Controversies in ERCP: Technical aspects

Abstract

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

Keywords: EUS; bile stones; endoscopic sphincterotomy; magnetic resonance cholangio pancreaticography; papillotomy; tumor.

Figure 1

Classification of size of biliary endoscopic sphincterotomy as defined by the Japanese Gastroenterological Endoscopic Society

Figure 2

Normal papilla (a) and different endoscopic sphincerotomy techniques (b-d). Needle knife papillotomy (b), needle knife fistulotomy (c) and NKF and transpancreatic sphincterotomy (d). A normal cholangiogram is shown in (e)

Figure 3

Patient with obstructive jaundice due to advanced gallbladder cancer and a history of Billroth-II-gastrectomy. Biliary sphincterotomy was performed using a wire-guided inverted sphincterotome (a). Retrograde cholangiography revealed a 2 cm stricture of the common bile duct (b). A partially covered self-expanding metal stent was inserted for drainage of the dilated hepatic and intrahepatic ducts (c and d)