Additional Information
Book Details
Abstract
ERCP, now in its second edition, is dedicated to simplifying and explaining everything that you need to know to effectively and safely practice endoscopic retrograde cholangiopancreatography. High-quality images, illustrative diagrams, and coverage of the latest techniques guide you through this complex topic and help you achieve optimal outcomes.
- Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you’re using or where you’re located.
- Deliver the most effective therapy with an in-depth review of intricate ERCP procedures, and equip yourself with the latest techniques, therapeutic modalities, and guidelines.
- Master the latest diagnostic and therapeutic techniques with ERCP - your visual and interactive guide to this increasingly important procedure!
- Apply the latest ERCP techniques with 11 new chapters covering Cholangioscopy: Videocholangioscopy; Echoendoscopic Ultrasound; Endoscopic Ultrasound; Combined Biliary and Duodenal Obstruction; and more.
- Enhance your learning with the help of summaries following each chapter, updated images throughout, and a wealth of illustrative diagrams demonstrating key information.
- See how it's done. Over 40 videos feature the latest procedures, such as Needle Knife Sphincterotomy, Biliary Sphincterotomy, Cannulation, and Fistulotomy.
- Access the fully searchable text, download all the images, and watch key videos online at www.expertconsult.com!
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | cover | ||
| Endsheet 2 | IFC1 | ||
| ERCP | i | ||
| Copyright page | iv | ||
| Dedication | v | ||
| List of Contributors | vi | ||
| Foreword | xi | ||
| Acknowledgments | xii | ||
| Table of Contents | xiii | ||
| Video Contents | xv | ||
| I General Topics | 1 | ||
| 1 Four Decades: | 2 | ||
| ERCP in Its Infancy | 2 | ||
| The Second Decade | 7 | ||
| The Third Decade | 8 | ||
| ERCP in the New Millennium | 8 | ||
| The Future of ERCP | 9 | ||
| Acknowledgments | 9 | ||
| References | 9.e1 | ||
| 2 The ERCP Room | 10 | ||
| Evolution of the ERCP Room | 10 | ||
| Staffing for the ERCP Procedure | 10 | ||
| Room Layout | 10 | ||
| Radiologic Imaging Equipment | 12 | ||
| Room Integration Systems | 13 | ||
| Endoscopist Work Area | 13 | ||
| Intra-Procedure | 13 | ||
| Pre- and Post-Procedure Work Area | 13 | ||
| Anesthesia or Sedation Work Area | 14 | ||
| Nursing and Technician Work Area | 14 | ||
| Miscellaneous Issues | 15 | ||
| References | 15.e1 | ||
| 3 Radiologic Issues and Radiation Safety during ERCP | 16 | ||
| Fluoroscopic Imaging Systems | 16 | ||
| Radiation Dose Management in Fluoroscopic Procedures | 18 | ||
| Occupational Ionizing Radiation Exposure | 19 | ||
| Creating and Viewing Images | 20 | ||
| Bile Duct Evaluation | 23 | ||
| Pancreatic Duct Evaluation | 24 | ||
| General Imaging Considerations | 26 | ||
| References | 31.e1 | ||
| 4 Endoscopes, Guidewires, and Accessories | 32 | ||
| Endoscopes | 32 | ||
| Side-Viewing Endoscopes | 32 | ||
| Forward-Viewing Endoscopes | 32 | ||
| Balloon-Assisted Enteroscopes | 32 | ||
| Echoendoscopes | 32 | ||
| Accessories | 33 | ||
| Standard Cannulation Catheters | 33 | ||
| Sphincterotomes | 34 | ||
