ERCP: This changed my practice - PowerPoint Presentation

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ERCP: This changed my practice

Jennifer J. Telford MD MPH FRCPC

CSGNA September 22, 2017

Victoria, BC

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Objectives

Tips to a difficult cannualtion

Management of large stones

Management of benign biliary strictures

Prevention of post-ERCP pancreatitis

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Difficult biliary cannulation

In expert hands, selective cannulation is achieved in over 90%

Difficult bile duct cannulation

10 minutes

>

5 attempts (continuous contact with the papilla)

Increased risk of post-ERCP pancreatitis

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Alternative techniques

Double

guidewire

technique

Pre-cut sphincterotomy

EUS-guided biliary access

Percutaneous biliary access

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Double-guidewire (DGW) technique

Inadvertent PD guidewire cannulation

Place the first wire into the PD and remove the sphincterotome

Re-attempt biliary cannulation with a second guidewire

The first wire facilitates cannulation by straightening the

intraduodenal

segment of the common channel

Variation on this technique is to place a PD stent

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Double-guide wire technique

3 randomized trials have assessed DGW in difficult biliary cannulation

Pooled success rate 58% (range 47%-79%)

Pooled PEP rate 22% (range 17%-38%)

Similar success rate to persisted cannualtion and pre-cut

papillotomy

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How I changed my practice

In a difficult biliary cannulation, if the guidewire cannulates the PD, then the double guidewire technique is used prior to a pre-cut

papillotomy

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Difficult CBD stones

Up to 15% of bile duct stones cannot be removed by conventional methods

Large size relative to duct/papilla

Distal stricture

Intra-hepatic location

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Endoscopic papillary balloon dilation

With or without endoscopic sphincterotomy

Through-the-scope balloon is passed over a guidewire into the bile duct to dilate the papilla and distal bile duct

B

alloon

dilation

(12-20 mm)

Minimum = size of largest stone

Maximum = size of bile

duct

Inflate slowly in a step-wise fashion

Maintain inflation until waist disappears (30-60 sec)

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Endoscopic papillary balloon dilation

International Consensus for EPLBD. GIE 2016;83:37

Indication

Large bile duct stones as an alternative to mechanical lithotripsy

Repeat procedures with prior sphincterotomy

In place of sphincterotomy in patients with coagulopathy

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How I changed my practice

If a large stone is identified on

cholangiogram

, a moderate sphincterotomy is performed and then EPLBD is performed prior to mechanical lithotripsy

Particularly when the distal bile duct diameter is less than the stone or the papilla is small

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Cholangioscopy

Cholangioscopy

= scoping the bile duct

Cholangioscope

passes through the accessory channel of the

duodenoscope

single

operator possible

Sphincterotomy

Cannulate

the bile duct directly or over a previously placed guidewire

Cholangioscope

has a channel to pass biopsy forceps or a lithotripsy wire into the duct

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Cholangioscopic EHL

EHL fiber is passed up the accessory channel of the

choloangioscope

High amplitude hydraulic pressure waves fragments the stone

Stone fragments are withdrawn with a biliary extraction basket or balloon

~90% success rate for complex stones

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Cholangioscopy complications

Infection

Bactermia

9%

Cholangitis in 7%

Prophylactic antibiotics

P

erforation if EHL probe touches bile duct wall or with prolonged EHL sessions due to heat generated

B

leeding

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Cholangioscopic

tissue acquisition

Indeterminate bile duct strictures

Suspected malignant but non-diagnostic brushing or biopsy during ERCP or EUS

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Other indications

Guidewire placement

Pancreatic duct

Tissue acquisition

Pancreaticolithiasis

Radiofrequency ablation of

intraductal

neoplasms

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How I changed my practice

For suspicious bile duct strictures with a negative brushing,

cholangioscopic

biopsy is performed at the next ERCP

For unsuccessful stone removal, a stent is placed and the case re-booked with

cholangioscopic

EHL

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Management of benign biliary strictures

Plastic stents (single or multiple) have been the standard of care for many years

Covered Self-Expandable Metal Stents (

cSEMS

)

Larger diameter

Patent longer

Therapeutic

Easy to insert

Ability to be removed

Increased cost of device but fewer ERCPs

Migration rate ~ 30%

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Fully covered SEMS for benign biliary strictures

Coté

et al. JAMA 2016;315:1250-1257

Randomized 112 patients to

cSEMS

vs. multiple plastic stents

S

tricture resolution at 12 months

cSEMS

93% Plastic 85%

Require fewer ERCPs

Complication rate was similar but more

cSEMS

migrated

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How I changed my practice

For benign distal biliary strictures

Insert a fully covered SEMS for 6 months

If the stricture has not resolved, then insert a second fully covered SEMS repeat for another 6 months

At 12 months, if the stricture has not resolved, then I consider endoscopic therapy to have failed and refer to surgery

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Prevention of post-ERCP pancreatitis

Post-ERCP pancreatitis (PEP) in 10% in the placebo arm of trials

PEP occurs in up to 30% of high risk individuals

Overall mortality rate from PEP is 0.7%

Decreased with avoiding diagnostic ERCPs, early pre-cut, PD stent, adequate IV hydration

Contradictory data regarding NSAIDs for PEP prevention, particularly in average-risk patients

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Indomethacin to prevent PEP

Patai

et al. GIE 2017;85:1144

Systematic review of NSAIDS to prevent PEP

4741 patients from 17 trials

Decreased rate of PEP 0.60 (95%CI 0.46-0.78, p=0.0001)

NNT 20

Rectal administration better than oral

Effective for average and high risk patients

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Indomethacin + Ringer’s Lactate to prevent PEP

Mok

et al. Gastrointestinal Endoscopy 2017;85:1005-13.)

Randomized 192 high risk patients to:

Saline bolus + placebo suppository (21%)

Saline bolus + indomethacin suppository (13%)

Ringer’s lactate bolus + placebo suppository (19%)

Ringer’s lactate bolus + indomethacin suppository 6%

Ringer’s lactate + indomethacin superior to placebo in decreased PEP and hospital re-admission

Ringer’s lactate 1L infused over 30 minutes pre-ERCP

Limited by small sample size

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How I changed my practice

P

atients at high risk of post-ERCP pancreatitis based on patient characteristics or planned procedure receive indomethacin 100 mg suppository prior to ERCP

Patients at high risk of post-ERCP pancreatitis based on the ERCP receive indomethacin 100 mg suppository following the ERCP

I have proposed to our ERCP group to routinely give indomethacin 100 mg suppository to all patients following ERCP

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Summary

Cannulation

–

DGW following inadvertent wire cannulation of PD

Big stones

–

Papillary balloon dilation

Big stones

–

Cholangioscopic

EHL

Indeterminate strictures

–

Cholangioscopic

biopsy

PEP prevention

–

Indomethacin 100 mg rectally post ERCP

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Thank you