Barbara Tribl - PDF document

Clinical benefit and risk of ERCP Barbara Tribl Endoscopic retrograde cholangiopancreatography (ERCP) • Endoscopic technique in which a specialized side - viewing upper endoscope is guided into the duodenum , allowing for instruments to be passed into the bile and pancreatic ducts . • Visualization of the bile and pancreatic duct is achieved by injection of contrast . By this way a variety of interventions can be done . • relatively

complex endoscopic procedure • requires specialized equipment • long learning curve to develop proficiency • Minimally invasive management of biliary and pancreatic disorders are challenged by a higher potential for serious complications than any other standard endoscopic technique ERCP Development • 1968 1st retrograde cannulation of papilla Vateri • 1969 1st duodensope with side viewing • 1970s ERCP replaced peroral and i.v. cholan

giography • 1973 1st endoscopic papillotomy in Erlangen – Removal of bile duct stones – Dilation of papillary stenoses – Palliative therapy of distal bile duct tumors • 1983 Ballondilation of papilla as an alternative to papillotomy • Biopsy and brush cytology • I nsertion of plastic and metallic stents • Stone removal from the bile duct and the pancreatic duct • Development of cholangioscopy • Lithotripsy • I nsertion of

nasobiliary drains ERCP Development • 1968 1st retrograde cannulation of papilla Vateri • 1969 1st duodensope with side viewing • 1970s ERCP replaced peroral and i.v. cholangiography • 1973 1st endoscopic papillotomy in Erlangen – Removal of bile duct stones – Dilation of papillary stenoses – Palliative therapy of distal bile duct tumors • 1983 Ballondilation of papilla as an alternative to papillotomy • Biopsy and brush

cytology • Insertion of plastic and metallic stents • Stone removal from the bile duct and the pancreatic duct • Development of cholangioscopy • Lithotripsy • Insertion of nasobiliary drains ERCP Development • 1968 1st retrograde cannulation of papilla Vateri • 1969 1st duodensope with side viewing • 1970s ERCP replaced peroral and i.v. cholangiography • 1973 1st endoscopic papillotomy in Erlangen – Removal of bile duct s

tones – Dilation of papillary stenoses – Palliative therapy of distal bile duct tumors • 1983 Ballondilation of papilla as an alternative to papillotomy • Biopsy and brush cytology • Insertion of plastic and metallic stents • Stone removal from the bile duct and the pancreatic duct • Development of cholangioscopy • Lithotripsy • Insertion of nasobiliary drains ERCP Development • 1968 1st retrograde cannulation of papilla Vater

i • 1969 1st duodensope with side viewing • 1970s ERCP replaced peroral and i.v. cholangiography • 1973 1st endoscopic papillotomy in Erlangen – Removal of bile duct stones – Dilation of papillary stenoses – Palliative therapy of distal bile duct tumors • 1983 Ballondilation of papilla as an alternative to papillotomy • Biopsy and brush cytology • Insertion of plastic and metallic stents • Stone removal from the bile duc

t and the pancreatic duct • Development of cholangioscopy • Lithotripsy • Insertion of nasobiliary drains Clinical indication CBD stones Electrohydraulic Lithotripsy Indications for ERCP - Biliary diseases Malignant and benign biliary duct strictures Stentimplantation Photodynamic therapy Radiofrequency ablation Indications anf Interventions Pancreatic diseases • Papillary adenoma / carcinoma • Evaluation of strictures of unknown dignity â€

¢ Treatment in acute and chronic pancreatitis • Drainage of pancreas pseusocysts ERCP Complications General complications common to all endoscopic procedures • M edication reactions • O xygen desaturation • C ardiopulmonary accidents • Hemorrhage or perforation induced by traumatic passage of the endoscope • Total: 0.8 – 1.3% • Mortality : 0.07% Specific complications d ue to pancreatobiliary instrumentation • Pancreatitis • S epsis • Hem

orrhage • Retroperitoneal duodenal perforation following therapeutic procedures • Total: 6.9% • Mortality : 0.1 – 0.3% Am J Gastroenterol . 2007;102(8): 1781 ascending cholangitis liver abscess acute cholecystitis , infected pancreatic pseudocyst endocarditis Specific complications - Post - ERCP pancreatitis Prevention Training and competence of endoscopist and endoscopic team – Experience of endoscopist – Number of cannulation attempts – Technique

of sphincterotomy Appropriate indication ESGE Guideline 2014 ( Endoscopy 2014; 46: 799 – 815) – R outine rectal administration of 100mg of diclofenac or indomethacin immediately before or after ERCP – P lacement of a 5 - Fr prophylactic pancreatic stent – Alternative: Sublingually administered glyceryl trinitrate or 250 μg somatostatin given in bolus injection Specific complications - Bleeding Prevention • typically as a consequence of

sphincterotomy • screening for – H istory of excessive bleeding – History of known bleeding disorder – U se of anticoagulants or antiplatelet agents – A complete blood count and coagulation studies should be checked in patients scheduled for ERCP – Substitution, if PLT 50.000/ml or PTT 50% – Some medication should be on hold before ERCP Specific complications - Perforation Prevention • Rare perforation of the esophagus , stomach , du

odenum , or jejunum – Increased risk in pts . with stenosis of any of these segments and in patients who have undergone gastric resection • Retroperitoneal duodenal perforation can occur , usually secondary to sphincterotomy • Cannulation of the papilla with guidewire recommended • Avoidance of precut - and needle knife - papillotomy Specific complications - Infection Prevention • Manipulation of an obstructed biliary or pancreatic system

• I ntroduction by contaminated endoscopic equipment – less frequent American Heart Association (AHA) and the American Society for Gastrointestinal Endoscopy (ASGE ): Guidelines for antibiotic prophylaxis for GI endoscopy (GIE 2014) ASGE Bile duct obstruction in absence of cholangitis - but incomplete drainage AHA Pts . with high risk of infective endocarditis Prosthetic valve History of infective endocarditis Pts . w HTX and

cardiac valvulopathy Pts . with congenital heart disease (CHD) Unrepaired cyanotic CHD Completely repaired CHD w prosthetic material or device 6 mo after the procedure Repaired CHD w residual defects Specific complications - Contamination Prevention • Outbreaks of multidrug - resistant pathogens ( Klebsiella , Escherichia coli , Pseudomonas aeruginosa ) associated with ERCP procedures have been reported • Source under discussion : Diff

iculties in cleaning the elevator mechanism of duodenoscopes • Recommendations from scientific societies and manufacturers have been reissued • August 4, 2015 the US Food and Drug Administration sent out a communication with supplemental measures to enhance reprocessing of duodenoscopes • Routine microbial surveillance for prophylaxis is recommended ERCP Conclusion • R elatively complex endoscopic procedure • M inimally invasive management of biliary

and pancreatic disorders • R eplacement of former surgical interventions • H igher potential for serious complications than any other standard endoscopic techniques • New Focus: carbapenem - resistant Enterobacteriaceae (CRE ) • Prevention of contamination by instruments – under discussion • The risk to patients of CRE infection following ERCP is low • For most patients : the benefits of this potentially lifesaving procedure outweigh t