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Sphincter of Oddi Manometry

The sphincter of Oddi (SO) is a complex smooth muscle structure surrounding the terminal common bile duct, main pancreatic duct, and the common channel, when present ( Fig. 16.1 ). The high-pressure zone generated by the sphincter ranges from 4 to 10 mm in length. The SO regulates the flow of bile and pancreatic exocrine juice and prevents duodenum-to-duct reflux (i.e., maintains a sterile intraductal environment). The…

Access (Precut) Papillotomy

The first and often most important step in endoscopic retrograde cholangiopancreatography (ERCP) is successful deep cannulation of the desired duct, most commonly the common bile duct (CBD). Although it remains the first step, cannulation of the CBD can be challenging even for the most experienced endoscopists. Yet obtaining deep access to the CBD is essential in order to undertake any diagnostic or therapeutic intervention. The need…

Cannulation of the Major Papilla

Despite advances in imaging and device technology over the past decade, endoscopic retrograde cholangiopancreatography (ERCP) continues to be technically challenging and subject to adverse events and procedure failure. To some extent this is accounted for by the knowledge that among the most difficult aspects of the procedure is the very first step: selective biliary cannulation (SBC). Outside of expert high-volume centers, failed biliary cannulation occurs in…

Medicolegal Issues in ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most dangerous procedures that gastroenterologists perform regularly; adverse events occur in at least 5% of cases, and lawsuits are common. However, the likelihood of being sued (as well as the success of a suit) can be greatly diminished if practitioners are aware of the reasons why suits are filed and act on that knowledge. There is substantial literature…

Quality Issues and Measures in ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that requires considerable endoscopic skill. It is associated with the highest adverse event rates of any endoscopic procedure. It is important that endoscopists with competency in ERCP are granted privileges to perform the procedure. In response to this, the American Society for Gastrointestinal Endoscopy (ASGE) has proposed specific criteria for the training and granting of clinical privileges…

Principles of Electrosurgery

Electrosurgery Electrosurgery harnesses electricity with the intention of creating various thermal effects to achieve resection, incision, hemostasis, and devitalization of target tissues. The therapeutic basis of all electrosurgery is the production of thermal energy at the cellular level, typically as a result of a high-frequency alternating current created by an electrosurgery generator or unit. Heat generated by this process is the result of resistance or impedance…

Preparation of the Patient for ERCP

The planning required for successful endoscopic retrograde cholangiopancreatography (ERCP) is more complex than that for routine endoscopic procedures and requires the synthesis of multiple variables. Preparation for ERCP involves preparing not just the patient, but also the endoscopist, the endoscopy team, the anesthesia team, and the necessary equipment. The purpose of this chapter is to review the most important preprocedural decisions and planning steps when ERCP…

ERCP Training

Endoscopic retrograde cholangiopancreatography (ERCP) continues to be one of the most technically challenging endoscopic procedures. Training in ERCP requires the mastery of a broad skill set for this procedure to be performed safely and effectively, given the higher rate and wider range of adverse events (post-ERCP pancreatitis, bleeding, and perforation) associated with ERCP in comparison to standard endoscopic procedures. In addition to developing a high level…

Adverse Events of ERCP: Prediction, Prevention, and Management

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic modality to a primarily therapeutic procedure for pancreatic and biliary disorders. ERCP alone or with associated biliary and pancreatic instrumentation and therapy can cause a variety of short-term adverse events, including pancreatitis, hemorrhage, perforation, and cardiopulmonary events ( Box 8.1 ). These adverse events can range from minor, with one or two additional hospital days followed by…

Indications for and Contraindications to ERCP

The appropriate use of endoscopic retrograde cholangiopancreatography (ERCP), as well as avoidance of this procedure when it is contraindicated or when there are alternative diagnostic procedures, is a quality issue for gastrointestinal (GI) endoscopists. The Standards of Practice guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) are widely regarded as the standard of care for GI endoscopists in the United States and have been widely…

Sedation in ERCP

Unlike routine endoscopic procedures, endoscopic retrograde cholangiopancreatography (ERCP) combines several unique challenges. Despite defined indications, the complexity and length of each procedure are often difficult to predict because of unforeseen challenges with cannulation and subsequent therapy. Patients are usually in the prone position to maintain a stable, short endoscope position. In addition, the prone position and overlying fluoroscopy unit make airway monitoring and interventions difficult, particularly…

