The expanding therapeutic use of endoscopic retrograde cholangiopancreatography, coupled with its technical demands and potential for adverse events, has spurred increased emphasis on adequate training and development of quality standards for ERCP procedures.
Bret Petersen, MD, a consultant in the Division of Gastroenterology and Hepatology at Mayo Clinic in Rochester, Minn., presented 10 tips for high-quality ERCP at the New York Society for Gastroenterology and Endoscopy’s 2022 Annual New York Course. Noting that an update to the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology quality indicators for ERCP is imminent (Gastrointest Endosc 2015;81[1]:54-66), Dr. Petersen focused on individual endoscopist-level judgment and technical aspects of ERCP performance in his set of tips.
Discerning Case Selection
One of the more interesting and rewarding aspects of ERCP is the high cognitive demand relative to other procedures commonly performed by endoscopists, Dr. Petersen said. However, with this comes the responsibility to have good judgment about which referrals for ERCP are appropriate, as well as consideration of feasibility, advisability, technical expertise, endoscopist skill and urgency, he said. Specific circumstances in which Dr. Petersen recommended ERCP be avoided include “purely diagnostic applications, futile palliation or routine preoperative studies where it won’t alter clinical management.”
Quality Pre-Procedure Imaging
Dr. Petersen stressed the importance of “high-quality cross-sectional imaging,” specifying that CT, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) could be used for biliary lesions, but for complex hilar lesions, MRCP should be used.
Appropriate Management of Anticoagulation
For standard ERCP, without simultaneous EUS intervention, changes to anticoagulation medications are not required unless a sphincterotomy is planned, Dr. Petersen said. “Sphincterotomy is the high-risk component,” he explained. “No change [in anticoagulation management] is necessary for stent removal or exchange, duct sweeps, etc.”
When a sphincterotomy is performed, the aim should be for the patient to have an international normalized ratio (INR) below 1.6, and the decision to alter anticoagulation management should consider the risk for thrombosis if the medication were discontinued, as well as the planned intervention. Dr. Petersen recommended referencing ASGE (Gastrointest Endosc 2016;83[1]:3-16) and British Society of Gastroenterology/European Society of Gastrointestinal Endoscopy (Gut 2021;70[9]:1611-1628) guidelines related to anticoagulation management when making decisions about whether or for how long to alter anticoagulation management in patients undergoing ERCP.
Appropriate Antibiotic Use
The appropriateness and duration of antibiotic use depend on the indication for ERCP. “Multiple studies have shown no benefit [of antibiotic coverage] for routine stones or for lesions that will be successfully decompressed,” Dr. Petersen said. However, he recognized that it is not always clear ahead of time which lesions will be decompressed. He noted that his group gives jaundiced or cholestatic patients antibiotics in advance and does not continue them if the lesion is decompressed successfully. Other circumstances under which antibiotic use is appropriate include patients with hilar tumors, primary sclerosing cholangitis, pancreatic fluid collections, or biliary or pancreatic duct leaks. For these patients, Dr. Petersen recommended continuing antibiotics for five or more days post-ERCP, depending on whether there are undrained segments or “gross pus visible at the time of the procedure.”
Mastering Depth of Endoscope Insertion
Becoming proficient in accessing the bile duct takes much longer than other aspects of ERCP training, such as stent placement or stone removal. However, “access is key to virtually everything we do,” stressed Dr. Petersen, and success partly depends on depth of endoscope insertion, which influences both the depth of duodenal intubation and torsion induced by extension in the stomach. “Depth of endoscope insertion is infrequently used optimally,” specifically for mid- and long depth, Dr. Petersen said. He encouraged “exploring and becoming familiar with depth of insertion to learn the effect of gastric insertion and duodenal depth on tip rotation and both vertical and horizontal axes toward the ampulla.” Proactive use of varied insertion depths and torque also enable improved radiographic imaging of focal lesions obscured by the endoscope.
Physician-Controlled, Wire-Guided Cannulation
Noting that cannulation technique varies with patient anatomy, Dr. Petersen presented evidence favoring physician-controlled and wire-guided cannulation over contrast-guided cannulation because both physician-controlled (Am J Gastroenterol 2016;111[12]:1841-1847) and wire-guided cannulation (J Gastroenterol Hepatol 2009;24[11]:1710-1715; Am J Gastroenterol 2009;104[9]:2343-2350; Gastrointest Endosc 2009;70[6]:1211-1219; Endoscopy 2013;45[8]:605-618) are associated with lower rates of post-ERCP pancreatitis. Dr. Petersen also recommended the use of angled hydrophilic wires over less responsive plastic wires and quoted studies suggesting that smaller caliber wires (Surg Endosc 2013;27[5]:1662-1667) are associated with equivalent success rates but lower pancreatitis rates than thicker wires.
