ERCP: This changed my practice Jennifer J. Telford MD MPH FRCPC CSGNA September 22, 2017 Victoria, BC

Objectives Tips to a difficult cannualtion Management of large stones Management of benign biliary strictures Prevention of post-ERCP pancreatitis

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

Alternative techniques Double guidewire technique Pre-cut sphincterotomy EUS-guided biliary access Percutaneous biliary access

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

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

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

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 Conventional methods = sphincterotomy and balloon or basket retrieval

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 Balloon 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)

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

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

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

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 EHL fiber contains 2 electrodes when immersed in water and current sent through the wires, high amplitude hydraulic pressure waves are generated to fragment the stone

Cholangioscopy complications Infection Bactermia 9% Cholangitis in 7% Prophylactic antibiotics Perforation if EHL probe touches bile duct wall or with prolonged EHL sessions due to heat generated Bleeding

Cholangioscopic tissue acquisition Indeterminate bile duct strictures Suspected malignant but non-diagnostic brushing or biopsy during ERCP or EUS

Other indications Guidewire placement Pancreatic duct Tissue acquisition Pancreaticolithiasis Radiofrequency ablation of intraductal neoplasms

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

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%

Fully covered SEMS for benign biliary strictures Coté et al. JAMA 2016;315:1250-1257 Randomized 112 patients to cSEMS vs. multiple plastic stents Stricture resolution at 12 months cSEMS 93% Plastic 85% Require fewer ERCPs Complication rate was similar but more cSEMS migrated

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

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

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

How I changed my practice Patients 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

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

Thank you