doctor, why are we doing this ercp? - aventri...10/4/2014 1 doctor, why are we doing this ercp?...
TRANSCRIPT
10/4/2014
1
Doctor, Why are we doing this ERCP?
Deepak Dath
Professor of Surgery, Liver and Pancreas Surgery
McMaster University
Saturday, October 4, 2014
Disclosure
Disclosure
• I am an ERCPist
• I am a liver and pancreas surgeon
• I work at the Juravinski Hospital in Hamilton
• I represent no companies
10/4/2014
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Objectives
• Answer your questions
• Review ERCP and techniques
• Consider the indications for ERCP
• Discuss common techniques to achieve outcomes
• Explore alternatives to ERCP
Questions from the floor
• Your opportunity to ask what you want
• Prize for the “best” question.
Dr., I’m new… what’s an ERCP?
• Endoscopic Retrograde Cholangio-Pancratiocogram
• A big word with lots of Latin, designed to confuse patients.
• Retrograde Against the natural flow of the bile
• Cholangio-Pancreaticogram – pictures of the CBD and pancreatic ducts
• ERCP – Essentially a Really Convoluted Procedure
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The side-viewing, operating scope
• Not used just for diagnosis
• Risks: 10% mild complication• Pancreatitis
• Perforation
• Infection
• Bleeding
• 90% uncomplicated
ERCP for Therapeutics!
• MRCP
• Gives a reasonable picture
• Patient has to lie still in a “pipe”
• Claustrophobia, implants etc
• Can’t fiddle with things
These are a few of my favourite things…
• Sphincterotome
• Balloon catheter
• Basket
• Stent
• Brush
• Needle Knife
• Balloon dilator
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Dr., what’s that beautiful music?
• Lucky music for ERCP• Faster cannulation
• Better stent placementNot evidence-based
• Not widely accepted
• OK, only I use it
• Putamayo, Coffee Lands
• Especially Guajira
Question from the floor.
Sphincterotomy? Dr., this is ERCP, not colonoscopy
• Sphincter of Oddi at the bottom end of the duct
• Hampers the passage of stones
• May obstruct the pancreas around a CBD stent
• So, cut it open using cautery on a tiny wire at the end of the catheter
• Watch out for diverticula – they don’t have a muscle lining and will cause a perforation
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Sphincterotome – the workhorse instrument
• Cannulation, cutting
Yesterday’s case -cholangitis
Yesterday’s case -cholangitis
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Tricky Sphincterotomy – the diverticulum
• Incision over the CBD only
• Risk of mucosal perforation
• High mortality with this perforation
What balloon? Are we having a party?
• Balloon cholangiogram• Blow up the balloon at the bottom of the duct and inject the dye
• Will distend the duct, show stones better, and give a better picture of the intrahepatic ducts
• Good for Primary Sclerosing Cholangitis
• Finds small leaks
• Balloon sweep• Insert the catheter high in the duct, inflate balloon, retract the catheter
• Good for removing stones
• Balloon dilatation• Open the sphincter without a cut (big stones/diverticulum)
Balloon Cholangiogram
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Question from the floor.
Doctor, did you say this was a basket case?
• A basket – a wire cage on a wire thread
• Insert the catheter, deploy the basket.• The stone may get caught inside the wires of the cage.
• Tighten the cage, pull out the stone.
• Watch for getting stuck!
• Crushing basket (Sohendra) – cringe!
Dr., what should I never do before the ERCP?
• Hide my lucky lead gown and lead collar
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Dr., how do you know if there are stones?
• Jaundice with pain• Blockage happens quickly, no time for physiologic adjustment
• Painless jaundice• Slow growth of a cancer--no pain, just jaundice when blockage is complete
• Ultrasound— only 50% sensitive at picking up stones• But: will see a dilated duct after about 2 days of blockage
• CT and MRI—better at seeing tumors and staging them
Dr., isn’t ERCP better than removing the stones at surgery?
• Well, yes and no.
• Timing: • Bigger stones don’t pass well, so do the ERCP before lap chole.
• Some patients have already had cholecystectomy and have recurrent stones
• Many patients will have passed their stones, and the intraoperative cholangiogram will show a clean CBD so, no ERCP necessary
• If the cholangiogram shows stones (small # of patients) – followup with ERCP
Question from the floor.
10/4/2014
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Dr., why stones now? Pt is 10 yrs post chole
• Stones in the cystic duct
• CBD dilates.
• Stones loosen and fall
• Block the CBD later
Dr., why elective vs. emergency stones?
• Elective• Obstruction without sepsis
• Emergency (true surgical emergency)• Obstruction with signs of sepsis
• Charcot’s triad:• Jaundice, RUQ Pain, fever
• Reynold’s Pentad:• add Hypotension and confusion
Dr., why is this taking you so long?
• Standard excuse list:
• I am not wearing my lucky lead
• My lucky music is not playing
• I can’t see through these lead glasses
• There’s bile in my shoes!
• Bifurcation inside the ampulla
• Strictures
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Question from the floor.
Dr., are you trying to make me radioactive?
• What is the dose I get?• “Scatter” radiation
• 0–3 mSv/year (max established at 20 mSv/year)
• Is it dangerous?• Small chance of harm long-term if protocols followed
• Wear eye protection
• What can I do to minimize it?• Stand away, shields, minimize beam time, reduce power
• ALARA (As Low As Reasonably Achievable)
Dr., is this cancer? What kind?
• Ductal (duodenal) obstruction due to cancer:• Pancreatic
• Bile duct
• Duodenal
• Ampullary
• Painless jaundice• Stent and improve condition
• Surgery, chemo or radiation
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Dr., can cancer symptoms be improved?
• Double-duct sign
• Incidental finding
• Obstruction with jaundice
• Stent• Plastic vs metallic
• Size vs cost
• prognosis
• Whipple Operation
Dr., do the stents need to be changed?
• Metallic self-expanding• Less likely
• Large bore,
• Coated with PTFE (Teflon)
• Plastic stents• 4-6 month patency rate
• Cheaper, but requires another procedure
• Some endoscopists book regular 4-monthly changes
Question from the floor.
10/4/2014
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Dr., are stents used for other benign disease?
• Pancreatitis• Swelling of head of gland with obstruction of CBD
• CBD injury• Post lap chole
• Cystic stump leak
Dr., what are alternatives to ERCP?
• Percutaneous Transhepatic Biliary Drain• More painful for the first 2 weeks
• Smaller calibre stents
• External components (Home care)
• Replaceable easier
• Better for higher strictures
• Able to traverse very dense cancers (CBD tumors)
• “Rescue” procedure for failed ERCP
Dr., what about MRCP?
• Pictures are not as good• Sometimes not diagnostic
• More difficult to get (scarce resource)
• Patients have to lie in a noisy, hot “pipe” for long times
• Not therapeutic
• However, no major risks!
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Dr., what do you think about ERCP?
• Great improvements over time – better equipment and skills
• More available
• Replaces some surgery
• Best option for cholangitis
• Frustrating procedure sometimes, but rewarding often
• Great opportunity to collaborate with nurses
Objectives
• Answer your questions
• Review ERCP and techniques –scope,
• Consider the indications for ERCP
• Discuss common techniques to achieve outcomes
• Explore alternatives to ERCP
Question from the floor.
10/4/2014
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Thank you. Enjoy Niagara!