Duodenoscope Reprocessing

An increasing amount of evidence suggests that Food and Drug Administration (FDA)–recommended measures for duodenoscope reprocessing are insufficient to guarantee against transmission of infection. As a result, improved techniques for endoscope reprocessing have attracted interest from many research groups. Reported outbreaks of endoscope-transmitted multidrug-resistant organisms (MDRO) emerged out of Europe and the United States in 2012 despite full compliance with reprocessing measures. Endoscopy-related infections are an…

Endoscopes, Guidewires, and Accessories

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred technique for the management of patients with a variety of benign and malignant pancreaticobiliary disorders. Procedural success and safety depend to a large extent on proper patient selection for the appropriate indication, proceduralist skills, and an organized and functional ERCP unit. In addition to a dedicated ERCP room and a fluoroscopy unit, essential equipment for ERCP includes a…

Radiologic Issues and Radiation Safety During ERCP

The scope and practice of endoscopic retrograde cholangiopancreatography (ERCP) has evolved over the past 2 decades. First, with the advances in magnetic resonance cholangiopancreatography (MRCP; see Chapter 34 ) in both academic and private settings alike, nearly all ERCP is therapeutic. Increased complexity and emerging capabilities of therapeutic ERCP often lead to longer procedure times and the potential for increased radiation exposure to patients, endoscopists, nurses,…

The ERCP Room

The ERCP room can range from very basic to state-of-the-art. Whereas smaller institutions with low ERCP volumes often perform ERCP in the radiology department or operating room, most centers with a larger ERCP volumes perform ERCP in dedicated rooms within the endoscopy unit. The basic ERCP room requires a quality fluoroscopy unit with still-image capability in addition to standard endoscopic equipment. Major innovations in the field…

Approaching 50 Years: The History of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) has been a remarkable technological advance that has evolved over its nearly 50 years in the field of gastrointestinal endoscopy and has redefined the medical and surgical approach to patients with pancreatic and biliary tract diseases. Since its inception in 1968, the medical community has witnessed significant achievements by the pioneers in endoscopy who incrementally advanced ERCP techniques from their infancy to…

Endo-hepatology

Key points Endo-hepatology has emerged as a new subspecialty in GI endoscopy, leveraging the strength of endoscopy and EUS in the diagnosis, prognosis, and treatment of patients with liver disease. EUS-shear-wave elastography (SWE) can quantitatively assess liver stiffness in both right and left lobes as well as the spleen. Contrast-enhanced (CE) EUS can increase detection and characterization of focal liver lesions and has demonstrated good tolerance…

Endoscopic ultrasonography-guided vascular interventions

Key points EUS-guided glue-coil therapy is a safe and effective method for treatment of or primary prophylaxis for gastric variceal bleeding. Combining coil implantation with glue injection is more effective than monotherapy. Attention should be paid to the varied polymerization rates of different glues in order to avoid complications. EUS-guided therapy is effective for treatment of ectopic varices and nonvariceal gastrointestinal bleeding. EUS enables access via…

EUS-guided pancreatic cyst chemoablation, EUS-guided radiofrequency ablation, and EUS-guided fine-needle injection

Key points EUS-guided pancreatic chemoablation has emerged as an innovative, promising, and minimally invasive approach for the treatment of appropriately selected neoplastic type pancreatic cysts. When performed at expert centers, the treatment response appears durable in majority of patients at long-term follow-up. EUS-RFA is an innovative minimally invasive treatment option for appropriately selected solid pancreatic mass lesions. The procedure is associated with a 10% to 15%…

EUS-guided bowel anastomosis

Key points An anastomosis can be established between the stomach and the jejunum under endoscopic ultrasound (EUS)-guidance in patients with gastric outlet obstruction. A lumen-apposing metal stent (LAMS) can be deployed either directly or via assisted-techniques using fluoroscopic and sonographic guidance. EUS-gastroenterostomy carries a higher technical and clinical success without serious adverse event. While experience is limited, the preliminary data appear promising. Transgastric endoscopic retrograde cholangiopanceratography…