Endoscopic Retrograde Cholangio-Pancreatography (ERCP) - Current Practice and Future Perspectives

1.Introduction18 2.Anatomy of the biliary and pancreatic ducts22 2.1.Embryology of the liver and pancreas22 2.2.Anatomy of the biliary tree23 2.2.1.The gallbladder23 2.2.2.The bile ducts24 2.3.Anatomy of the pancreatic ducts27 2.4.Summary and conclusions29 3.Indications and contraindications for ERCP32 3.1.Two sides of risk of complications33 3.2.The risk factors to be considered and - if possible - to be avoided by the endoscopist33 3.3.The risk from contrast agents35 3.4.The risk of concomitant medications: Antiplatelet agents (APA) and anticoagulation35 4.Approaching the papilla38 4.1.The way to the papilla38 4.1.1.Endoscopes38 4.1.2.Passing the endoscope to the papilla38 4.1.3.Finding to papilla38 4.1.4.The normal papilla39 4.2.Cannulation technique of the papilla39 4.2.1.Cannulation of the papilla - published data39 4.2.2.Special situations40 4.2.3.Pancreatic guidewire ("double" guidewire) technique40 4.2.4.Precut techniques42 4.2.5.Cannulation of the minor papilla44 4.3.Endoscopic sphincterotomy and papillary large balloon dilatation44 4.3.1.The technique of endoscopic sphincterotomy44 4.3.2.Outcome of endoscopic sphincterotomy at long-term follow-up45 4.3.3.Endoscopic papillary large balloon dilatation45 4.3.4.How I do it45 4.4.Endoscopic retrograde cholangio-pancreatography (ERCP) in patients with operatively altered anatomy47 4.4.1.Published data47 4.4.2.How I do it50 5.Bile ducts56 5.1.Choledochal stones56 5.1.1.Extraction technique57 5.1.2.The large stone58 5.1.3.Hepatolithiasis58 5.1.4.Lithotripsy techniques59 5.1.5.Biliary stenting61 5.2.Malignant biliary obstruction: Why and when should I do ERCP?62 5.2.1.Published data64 5.2.2.How I do it66 5.3.The use of non-expandable plastic stents (NEPS) in ERCP70 5.3.1.Introducing the subject70 5.3.2.Indications for placement of NEPS70 5.3.2.1.Malignant bile duct stenosis71 5.3.2.2.Benign biliary strictures71 5.3.2.3.Bile duct leakage71 5.3.3.Comparative studies of the efficacy of different types of NEPS72 5.3.3.1.Comparative studies of NEPS versus SEMS72 5.3.3.2.NEPSs vs UC-SEMS73 5.3.3.3.NEPSs vs C-SEMS73 5.3.4.Adverse events and complications73 5.3.5.The experience of our centre74 5.3.6.Summary75 5.3.7.Figures75 5.3.8.References77 5.4.The use of self-expandable metal stents (SEMS, C-SEMS) in ERCP 79 5.4.1.Uncovered or covered SEMS?80 5.4.2.How I do it82 5.5.Radiofrequency ablation and photodynamic therapy in biliary malignacy85 5.5.1.Photodynamic therapy (PDT)85 5.5.2.Reason for introducing PDT as a local tumor ablation in cholangiocarcinoma86 5.5.3.Indications of PDT in CCA86 5.5.4.Techniques of PDT86 5.5.5.Effect and outcomes of PDT88 5.5.6.Photodynamic therapy in unresectable CCA88 5.5.7.PDT in advanced hilar CCA89 5.5.8.PDT for recurrent tumors after resection or as a neoadjuvant treatment89 5.5.9.Assessment of response to PDT90 5.5.10.Morbidity and adverse events90 5.5.11.Future directions of PDT and conclusions90 5.5.12.Endoscopic intraductal radiofrequency ablation (RFA)91 5.5.13.The radiofrequency catheter device91 5.5.14.Indications92 5.5.15.Endobiliary RFA prior to self-expanding metal stent (SEMS) placement92 5.5.16.Endobiliary RFA application in the management of obstructing SEMS93 5.5.17.Complications93 5.5.18.Conclusion94 5.6.Sclerosing cholangitis97 5.6.1.Primary sclerosing cholangitis (PSC)97 5.6.1.1.How I do it98 5.6.1.2.Complications of ERCP in PSC patients99 5.6.1.3.Screening for biliary malignancy in PSC99 5.6.1.4.Treatment of