| Access Sphincterotomes | 34 | ||
| Guidewires | 35 | ||
| Wire Safety | 36 | ||
| Exchange Assistance Devices (Short-Wire ERCP Systems) | 36 | ||
| Rapid Exchange Biliary System | 36 | ||
| Fusion System | 37 | ||
| V-System | 37 | ||
| Drainage Devices | 38 | ||
| Plastic Stents | 38 | ||
| Self-Expandable Metal Stents | 39 | ||
| Nasobiliary and Pancreatic Drainage Catheters | 40 | ||
| Tissue Sampling Devices | 40 | ||
| Stricture Dilation Devices | 40 | ||
| Stone Extraction Accessories | 41 | ||
| Mechanical Lithotriptors | 41 | ||
| Cholangiopancreatoscopy | 41 | ||
| Intraductal Ultrasound Probes | 42 | ||
| Probe-Based Confocal Laser Endomicroscopy (pCLE) | 43 | ||
| Other Accessories | 43 | ||
| Radiographic Contrast Media Used in ERCP | 43 | ||
| Accessories for Use in Patients with Altered Anatomy | 44 | ||
| Single-Use versus Reusable Accessories | 44 | ||
| Storage of Accessories | 44 | ||
| Role of the U.S. Food and Drug Administration in Device Evaluation and Monitoring | 44 | ||
| Radiation Exposure | 44 | ||
| References | 45.e1 | ||
| 5 Sedation in ERCP | 46 | ||
| Defining the Continuum of Sedation | 46 | ||
| Defining Sedation-Related Adverse Events | 47 | ||
| Safety of Alternative Approaches to Sedation in ERCP | 47 | ||
| Anesthesiologist-Administered Sedation | 47 | ||
| Nonanesthesiologist-Administered (Endoscopist-Administered) Sedation | 47 | ||
| Risk Assessment | 48 | ||
| Monitoring | 48 | ||
| Conclusion | 49 | ||
| References | 50.e1 | ||
| 6 Indications for and Contraindications to ERCP | 51 | ||
| Indications for and Contraindications to ERCP | 51 | ||
| Indications for ERCP | 52 | ||
| Special Cases | 55 | ||
| Contraindications to ERCP | 55 | ||
| References | 56.e1 | ||
| 7 Adverse Events of ERCP: | 57 | ||
| Definitions of Complications, Adverse Events, Unplanned Events and Other Negative Outcomes | 57 | ||
| Analyses of Adverse Event Rates | 57 | ||
| Overall Adverse Events of ERCP and Sphincterotomy | 57 | ||
| Pancreatitis | 58 | ||
| Patient-Related Risk Factors for Post-ERCP Pancreatitis | 59 | ||
| Technique-Related Risk Factors for Post-ERCP Pancreatitis | 60 | ||
| Specific Techniques to Reduce Risk of Post-ERCP Pancreatitis | 60 | ||
| Pharmacological Agents | 62 | ||
| Prevention and Treatment of Post-ERCP Pancreatitis | 62 | ||
| Hemorrhage | 62 | ||
| Risk Factors for Hemorrhage after Sphincterotomy | 63 | ||
| Methods to Prevent and Treat Hemorrhage | 63 | ||
| Perforation | 63 | ||
| Cholangitis and Cholecystitis | 64 | ||
| Long-Term Adverse Events and Sequelae | 64 | ||
| Operator Experience and Adverse Events | 65 | ||
| References | 65.e1 | ||
| 8 ERCP Training | 66 | ||
| Clinical Training in ERCP | 66 | ||
| Other Guidelines | 67 | ||
| Maintenance of ERCP Skills | 68 | ||
| Training Models and Simulators | 68 | ||
| ERCP Training in Live Animals | 68 | ||
| Ex Vivo Porcine Tissue Models (Composite and Explanted Organ Simulators) | 69 | ||
| Computer Simulators | 70 | ||
| Mechanical Models | 70 | ||
| Comparison of ERCP Training Models | 70 | ||
| Acquiring Teaching Skills as a Tutor for Hands-On Workshops | 71 | ||
| Open Questions and Perspectives for ERCP Training in the Future | 72 | ||
| References | 72.e1 | ||
