Biliopancreatic Endoscopy: Practical Application

252 Pages·2018·15.785 MB·English

by  Kwok-Hung Lai, Lein-Ray Mo, Hsiu-Po Wang, (eds.)

Biliopancreatic
Endoscopy
Practical Application
Kwok-Hung Lai
Lein-Ray Mo
Hsiu-Po Wang
Editors
123
Biliopancreatic Endoscopy
Kwok-Hung Lai • Lein-Ray Mo
Hsiu-Po Wang
Editors
Biliopancreatic
Endoscopy
Practical Application
Editors
Kwok-Hung Lai Lein-Ray Mo
Division of Gastroenterology and Show-Chwan Health Care System
Hepatology Chang-Hua, Taiwan
Kaohsiung Veterans General Hospital
Medical College
Kaohsiung, Taiwan
National Taiwan University
Taipei, Taiwan
Hsiu-Po Wang
Division of Gastroenterology,
Department of Internal Medicine
National Taiwan University Hospital,
National Taiwan University
Taipei, Taiwan
ISBN 978-981-10-4366-6 ISBN 978-981-10-4367-3 (eBook)
https://doi.org/10.1007/978-981-10-4367-3
Library of Congress Control Number: 2017964098
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Preface
Endoscopic retrograde cholangiopancreatography (ERCP) was initially used
for the diagnosis of biliary and pancreatic diseases in the last century. Even
with the advent of new facilities and improvement of the techniques, ERCP is
still considered to be an invasive and uncomfortable procedure. Nowadays,
the method of ERCP is popularly applied to enlarge the papillary orifice for
the removal of biliary and pancreatic stones, to relieve obstruction of distal
bile duct or pancreatic duct by nasobiliary/nasopancreatic drainage or stent-
ing, and to remove the premalignant tumor of the papilla. In the twenty-first
century, the rights and safety of patients as well as the efficacy of clinical
management are the basic requirements in the teaching hospital. To perform
a good ERCP, it needs the experience of an endoscopist, to recognize the his-
tory of patients and available facilities, to be careful and patient during the
procedure. A competent ERCPist should practice more than 200 successful
procedures under the supervision of an experienced expert. However, a per-
fect ERCP simulation system is not available even today, and most of the
trainees get their technical experiences initially from real patients. In addi-
tion, the budgets for medical care are not limitless particularly in countries
with national health insurance such as Taiwan. The patients’ characteristics
and techniques used for ERCP may have some differences between the
Western and Eastern countries. How to choose the cost-effective and safe
procedure to help patients is an important requisite for clinical practice and
training programs. Endoscopic ultrasonography is a useful modality for the
diagnosis and interventional treatment of biliary and pancreatic diseases, but
it also requires special skills and experiences of endoscopists to complete the
procedures.
I would like to appreciate our senior members of the Digestive Endoscopy
Society of Taiwan for sharing their experiences in clinical practice and for
summarizing the literatures on recent advances concerning biliopancreatic
endoscopy. This book will help the readers to improve their basic technique
and selection of the best method and facilities, and to provide a safe, effective
medical service to their patients in the future.
Kaohsiung, Taiwan Kwok-Hung Lai
v
Contents
Fundamentals of ERCP: Indications, Equipment,
and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Kwok-Hung Lai
Basic Technique of ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Lein-Ray Mo
Endoscopic Sphincterotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Jui-Hao Chen
Endoscopic Papillary Balloon Dilation . . . . . . . . . . . . . . . . . . . . . . . . . 35
Wei-Chih Liao
Endoscopic Papillary Large Balloon Dilation (EPLBD) . . . . . . . . . . . 43
Hoi-Hung Chan and Kwok-Hung Lai
Endoscopic Nasopancreatic and Nasobiliary Drainage
(ENPD and ENBD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Chih-Jen Chen, Ching-Chung Lin, and Cheng-Hsin Chu
Biliary Endoprosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Nai-Jen Liu
Endoscopic Retrograde Cholangiopancreatography
in Surgically Altered Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Cheng-Hui Lin
ERCP for Pancreatic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Cheuk-Kay Sun
ERCP for Biliary-Pancreatic Tissue Acquisition . . . . . . . . . . . . . . . . . 107
Wen-Hsin Huang
EUS for Biliopancreatic Tissue Acquisition . . . . . . . . . . . . . . . . . . . . . 117
Tsu-Yao Cheng
Fundamental Techniques of EUS in Pancreatico-biliary
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Hong-Zen Yeh
Role of Endoscopic Ultrasonography in the Management
of Benign Biliopancreatic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Jiann-Hwa Chen
vii
viii Contents
Role of Endoscopic Ultrasonography in the Management
of Malignant Pancreatico-biliary Disease . . . . . . . . . . . . . . . . . . . . . . . 149
Meng-Shun Sun
Intraductal Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Chien-Hua Chen
Endoscopic Treatment of Complications After Liver
Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Ching-Sung Lee
Endoscopic Papillectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Hsiu-Po Wang