biliary lesions in PSC99 5.6.1.5.IgG4-associated cholangitis (IAC)101 5.6.2.Secondary sclerosing cholangitis (SSC)105 5.6.3.Published data106 5.6.4.How I do it106 5.6.5.The author's experience108 5.7.Role of ERCP in post-operative biliary complications109 5.7.1.Why and when should I do ERCP?109 5.7.2.ERCP in biliary complications after cholecystectomy109 5.7.3.Bile duct injuries after liver transplantation110 5.7.4.Other post-operative complications114 5.7.5.How I do it115 5.7.6.References115 5.8.Hemobilia and portal hypertensive biliopathy116 5.8.1.Hemobilia116 5.8.2.Published data117 5.8.3.Portal hypertensive biliopathy (PHB)118 5.8.4.How I do it119 5.9.Biliary "rendezvous" procedures and role of ERCP in infected bilioma120 5.9.1.Percutaneous and EUS-guided access for biliary rendezvous procedures120 5.9.1.1.Published data121 5.9.1.2.How I do it121 5.9.2.Role of ERCP in hepatic abscess with biliary communication and in bilioma123 5.9.2.1.Published data124 5.9.2.2.How I do it124 5.9.3.Referenzes and further literature127 6.Pancreas130 6.1.Role of ERCP in acute biliary pancreatitis130 6.1.1.Initial diagnosis of biliary pancreatitis131 6.1.2.Delayed diagnosis of biliary pancreatitis133 6.1.3.Diagnosis of "idiopathic pancreatitis" and biliary pancreatitis due to microlithiasis133 6.1.4.ERCP133 6.1.4.1.Preparing for ERCP134 6.1.4.2.ERCP technique134 6.1.4.3.Complications post ERCP in acute biliary pancreatitis135 6.1.4.4.Areas of uncertainty135 6.1.5.Special cases136 6.1.5.1.Indications for ERCP in ABP-type of disease and timing136 6.1.5.2.Early ERCP in ABP without cholangitis137 6.1.5.3.Recurrent ABP: the protective role of cholecystectomy and endoscopic sphincterotomy137 6.1.6.Conclusion - The guidelines139 6.2.Role of ERCP in complications of acute pancreatitis144 6.2.1.Definitions144 6.2.1.1.Pancreatic fluid collections144 6.2.1.2.Pancreatic duct disruption145 6.2.2.Therapeutic considerations145 6.2.2.1.Treatment of PC and WON145 6.2.2.2.Indication for ERP146 6.2.3.Technique of transmural drainage146 6.2.4.Endoscopic necrosetomy for treatment of infected won148 6.2.5.Clinical outcomes of EUS-guided drainage149 6.2.6.Treatment of persistent pancreatic duct leaks149 6.2.7.Summary150 6.3.Pancreatic duct leakage: traumatic and iatrogenic injury to the pancreatic duct151 6.3.1.Classification of pancreatic duct leakage152 6.3.1.1.Etiology and severity152 6.3.1.2.Size and location of the pancreatic damage152 6.3.2.Pancreatic fistula153 6.3.2.1.Internal fistula153 6.3.2.2.External fistula153 6.3.3.Published data153 6.3.3.1.Diagnosis153 6.3.4.Treatment154 6.3.5.How I do it155 6.3.6.Conclusion155 6.4.The role of ERCP in chronic pancreatitis (CP)157 6.4.1.Materials, methods and required devices157 6.4.2.How I do it158 6.4.3.Endoscopic treatments of MPD lesions158 6.4.3.1.MPD access and pancreatic sphincterotomy158 6.4.3.2.Treatment of pancreatic duct stenosis160 6.4.3.3.Treatment of pancreatic stones161 6.4.3.4.Sustained patency of the MPD161 6.4.4.Endoscopic treatment of CP complications162 6.4.4.1.Pancreatic pseudocysts162 6.4.4.2.Biliary stenosis162 6.4.4.3.Duodenal stenosis, impaired pancreatic exocrine or endocrine function162 7.Cholangioscopy techniques164 7.1."Mother-baby" cholangioscopy164 7.1.1.Published data: Peroral cholangioscopy (SpyGlass®)164 7.1.2.Published data: Direct retrograde cholangioscopy (DRC)168 7.1.3.How I do it: POCS (SpyGlass®)169 7.1.4.How I do it: DRC (direct retrograde cholangioscopy)170 7.2.Pancreatoscopy170 7.2.1.How I do it: Pancreatoscopy170 8.List of abbreviations172 Index174