Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic visualization of the papilla of Vater was achieved in 98 of our first 100 attempts. Cannulation was successful in 87% of cases, achieving pancreatography alone in 29, cholangiography alone in 27, and both in 31. The relevant duct was adequately visualized in 72.5% of patients with biliary tract disease and in 72% of those with pancreatic disease. Complications were acceptably few. The procedure has proven valuable in difficult cases of obstructive jaundice and biliary type pain syndromes without jaundice. Many questions remain, however, as to its value in the diagnosis and evaluation of pancreatic disease.     

Deep sedation for endoscopic retrograde cholangiopacreatography

Sedation and analgesia comprise an important element of unpleasant and often prolonged endoscopic retrograde cholangiopacreatography (ERCP), contributing, however, to better patient tolerance and compliance and to the reduction of injuries during the procedure due to inappropriate co-operation. Although most of the studies used a moderate level of sedation, the literature has revealed the superiority of deep sedation and general anesthesia in performing ERCP. The anes- the siol ogist’s presence is mandatory in these cases. A mod erate sedation level for ERCP seems to be adeq uate for octogenarians. The sedative agent of choice for sedation in ERCP seems to be propofol due to its fast distribution and fast elimination time without a cumulative effect after infusion, resulting in shorter recovery time. Its therapeutic spectrum, however, is much narrower and therefore careful monitoring is much more de manding in order to differentiate between moder ate, deep sedation and general anesthesia. Apart from conventional monitoring, capnography and Bispectral index or Narcot rend monitoring of the level of sedation seem to be useful in titrating sedatives in ERCP.     

Endoscopic retrograde cholangiopancreatography in childhood.

ERCP was performed in 19 children and adolescents aged 4 to 16 years. In 13 children the examination was done under general anesthesia, in 6 cases with the usual premedication using dolsin and atropine. Indications for examination were unclear abdominal pain with occasional amylase elevation, in 3 patients status after an abdominal injury. In 16 patients the examination clarified the complaints by detecting organic disease of the gallbladder or the pancreas. ERCP is an important procedure in the event of uncertain diagnosis in children and adolescents and, if the indication is correct, and the technique good, is well tolerated by the patients.     

Endoscopic retrograde pancreatography

Thirty-five pancreatograms were selected from 62 which were obtained during endoscopic cannulation of the papilla of Vater with retrograde injection of radiopaque medium. Pancreatograms were selected on the basis of the quality of the study and on the absence of any clinically demonstrable pancreatic disease. Measurements were made of the main pancreatic duct (MPD) in the head, body, and tail, as well as the length of the duct. Althought there is a wide range of normal, practical reference figures for the diameters of the main duct in the head, body, and tail are 3, 2, and 1 mm, respectively. The length averages 15.4 cm. No correlation was found between the measurements and the body surface area, age, or sex of the patient. Comparisons are made with other autopsy and endoscopic studies, and attention is focused on the salient anatomic features, including normal points of narrowing of the duct, the accessory pancreatic duct (APD), and the main pancreatic duct branches (MPDB).     

Endoscopic retrograde cholangiopancreatography in familial pancreatitis.

A young man and his father, both with pancreatitis, were recently seen at the Mayo Clinic. The histories, physical findings, and laboratory values were those of chronic pancreatitis. Endoscopic retrograde cholangiopancreatography was valuable in confirming the gross pathological changes and in orienting the surgeon preoperatively.     

Endoscopic retrograde cholangiopancreatography in elderly patients.

BACKGROUND: the presentation of common bile duct disease, value of investigations and treatment outcome in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were assessed. METHODOLOGY: the clinical presentation, liver function tests, full blood counts, abdominal ultrasound and ERCP results were assessed retrospectively in 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequentially investigated for possible common bile duct disease. RESULTS: 59 patients had common bile duct gallstones, 35 had malignant biliary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant group. In the gallstones-alone group 43% had atypical presentations (non-specific symptoms or painless jaundice). Non-specific symptoms were found in 19% of the gallstones-alone group but in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy. The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of ultrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diagnosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patients (60%). Endoscopic clearance of common bile duct gallstones was successful in 53 of 54 attempts (98%). Palliative ERCP treatment was performed in 30 patients who had malignant biliary obstruction and was successful in 22 (73%); in a further four patients (13%) an endoprothesis was successfully inserted percutaneously. The commonest complication of ERCP was cholangitis (four patients); pancreatitis and biliary perforation occurred in one patient each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years). Carcinoma of the ampulla was associated with a relatively good prognosis (three patients survived 18 months or more). CONCLUSION: in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.     

Endoscopic retrograde cholangiopancreatography-induced severe acute pancreatitis.

BACKGROUND/AIMS: There is scant information in the literature about the outcomes of endoscopic retrograde cholangiopancreatography (ERCP)-induced severe acute pancreatitis (ESAP). Compared to other causes, higher morbidity and mortality have been reported in ERCP-induced acute pancreatitis. We undertook this study to determine the differences between ESAP and SAP due to other causes (OSAP). METHODS: We retrospectively identified all cases of SAP admitted to our institution during the years 1992-2001. We reviewed the medical records of all SAP patients to obtain information on demographics, interventions, local and systemic complications and outcomes. RESULTS: We identified 207 patients with SAP, of whom 16 (7.7%) had ESAP and 191 OSAP. There was no difference between ESAP and OSAP with regard to demographics, clinical interventions, local and systemic complications and outcomes. Both groups had a similar mortality (25 vs. 18%). CONCLUSION: ESAP has a similar morbidity and mortality compared to OSAP.     

Endoscopic retrograde brush cytology. A new technique

Endoscopic retrograde cholangiopancreatography has been shown to be a very valuable adjunct in the diagnosis of malignancy involving the biliary and/or pancreatic ductal system. However, characteristic endoscopic retrograde cholangiopancreatography radiographic findings associated with malignant strictures are frequently not specific and cytological confirmation becomes essential for the diagnosis. Unfortunately, the current overall diagnostic yield of positive cytology in such circumstances ranges from 18%-56% depending on the technique. A new brush device has been designed which is uniquely adapted to pancreaticobiliary strictures of varying anatomical configurations. This study shows results using this new cytology brush in a series of 53 patients with pancreaticobiliary malignancy. A significant improvement in the cytological yield of tumor confirmation was obtained with a diagnostic sensitivity of 70% and specificity of 100% using the new brush technique.     

Endoscopic retrograde cholangiopancreatography in infants and children.

BACKGROUND: Although many reports describe the use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in children, few mention therapeutic application of this technique in pediatric patients with pancreatic or biliary disease. METHODS: We report our 4-year experience of 80 ERCPs performed in 59 children for obstructive jaundice or cholestasis with dilatation of the biliary tree (32 children), biliary atresia (11), recurrent pancreatitis (8), and blunt trauma to the abdomen (8). RESULTS: The patients' ages ranged from 5 weeks to 18 years. The appropriate duct was cannulated in 94% of cases. Common bile duct sphincterotomy was performed in 35 patients and pancreatic duct sphincterotomy in one. Multiple procedures were done in 16 patients where biliary stents were inserted; in one patient with chronic pancreatitis and pancreaticolithiasis, pancreatic stent was inserted. Four patients developed mild pancreatitis, one had moderate pancreatitis and one had leak of contrast, which was treated by administration of clear fluids orally for one day. One patient with benign stenosis of the hepatic duct developed cholangitis after migration of the stent into the bowel lumen. CONCLUSION: Diagnostic and therapeutic ERCP can be done as safely and effectively in pediatric patients as in adults.