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Preparation for Pancreaticobiliary Endoscopy
Introduction
Pancreaticobiliary endoscopy focuses on the diagnosis and therapy of conditions involving the pancreas and biliary tree, and distinguishes itself from luminal endoscopy by a greater use of side-viewing endoscopes and echoendoscopes and the use of fluoroscopy. As discussed in Chapter 1 , endoscopic retrograde cholangiopancreatography (ERCP) was first performed in the early 1970s, and endoscopic ultrasound (EUS) was introduced in 1980 for transluminal evaluation of the pancreas. During those early years, both ERCP and EUS were primarily diagnostic modalities and lacked therapeutic capabilities. Since then, pancreaticobiliary endoscopy has grown rapidly within the field of gastroenterology, with the development of new endoscopic devices, improvements in endoscopic imaging, and innovation in endoscopic techniques. Concurrent advancements in noninvasive imaging with increased resolution of computerized tomography (CT) scans and the advent of magnetic resonance cholangiopancreatography (MRCP) have redefined the role of pancreaticobiliary endoscopy. In addition, as will be discussed later in this chapter, the therapeutic potential of EUS is increasingly being recognized, and innovative therapeutic procedures using combined EUS and ERCP techniques are being developed.
Though pancreaticobiliary endoscopy may utilize different equipment and devices relative to luminal endoscopy, the fundamentals of patient preparation, reporting, documentation, and risk management overlap and remain applicable to these patients. This chapter will highlight some of the specific preparations that may be required for patients undergoing pancreaticobiliary procedures.
Patient-Related Preparation
Preprocedure Visit
Pancreaticobiliary diseases may range from relatively straightforward uncomplicated disorders such as choledocholithiasis or postoperative cystic duct leaks to more complex and challenging diseases such as primary sclerosing cholangitis, chronic pancreatitis, and disconnected pancreatic duct syndromes. In some cases, the availability of complementary diagnostic imaging (such as MRCP) and therapeutic procedures (interventional radiology, surgery) may impact management.
Therefore prior to performing pancreaticobiliary endoscopy, the indication for which the patient is referred must be carefully reviewed. This may or may not involve a clinic visit and physical examination. Typically, a comprehensive review of the laboratory and imaging data is required. For all patients, a frank discussion regarding the risks, benefits, and alternatives to the procedure must precede any endoscopic procedure. Clinic visits are more helpful for patients who will require multiple procedures and postprocedure admission to prepare them for periprocedural management. This provides an opportunity to establish a relationship and to prepare the patient for the sequence of events involved in their care.
Increasingly, endoscopists meet a patient for the first time in the preprocedure area on the day of endoscopy (open-access endoscopy). Open-access endoscopy has gained popularity due to the increasing number of patients referred for screening colonoscopy who do not require a specialist visit prior to the procedure. With the increasing demand for endoscopic procedures, open-access endoscopy is also practiced in busy pancreaticobiliary endoscopy units. The basic tenets of open-access endoscopy include appropriateness of referral, patient acceptance and preparedness for endoscopy, informed consent, diagnostic yield of the endoscopy, and assurance that appropriate follow-up will be adhered to. For pancreaticobiliary endoscopy, it is important to review these requests on an individual basis. In such cases, the endoscopist should review the pertinent patient data prior to meeting the patient and allow time for a discussion, as stated earlier. Patient dissatisfaction and communication lapses are the leading cause of medicolegal claims, and may be much more common than true malpractice or medical negligence.
Most pancreaticobiliary endoscopy is now performed under anesthesiology supervision. Preprocedure consultation may also be useful for patients with comorbidities to allow a preprocedure anesthesia evaluation that enables the anesthesiology team to complete their assessment of the patient and obtain any additional testing, such as an electrocardiogram or cardiac evaluation. This process may decrease procedural cancellations on the day of the endoscopy and can facilitate flow in the endoscopy unit.
Informed Consent
Consent is a voluntary agreement by a person with functional capacity for decision making, allowing a procedure to be performed on himself or herself. It is based on the principles of self-determination and autonomy, and requires that the provider or provider's representative provides the patient with substantive information necessary to make a reasoned decision. In most circumstances, informed consent is also a requisite legal document, and failure to properly obtain informed consent can constitute medical battery and negligence.
It is especially important for pancreaticobiliary endoscopists to understand the concept of informed consent, as these procedures are frequently complex and may be associated with a higher rate of more serious adverse effects than other endoscopic procedures. Informed consent should be obtained after a detailed discussion of the nature of the proposed procedure, indication, and benefits, as well as potential risks and complications. Whenever possible, it is recommended that information in the form of non-technically worded handouts, fliers, or informational videos be shared with patients in advance of the procedure, giving them ample time to comprehend the planned procedure and allay their concerns. A preprocedure visit or a well-documented preprocedure phone call can sometimes be utilized to help improve understanding of the procedure, and may allow time if there are additional concerns.
The consequences of not undergoing the procedure and the presence of alternatives to the procedure may also be very relevant to the discussion. Sometimes unanticipated procedures are needed in addition to the planned procedure, e.g., adding an unplanned EUS-guided rendezvous during a planned ERCP. Therefore some centers may require that these additional procedures be included as a part of the informed consent process. As a patient may withdraw consent at any time until the start of the procedure, it may be best if the consent is obtained on the day of the procedure. Often, the consent has a window of coverage within which the procedure must occur, or the consent will need to be repeated.
It is also recommended that a physician performing or participating in the procedure obtains the informed consent, thereby providing another opportunity to address any questions. Inadequacies in the informed consent process may impact patient-physician relationships, and are also one of leading components of legal claims and lawsuits against pancreaticobiliary endoscopists.
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