Therapeutic and Advanced ERCP, An Issue of Gastrointestinal Endoscopy Clinics Book

Foreword: Therapeutic and Advanced ERCP Is Rapidly Progressing Charles J. Lightdale xiii

Preface: Therapeutic and Advanced Endoscopic Retrograde Cholangiopancreatography Michel Kahaleh iv

Therapeutic Endoscopic Retrograde Cholangiopancreatography and Instrumentation Davinderbir S. Pannu Peter V. Draganov 401

Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection.

Advanced Cannulation Technique and Precut John Baillie 417

For most ERCP endoscopists, the greatest hurdle to a successful procedure is deep cannulation of the bile duct. This article explores basic cannulation technique, then reviews a variety of instruments and techniques designed to increase the average endoscopist's success rate. Expert ERCP endoscopists have a few favorite techniques that have proved reliable overtime. The most frequently used ones are highlighted in this review.

Endoscopic Retrograde Cholangiopancreatography for Stone Burden in the Bile and Pancreatic Ducts Laura Rosenkranz Sandeep N. Patel 435

Stones in biliary and pancreatic ducts are entities that plague hundreds of thousands of patients worldwide every year. Symptoms can be mild (pain) to life threatening (cholangitis, severe acute pancreatitis). In the last few decades, management of these stones has transitioned from exclusively surgical to now predominantly endoscopic techniques. This article reviews the evolution of endoscopic techniques used in the management of stones in the common bile duct and pancreatic duct.

Endoscopic Retrograde Cholangioscopy and Advanced Biliary Imaging Amrita Sethi 451

Developments in endoscopic retrograde cholangioscopy provide multiple new advanced methods of biliary imaging. Cholangioscopy provides direct visualization of epithelium with white light as well as advanced modalities, such as narrow band imaging and autofluorescence. In vivo histologic images can be achieved with confocal endomicroscopy. Cross-sectional imaging is also possible with intraductal ultrasonography and optical coherence tomography. This article describes these advanced imaging techniques, which can be used together to assist in the diagnosis of biliary strictures and lesions.

Sampling at ERCP for Cyto- and Histopathologicical Examination Jean-Marc Dumonceau 461

Sampling at ERCP may be performed at the level of the papilla or of the biliopancreatic ducts. Samples collected at the level of the biliopancreatic ducts allow for diagnosing malignancy with a specificity close to 100% but present a moderate sensitivity in most studies. In this article, the different aspects of sampling at ERCP are discussed, and a special focus is placed on the means that are routinely available to the endoscopist for obtaining a high sensitivity for the diagnosis-of malignancy.

Endoscopic Retrograde Cholangiopancreatography for Distal Malignant Biliary Stricture Hiroyuki Isayama Yousuke Nakai Kazumichi Kawakubo Hirofumi Kogure Tsuyoshi Hamada Osamu Togawa Naoki Sasahira Kenji Hirano Takeshi Tsujino Kazuhiko Koike|p479

Endoscopic biliary stent placement is widely accepted as palliation for malignant biliary obstruction or as a treatment of benign biliary stricture. Although various biliary stent designs have become available since self-expandable metallic stents were introduced, no single ideal stent has been developed. An ideal stent should be patent until death, or surgery, in patients with resectable malignant biliary obstruction. Fewer complications, maneuverability, cost-effectiveness, and removability are also important factors. Alternatively, should we develop a novel method for biliary drainage other than biliary stenting via endoscopic retrograde cholangiopancreatography? This article reviews the current status of biliary stenting for malignant biliary obstructions.

Endoscopic Ultrasonography-Guided Endoscopic Retrograde Cholangiopancreatography: Endosonographic Cholangiopancreatography Manuel Perez-Miranda Robert L. Barclay Michel Kahaleh 491

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to gaining access to the biliary and pancreatic ductal systems. However, in a small subset of cases anatomic constraints imposed by disease states or abnormal anatomy preclude ductal access via conventional ERCP. With the advent of endoscopic ultrasonography (EUS), with its unique capabilities of accurate imaging and ductal access via transmural puncture, there is now an alternative to surgical and percutaneous radio logic approaches in situations inaccessible to ERCP: endosonographic cholangiopancreatography (ESCP). This article reviews the background, technical details, published experience, and role of ESCP in clinical practice.

Endoscopic Management of Benign Biliary Strictures Calvin H.Y. Chan Jennifer J. Telford 511

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

Video of a plastic biliary stent exchange in a patient with a benign distal biliary stricture secondary to chronic pancreatitis accompanies this article.

Treatment of Common Bile Duct Injuries After Surgery Claudio Navarrete Jaquelina M. Gobelet 539

The treatment of common biliary duct injuries after surgery is a permanent challenge for physicians, and management by a multidisciplinary team is often required. The endoscopic approach is a valuable tool because it is able to assess the problem and also provide a therapeutic option for both fistulas and stenosis of the biliary tree. This article discusses the en doscopic management of postsurgical injuries of the common bile duct and discusses the application of practical tools.

Metal Stents for Hilar Lesions Indu Srinivasan Michel Kahaleh 555

Strictures at the hilum are caused by varied conditions and don't usually be come symptomatic until obstructing the bile ducts, thus posing diagnostic and therapeutic challenges to physicians. ERCP is the method of choice for tissue diagnosis and decompression. MRCP or MRI with dedicated liver protocol provides a unique ability to visualize anatomy and promote procedure planning. In patients with unresectable tumor, endoscopic biliary stenting is a palliative approach. Percutaneous or EUS-guided approach is reserved for endoscopic failure. Various new modalities such as radio therapy, chemotherapy and Photodynamic therapy have emerged but their superiority needs to be confirmed with Randomized Control studies.

Complications of Endoscopic Retrograde Cholangiopancreatography: Avoidance and Management Martin L. Freeman 567

Endoscopic retrograde cholangiopancreatography (ERCP) is now almost exclusively a therapeutic modality for pancreatic as well as biliary disorders. ERCP alone or with associated pancreatic and biliary therapy can cause a spectrum of mild and severe complications, including pancreatitis, hemorrhage, perforation, and cardiopulmonary events. Understanding of complications of ERCP has progressed substantially in the past decade, including widespread adoption of standardized consensus-based definitions of complications, large multicenter multivariate studies that have permitted clearer understanding of patient and technique-related risk factors for complications, and introduction of new technical approaches to minimize risks of ERCP.

Endoscopic Retrograde Cholangiopancreatography: Maximizing Benefits and Minimizing Risks Peter B. Cotton 587

Endoscopic retrograde cholangiopancreatography (ERCP) has become enormously popular throughout the world because of its proven value in the management of patients with known and suspected biliary and pancreatic disease. The results of ERCP are operator dependent, and there are significant risks. Adverse events are more likely when procedures are per formed by endoscopists with inadequate training and experience. The best outcomes should occur when procedures are done for the best reasons, using optimal techniques in an ideal environment and a well-trained team, conscious of the risks and the ways to minimize them. This article discusses these intertwining elements of ERCP.

Index 601