Respecting Boundaries
Adverse outcomes including injury, bleeding and perforation are of concern when performing needle knife sphincterotomy. However, Dr. Petersen highlighted findings from meta-analyses that have shown that needle-knife sphincterotomy has similar overall adverse event rates and lower post-ERCP pancreatitis rates if initiated early (Endoscopy 2016;48[7]:657-683). “If one recognizes cannulation challenges and converts to a needle-knife approach within the first five minutes or after the first few cannulation attempts, the risk [for pancreatitis] is significantly lower,” he said.
He emphasized “respecting the boundaries of standard sphincterotomy during needle-knife sphincterotomy,” advising endoscopists to “follow the same path, the same depth and the same length of incisions” used during standard sphincterotomy to avoid the high-risk outcomes that are often feared.
Savvy Stone Removal
Removing stones often presents various challenges, depending on number, location and size. In the case of small stones, even finding them all can be difficult due to their location and the density of surrounding contrast, Dr. Petersen said. From an imaging standpoint, he recommended early filming during contrast instillation from above without initial use of balloon occlusion, opening the hilar view by tangential radiography and limited use of contrast. For removal of larger stones, Dr. Petersen said he prefers a moderate-length sphincterotomy plus balloon dilation because it is associated with lower risk for adverse events and perforation, as well as reduced need for mechanical lithotripsy (World J Gastroenterol 2013;19[45]:8258-8268).
For cystic duct stones, there are additional considerations and techniques. Mirizzi syndrome, which Dr. Petersen said can be overlooked easily usually is amenable to endoscopic palliation and even complete therapy, when recognized. In patients with obstructive cholecystitis, Dr. Petersen said he often “stents the gallbladder to alleviate acute cholecystitis in inoperable patients.” Otherwise, accessible cystic duct stones often can be pushed “back to the gallbladder from the upper duct” or removed “to the duodenum from the mid to lower duct.”
Stone removal in patients with coagulopathies can be managed in several ways, including:
- initial stent placement and subsequent sphincterotomy with stone removal after correction of the INR;
- stone removal after sphincter dilation, without sphincterotomy, after placement of a prophylactic pancreatic stent plus rectal indomethacin; and
- standard sphincterotomy and duct clearance, followed by placement of a fully covered metal stent for a month, to tamponade the sphincter incision.
Proper Stent Placement
Stenting “is all about access, stricture sampling of lesions, if indeterminate for cancer, and stent placement,” which “boils down to stent type, caliber, length, number and location,” Dr. Petersen said. He advised various stent types and durations for certain indications (Table).
| Table. Stent Type and Duration Recommendations for Selected Indications | ||
| Indication | Stent type/ number | Duration, months |
|---|---|---|
| Post- cholecystectomy leak | Single plastic | 1 |
| Benign extrahepatic stricture | Multiple plastic | 6-12 |
| FCSEMS | 6 | |
| Benign hilar stricture | Multiple plastic | >6 |
| Malignant extrahepatic stricture | Plastic vs. bare SEMS vs. FCSEMS | Indefinite |
| Malignant hilar stricture | Plastic (especially if potential surgery or transplantation) vs. bare SEMS (palliation only) | Indefinite |
| Palliation of bleeding | FCSEMS | 1 |
| Palliation of sphincter leak | FCSEMS | 1-2 |
| FC, fully covered; SEMS, self-expandable metal stent. | ||
Pancreatitis Prophylaxis
Minimization of pancreatitis risk begins with “careful selection of patients,” proper “training of your staff, … self-management of the guidewire … and gentle techniques,” according to Dr. Petersen. In addition, he said prophylaxis involves nonsteroidal anti-inflammatory drugs (NSAIDs), although there is a lack of consensus on whether this should be administered to all patients or just those at high risk for pancreatitis; temporary pancreatic stents; generous provision of IV fluids; and a clear liquid diet for 24 hours post-sphincterotomy.
Dr. Petersen noted that many clinicians do not use both pancreatic stents and rectal NSAIDs together, although he pointed to pending results from a recently completed National Institutes of Health–sponsored multicenter study, led by B. Joseph Elmunzer, MD, MSc, from the Medical University of South Carolina, in Charleston, aimed at addressing this question.
To summarize his most important recommendations for maximizing ERCP quality, Dr. Petersen reemphasized “attention to detail,” “mastery of mechanics,” with continued dedication beyond your initial training, and “judgment that’s free of bias and uses lessons that you’ve learned.”
—Natasha Albaneze
This article is from the July 2023 print issue.