The ERCP Room

Evolution of the ERCP Room

The basic intent of ERCP has not changed. Endoscopic visualization of the ampulla and cannulation of the desired ductal system with high-quality radiographic imaging guiding the appropriate therapy is still the goal. In the great majority of cases the basic equipment is all that is needed to remove a stone or place a stent across uncomplicated strictures. What has changed is the potential complexity of ERCP, especially at tertiary referral centers. The need for high-quality radiographic imaging of focal pathology in larger patients has led to modified digital fluoroscopy equipment with improved resolution, reduced radiation exposure, and the ability to function continuously for long procedures without overheating. In addition, wider tables (>30 inches) capable of accommodating larger, heavier patients (≥450 lbs.) and space for anesthesia to assist in these procedures have become essential. Additional room space is also needed to accommodate larger beds and stretchers to allow for bariatric patients ( Fig. 2.1 ). The use of a mobile or fixed C-arm system is often employed to improve visualization of the biliary tree by allowing the plane of examination to be altered to profile the bifurcation and selected ductal systems. Additional space for supplemental equipment for cholangioscopy, EUS, laser lithotripsy, electrohydraulic lithotripsy, deep enteroscopy, and other adjuvant techniques has increased the size of the typical advanced ERCP room. Space for anesthesia equipment has further increased the need for additional space at the patient's head. All this, in combination with the need to accommodate morbidly obese patients and store a large variety of devices in close proximity to the patient, has increased the size of well-designed, advanced interventional endoscopy rooms to greater than 500 square feet.

Staffing for the ERCP Procedure

Staffing for ERCP procedures varies across the world. Typically, a physician and a minimum of two additional assistants are necessary. The first assistant (nurse or technician) stands immediately adjacent to the physician and operates devices such as guidewires and accessories. A sedation nurse or member of the anesthesia staff is positioned at the patient's head and administers sedation or anesthesia while monitoring the patient throughout the procedure. Often, a second assistant (nurse or technician) assists in preparing devices for use and documents specifics of the procedure. In some settings a radiology technician is also needed to operate the radiographic equipment. In many centers, a trainee is often present. This creates a close working environment for the procedure with at least three individuals clustered around the patient's head. A well-designed workspace makes this proximity tolerable and efficient.

Room Layout

The key to successful room design is early collaboration with all the disciplines that will be involved in performance and delivery of ERCP so that the room is functional and beneficial to all parties. Collaborative input from ERCP physicians, the endoscopy nursing team and technicians, anesthesia team, patient advocates, radiologists and technicians, radiation safety technicians, the ergonomics consultant, and the construction or design team can result in major design evolution to allow the final design to be optimized for the work group. The layout of a typical tertiary-level ERCP room is depicted in Fig. 2.2 . The ERCP room can be divided into multiple work areas. The epicenter of the ERCP room is the fluoroscopy table. The physician stands adjacent to the patient's head while performing ERCP. In this room design the physician also has direct access to the radiographic equipment controls that allow movement of the fixed C-arm or table to obtain the optimum radiographic imaging. The first assistant's workspace is immediately to the right of the physician. Space for a trainee is preferably located immediately to the physician's left side. Adjacent to the first assistant's work space is a preparation area for a second assistant with a countertop or movable table to prepare devices. This space should be immediately adjacent to the in-room storage of the most often used devices. Directly above the patient's head is space for the sedation nurse or anesthesia team member. This space also includes room for all necessary medications, monitoring equipment, and resuscitative equipment. When using anesthesia, often there are two carts: the anesthesia machine at the patient's head, and a secondary cart for medication and equipment storage, which must be within easy reach of the anesthesia provider. An optimal room design will allow ample space for these pieces of equipment, and easy access to all spaces during the procedure. Ideally, adequate additional space for radiograph review and report generation should be available. This space may be behind a protective lead glass screen or in another space altogether. In some configurations, a separate control room space for the radiographic equipment may be necessary; alternatively, if required, a radiation technologist may be in the room.

