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

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

3. 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

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

5. 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

7. 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

8. 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

9. 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

10. 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)

12. 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

13. 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

14. 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

16. 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

17. 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

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

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

20. 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

21. 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%

22. Fully covered SEMS for benign biliary strictures
Coté et al. JAMA 2016;315:
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

24. 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

25. 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

26. 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 , p=0.0001)
NNT 20
Rectal administration better than oral
Effective for average and high risk patients

27. 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

28. 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

29. Thank you