Peroral Cholangioscopy/Pancreatoscopy . . . . . . . . . . . . . . . . . . . . . . . 201
Wei-Chi Sun and Hoi-Hung Chan
Sphincter of Oddi Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Tseng-Shing Chen
Management of Post-ERCP Complications . . . . . . . . . . . . . . . . . . . . . 225
Cheuk-Kay Sun
Endoscopic Ultrasonography (EUS) Related Complications
and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Chun-Jung Lin
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Fundamentals of ERCP:
Indications, Equipment,
and Preparation
Kwok-Hung Lai
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is widespread
use for the clinical management of biliopancreatic disease. Even the diag-
nosis of most biliopancreatic diseases can be established by noninvasive
imaging modalities including computed tomography (CT scan), magnetic
resonance imaging (MRI), or endoscopic ultrasonography (EUS); ERCP
is still required for the study of sphincter function, observation of the
intraductal lesions, acquisition of specimen for histological diagnosis, and
further endoscopic treatment. ERCP is considered as an invasive proce-
dure; the experience of endoscopists and working teams is the major factor
influencing the success rate. A competent ERCP endoscopist is defined as
completing a minimum of 200 procedures and achieving an overall biliary
cannulation rate of at least 85% [1–3]. In the teaching hospitals, the ERCPs
performed by supervised trainees were reported to be as safe as the com-
petent ERCP endoscopists [4]. Some special techniques such as double
guidewire method, precut sphincterotomy, pancreatic stenting, or rendez-
vous method with EUS can increase the success rate of difficult ERCP, but
the complication rate is higher than conventional methods even performed
by the experts [5]. Screening of the patients with appropriate indications,
selection of suitable methods and equipment, and well preparation before
the procedures are paramount for the safety and success of ERCP.
K.-H. Lai, M.D.
Division of Gastroenterology and Hepatology,
Kaohsiung Veterans General Hospital,
Kaohsiung, Taiwan
School of Medicine, National Yang-Ming University,
Taipei, Taiwan
Department of Medicine, National Defense
Medical Center, Taipei, Taiwan
e-mail: [email protected]
© Springer Nature Singapore Pte Ltd. 2018 1
K.-H. Lai et al. (eds.), Biliopancreatic Endoscopy, https://doi.org/10.1007/978-981-10-4367-3_1
2 K.-H. Lai
Keywords
Indication • Contraindication • Equipment • Preparation • Evaluation of
patient • Endoscopic retrograde cholangiopancreatography • ERCP •
Duodenoscope • Choledochoscope • Echoendoscope • Cannula •
Guidewire • Sphincterotome • Balloon • Dilator • Stent • Nasobiliary cath-
eter • Brushing catheter • Accessories • History • Physical examination •
Laboratory test • Informed consent • Instruction • Antiplatelet therapy •
Anticoagulation therapy • Bleeding tendency • Intracardiac device •
Contrast medium • Allergy • Pregnancy • Antibiotic prophylaxis •
Premedication • Sedation • Radiation protection
Introduction Indications and Contraindications
Endoscopic retrograde cholangiopancreatogra- The indications for ERCP are assessment and
phy (ERCP) is widespread use for the clinical treatment of biliary obstruction due to common
management of biliopancreatic disease. Even the bile duct stones, benign and malignant biliary
diagnosis of most biliopancreatic diseases can be stricture, sphincter of Oddi dysfunction, recur-
established by noninvasive imaging modalities rent pancreatitis and its complication such as
including computed tomography (CT scan), mag- stricture, stones and pseudocyst formation,
netic resonance imaging (MRI), or endoscopic ampullary tumor, and postoperative biliary leak-
ultrasonography (EUS); ERCP is still required age. The indications and types of diagnostic and
for the study of sphincter function, observation of therapeutic ERCP are shown in Table 1. In the
the intraductal lesions, acquisition of specimen patients with pancreatic and biliary cancers,
for histological diagnosis, and further endoscopic ERCP is only indicated for histological diagnosis
treatment. ERCP is considered as an invasive and palliative treatment of biliary obstruction
procedure; the experience of endoscopists and when surgery is not elected. Preoperative ERCP
working teams is the major factor influencing the
success rate. A competent ERCP endoscopist is
defined as completing a minimum of 200 proce- Table 1 Indications of diagnostic and therapeutic ERCP
dures and achieving an overall biliary cannula- Diagnostic
tion rate of at least 85% [1–3]. In the teaching 1. Unexplainable biliary pain not diagnosed by other
hospitals, the ERCPs performed by supervised noninvasive images
trainees were reported to be as safe as the compe- 2. Cholangioscopy or pancreatoscopy
tent ERCP endoscopists [4]. Some special tech- 3. Intraductal sonography
niques such as double guidewire method, precut 4. Brushing cytology or biopsy
sphincterotomy, pancreatic stenting, or rendez- 5. Collection of bile for analysis
6. Sphincter of Oddi manometry
vous method with EUS can increase the success
Therapeutic
rate of difficult ERCP, but the complication rate