| 9 Preparation for ERCP | 73 | ||
| Should This Patient Undergo ERCP? | 73 | ||
| When, Where, and by Whom? | 73 | ||
| Evaluation of the Patient Prior to ERCP | 73 | ||
| History and Physical Examination | 73 | ||
| Laboratory Testing | 74 | ||
| Review of Imaging Studies | 74 | ||
| Preparing the Patient—Day(s) Prior to ERCP | 74 | ||
| Management of Antithrombotic Agents | 74 | ||
| Antiplatelet Agents | 74 | ||
| Anticoagulants | 75 | ||
| Duration of Fasting | 75 | ||
| Method of Sedation, Proper Personnel, and Patient Monitoring | 75 | ||
| Selecting Sedation for ERCP | 75 | ||
| Proper Personnel | 76 | ||
| Proper Monitoring and Intervention Equipment | 76 | ||
| Preparing the Endoscopy Team | 76 | ||
| Preparing the Patient—Day of the ERCP | 77 | ||
| Informed Consent | 77 | ||
| Periprocedural Antibiotics | 77 | ||
| Positioning the Patient and Preparing for Radiography | 77 | ||
| Reviewing Intravenous Access and Allergies | 78 | ||
| References | 79.e1 | ||
| 10 Principles of Electrosurgery | 80 | ||
| A Brief History of Electrosurgery and ERCP | 80 | ||
| Basics of Electricity as Applied to Electrosurgery | 80 | ||
| Basics of Electricity | 80 | ||
| The Electrosurgical Unit | 81 | ||
| Monopolar versus Bipolar Circuits | 81 | ||
| Maximizing Safety | 81 | ||
| Pacemakers | 82 | ||
| Neuromuscular Stimulation | 82 | ||
| Current Leaks | 82 | ||
| Clinical Applications of Electrosurgery in ERCP | 82 | ||
| Sphincterotomy | 82 | ||
| Needle-Knife Access Papillotomy | 83 | ||
| Electrohydraulic Lithotripsy (EHL) | 83 | ||
| Ampullectomy or Papillectomy | 83 | ||
| Pseudocyst Drainage and Necrosectomy | 83 | ||
| Radiofrequency Ablation (RFA) in the Bile Duct | 83 | ||
| References | 84.e1 | ||
| 11 Quality Issues and Measures in ERCP | 85 | ||
| Preprocedure Quality Indicators | 85 | ||
| Appropriate Indication | 85 | ||
| Informed Consent | 86 | ||
| Assessment of Procedural Difficulty | 87 | ||
| Prophylactic Antibiotics | 87 | ||
| Intraprocedure Quality Indicators | 87 | ||
| Cannulation Rates | 88 | ||
| Removal of Common Bile Duct Stones | 88 | ||
| Stent Placement for Biliary Obstruction below the Bifurcation | 88 | ||
| Postprocedure Quality Indicators | 89 | ||
| Comprehensive Documentation | 89 | ||
| Adverse Event Rates | 89 | ||
| Fluoroscopy Duration | 90 | ||
| Initiating Quality Measurements | 90 | ||
| Summary | 90 | ||
| References | 91.e1 | ||
| 12 Medicolegal Issues in ERCP | 92 | ||
| How Often Are Gastroenterologists and Endoscopists Sued? | 92 | ||
| How Common Are Lawsuits Involving ERCP? | 92 | ||
| What Are The Key Legal Principles? | 93 | ||
| Elements of a Malpractice Case: The Principles of Tort Law | 93 | ||
| Duty | 93 | ||
| Breach of Duty | 93 | ||
| Causation | 93 | ||
| Injury | 93 | ||
| Standards of Care and Guidelines | 93 | ||
| Guidelines | 93 | ||
| Who May Be Liable? | 94 | ||
| Employer Liability | 94 | ||
| Preceptor | 94 | ||
| Proctor | 94 | ||
| Administrator | 94 | ||
| Hospital Liability | 94 | ||
| Summary | 94 | ||
| Informed Consent | 94 | ||
| Theory of Informed Consent | 95 | ||
| Material Risks | 95 | ||
| Controversial Areas | 95 | ||
| Exceptions to Informed Consent | 95 | ||
