. emergency stones?

• Elective• Obstruction without sepsis

• Emergency (true surgical emergency)• Obstruction with signs of sepsis

• Charcot’s triad:• Jaundice, RUQ Pain, fever

• Reynold’s Pentad:• add Hypotension and confusion

Dr., why is this taking you so long?

• Standard excuse list:

• I am not wearing my lucky lead

• My lucky music is not playing

• I can’t see through these lead glasses

• There’s bile in my shoes!

• Bifurcation inside the ampulla

• Strictures

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Question from the floor.

Dr., are you trying to make me radioactive?

• What is the dose I get?• “Scatter” radiation

• 0–3 mSv/year (max established at 20 mSv/year)

• Is it dangerous?• Small chance of harm long-term if protocols followed

• Wear eye protection

• What can I do to minimize it?• Stand away, shields, minimize beam time, reduce power

• ALARA (As Low As Reasonably Achievable)

Dr., is this cancer? What kind?

• Ductal (duodenal) obstruction due to cancer:• Pancreatic

• Bile duct

• Duodenal

• Ampullary

• Painless jaundice• Stent and improve condition

• Surgery, chemo or radiation

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Dr., can cancer symptoms be improved?

• Double-duct sign

• Incidental finding

• Obstruction with jaundice

• Stent• Plastic vs metallic

• Size vs cost

• prognosis

• Whipple Operation

Dr., do the stents need to be changed?

• Metallic self-expanding• Less likely

• Large bore,

• Coated with PTFE (Teflon)

• Plastic stents• 4-6 month patency rate

• Cheaper, but requires another procedure

• Some endoscopists book regular 4-monthly changes

Question from the floor.

10/4/2014

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Dr., are stents used for other benign disease?

• Pancreatitis• Swelling of head of gland with obstruction of CBD

• CBD injury• Post lap chole

• Cystic stump leak

Dr., what are alternatives to ERCP?

• Percutaneous Transhepatic Biliary Drain• More painful for the first 2 weeks

• Smaller calibre stents

• External components (Home care)

• Replaceable easier

• Better for higher strictures

• Able to traverse very dense cancers (CBD tumors)

• “Rescue” procedure for failed ERCP

Dr., what about MRCP?

• Pictures are not as good• Sometimes not diagnostic

• More difficult to get (scarce resource)

• Patients have to lie in a noisy, hot “pipe” for long times

• Not therapeutic

• However, no major risks!

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Dr., what do you think about ERCP?

• Great improvements over time – better equipment and skills

• More available

• Replaces some surgery

• Best option for cholangitis

• Frustrating procedure sometimes, but rewarding often

• Great opportunity to collaborate with nurses

Objectives

• Answer your questions

• Review ERCP and techniques –scope,

• Consider the indications for ERCP

• Discuss common techniques to achieve outcomes

• Explore alternatives to ERCP

Question from the floor.

10/4/2014

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Thank you. Enjoy Niagara!