The physician should have immediate access to all the endoscopic and radiographic controls that are necessary to complete ERCP. The use of ceiling booms greatly facilitates the placement of processors and devices in close proximity to the physician and assistant with minimal cords or tubing on the floor of the procedure room ( Fig. 2.3 ). The boom can be used to house the endoscope processor and light source, electrocautery unit, and other ancillary equipment such as a CO ₂ insufflator, water irrigation system, EUS equipment (if compact), and other devices. The typical room design has the endoscopic and radiographic monitors directly across from the physician to allow a direct line of sight ( Fig. 2.4 ). The monitors should be adjustable in height to accommodate physicians of various heights and be freely mobile during patient positioning and procedure preparation. An ancillary monitor to display additional images or information such as choledochoscopy, manometry, EUS, or even patient vital signs greatly facilitates the completion of procedures without awkward head angulation. Rooms with video integration systems allow multiple video sources to be displayed on the monitor array in the patient room. This can be particularly helpful if viewing an imaging study (computed tomography and magnetic resonance imaging) is necessary during the procedure. The monitors should be in the line of sight of the first assistant as well to allow coordinated device manipulation with endoscopic and/or fluoroscopic guidance. There should be ample space for ancillary devices (EUS processors, choledochoscopy devices, etc.) to be placed in the room in close proximity to the physician. In larger centers with multiple ERCP rooms, infrequently used equipment may be placed on carts that can be moved from room to room. In the overall layout of the room, there should be sufficient space for patients to be moved on large stretchers or beds. Mobile ceiling-mounted booms greatly facilitate patient movement. For improved efficiency, a portal for endoscope cleaning should be considered to allow rapid movement of used endoscopes to the cleaning room to facilitate room turnover. If this is not available, appropriate containers for rapid and safe transport of used endoscopes should be kept in the ERCP suite adjacent to the endoscope reprocessor ( Fig. 2.5 ).

Radiologic Imaging Equipment

The selection of a radiologic system is one of the most important and expensive decisions to be made during ERCP room design or upgrade. Most hospital systems have purchasing agreements and alignments with specific vendors, and all major manufacturers of radiology and fluoroscopy rooms have a unit that can be well adapted to ERCP. There are also dedicated ERCP systems and portable digital C-arm systems. A review of the principles of radiographic imaging and different imaging systems is found in Chapter 3 . The transition to digital imaging systems in the last decade has greatly simplified image processing and storage while essentially eliminating the need for in-room radiologic support. The selection of a radiologic system is dependent on many factors, including case volume, type, and patient mix. For low-volume, relatively simple ERCP cases, many available systems are adequate. For high-volume, complex case work (American Society for Gastrointestinal Endoscopy [ASGE] grade of difficulty type 2 or 3 cases), a high-end dedicated fixed C-arm is often best. High-end fixed rooms have sufficient power and imaging systems to optimally image obese patients and complex strictures and allow visualization of devices and guidewires in situations where mobile units are inadequate. In addition, pulse rates may be adjusted for more rapid image acquisition during difficult maneuvers while still avoiding continuous fluoroscopy. Digital flat panel detectors provide improved image quality, have durability over traditional analog image intensifiers, and allow magnification of the image without increasing radiation dose. They are available on most fixed fluoroscopy systems and many portable C-arm platforms, but at a substantially increased cost. A list of available fluoroscopy units is provided in Table 2.1 . In addition, the radiation generation and cooling properties of fixed units allow for prolonged procedure times without overheating or image degradation. Investment in a fixed fluoroscopy room also allows the room design to include dedicated shielding and radiation protection for the staff. The addition of a radiation-attenuating drape around the image detector has been shown to significantly decrease the radiation dose to staff during ERCP. The use of ceiling-mounted and table-mounted shielding can greatly reduce radiation scatter and staff exposure ( Fig. 2.6a ). Portable shields on wheels may also be integrated to provide additional shielding ( Fig. 2.6b ). Building codes and hospital safety mandates may also require shielding of the walls and doors of the suite.