1. Endoscopic sphincterotomy or balloon dilation to
is higher than conventional methods even per-
remove common bile duct stones
formed by the experts [5]. Screening of the
2. Dilatation or stenting of benign or malignant biliary
patients with appropriate indications, selection of
or pancreatic stricture
suitable methods and equipment, and well prepa- 3. Nasobiliary, nasopancreatic drainage, or temporary
ration before the procedures are paramount for stenting for jaundice or pancreatitis
the safety and success of ERCP. 4. Ampullectomy
Fundamentals of ERCP: Indications, Equipment, and Preparation 3
is not required in patients undergoing cholecys- through the guidewires. Cannulas, guidewires, and
tectomy if there is low probability of concomitant sphincterotomes are the frequently used accessories
choledocholithiasis [6, 7]. In patients with clini- for therapeutic ERCP. Each item of accessory
cally suspected type 2 or 3 sphincter of Oddi dys- devices has many types, with different sizes, func-
function, sphincter of Oddi manometry (SOM) tions, and prices. The selection of accessories for
may be indicated after diagnostic ERCP. Bile col- cannulation depends on the endoscopists’ prefer-
lection for microscopic examination of crystals ence and financial consideration. The size and
and parasitic ova is suggested in endemic area or length of accessory devices must fit the endoscope,
clinically suspicion of stones but negative ERCP. particularly the colonoscope or enteroscope with
The absolute contraindications include patients’ smaller working channel and longer length which
refusal, unstable cardiopulmonary, neurological or was used for the patient with surg ically altered
cardiovascular condition, pharyngeal or esopha- anatomy. The success rate of selective bile duct can-
geal obstruction, and suspected hollow organ per- nulation using a standard catheter with or without
foration. Relative contraindications include severe guidewire ranged from 66 to 81.7%, whereas the
coagulopathy, pregnancy, known to have structural success rate by using a sphincterotome with a
abnormality of upper gastrointestinal tract (e.g., guidewire ranged from 84 to 97% [8, 10]. The stan-
stricture of esophagus, pyloric obstruction, parae- dard catheter with or without a guidewire are lim-
sophageal herniation or volvulus, etc.), prior his- ited in their ability to vary the angle to gain access
tory of anaphylactic reaction of contrast media, into the desired duct. Although the distal end of
inadequate preparation for endoscopic therapy, catheter can be manipulated to make a curve before
and inadequate surgical backup. cannulation, it is sometimes difficult to selective
cannulation in the patient with a prominent native
papilla and its orifice faced downwardly. Although
Equipment routine use of a sphincterotome with guidewire for
initial cannulation and native papilla can achieve a
Side-view duodenoscope with a biopsy channel higher success rate of selection cannulation, it may
≥3.2 mm is recommended for routine increase the medical expense if the patient is not
ERCP. Therapeutic duodenoscope with a larger planned for subsequent sphincterotomy. The cathe-
biopsy channel ≥4.2 mm is needed for special ter or sphincterotome with a smaller tapered tip
purposes such as large plastic stent insertion (3 or 3.5 Fr) may improve ductal access in the minor
(≥10 Fr), mechanical lithotripsy, or choledocho- papilla or major papilla with a small orifice. Some
scopic examination. Therapeutic end-view endo- small tapered catheter or sphincterotomes only
scopes, enteroscopes with/without balloon accommodate to a smaller caliber guidewire
assistance, or colonoscopes can be used for (0.018–0.025 in). Exchanging to a conventional
patients with surgically altered anatomy. Besides catheter and larger guidewire (0.035 in.) or using a
the baby and spyglass choledochoscope, the stronger 0.025 in. guidewire (e.g., Visiglide 2,
ultraslim gastroscope can also be used to exam- Jagwire stiff) after selective cannulation may be
ine the bile duct through the enlarged papillary needed if it is followed by a stent insertion or bal-
orifice. Therapeutic curvilinear echoendoscope is loon dilation through a stricture or stenotic papilla.
needed for EUS-guided procedures [8, 9]. Needle knife sphincterotome should be prepared for
Accessories including cannulas, guidewires, precut sphincterotomy or fistulotomy in the patients
sphincterotomes, balloons or tapered dilators, bas- with difficult selective cannulation of bile duct or
kets, lithotripters, plastic or metallic stents, nasobili- endoscopic drainage of pancreatic pseudocyst [8–11].
ary catheters, brushing catheters, or injection Some catheters or sphincterotomes with special
needles should be prepared according to the thera- designs such as multiple lumens, swing tip, metal
peutic purposes. The basic technology of ERCP is tip, dome tip, clevercut (coating of proximal cutting
selective cannulation and guidewire insertion. Most wire), short wire system, and preloaded with guide-
of the therapeutic ERCP p rocedures are performed wire are available, but their list prices are higher