| Informed Refusal | 95 | ||
| Legal Consequences of Failing to Obtain Informed Consent | 95 | ||
| Why Do ERCP Lawsuits Occur? | 96 | ||
| Marginal Indications | 96 | ||
| Poor Communications | 96 | ||
| Poor Endoscopic Technique | 96 | ||
| Sedation or Anesthesia Problems | 96 | ||
| Poor Aftercare | 96 | ||
| Nosocomial Infection | 97 | ||
| Delay in Performing ERCP | 97 | ||
| How to Minimize the Risk of Litigation | 97 | ||
| Training and Accountability | 97 | ||
| Levels of Complexity in Training and Practice | 97 | ||
| How Is Competence Ensured and Documented? | 97 | ||
| Certification? | 98 | ||
| Recognizing Higher Risk Situations | 98 | ||
| Higher Risk Patients | 98 | ||
| Higher Risk Procedures | 98 | ||
| The Context of the Procedure | 98 | ||
| Risk–Benefit | 98 | ||
| Professional Behavior | 98 | ||
| Doing Informed Consent Right | 99 | ||
| Documenting the Consent Process: “He Said, She Said” | 99 | ||
| Special Care Needed with “Open Access” and Urgent ERCP | 99 | ||
| Live Teaching Demonstrations | 99 | ||
| Managing Adverse Events | 101 | ||
| If You Are Sued | 101 | ||
| Expert Testimony | 101 | ||
| Summary | 102 | ||
| References | 102.e1 | ||
| II Techniques | 103 | ||
| 13 Cannulation of the Major Papilla | 104 | ||
| Establishing the Duodenal Position | 104 | ||
| Devices and Equipment (see also Chapter 4) | 105 | ||
| Cannulation Technique | 105 | ||
| Wire or Contrast? | 105 | ||
| Papilla Assessment and Basic Technique | 106 | ||
| Small Papilla | 109 | ||
| Periampullary Diverticulum | 109 | ||
| Difficult Cannulation | 110 | ||
| Repeated Cannulation of the Pancreatic Duct without Biliary Access | 110 | ||
| Needle-Knife Sphincterotomy (see also Chapter 14) | 113 | ||
| NKS Technique | 113 | ||
| Cannulation of the Pancreatic Duct | 114 | ||
| Quality and Enhancing Outcomes (see also Chapter 11) | 115 | ||
| References | 115.e1 | ||
| 14 Access (Precut) Papillotomy | 116 | ||
| Indication for Precut Papillotomy | 116 | ||
| Precut Accessories | 116 | ||
| Techniques | 117 | ||
| Needle-Knife from the Orifice | 117 | ||
| Needle-Knife above the Orifice (Fistulotomy) | 118 | ||
| Needle Knife with an Insulated Tip | 119 | ||
| Short-Nose Precut Sphincterotomy | 120 | ||
| Transpancreatic Sphincterotomy | 120 | ||
| Unconventional Techniques | 120 | ||
| Use of Pancreatic Stents | 120 | ||
| Adverse Events | 121 | ||
| Pancreatitis | 122 | ||
| Bleeding | 123 | ||
| Perforation | 123 | ||
| Failed Access and Cost | 123 | ||
| Summary | 123 | ||
| References | 123.e1 | ||
| 15 Sphincter of Oddi Manometry | 124 | ||
| Method of SOM | 124 | ||
| Sedation | 124 | ||
| Equipment | 125 | ||
| Technical Performance of SOM (Video 15.1) | 126 | ||
| Interpretation Criteria | 127 | ||
| Reproducibility of SOM | 128 | ||
| Adverse Events of SOM | 128 | ||
| Summary | 128 | ||
| References | 128.e1 | ||
| 16 Biliary Sphincterotomy | 129 | ||
| Description of the Technique | 129 | ||
| Instruments (see also Chapter 4) | 129 | ||
| Procedure | 130 | ||
| ES in Patients with Difficult Anatomy | 133 | ||
| Alternatives to ES | 134 | ||
| Indications | 134 | ||
| Contraindications | 135 | ||
| Adverse Events and Their Management | 135 | ||
| ES-Related Pancreatitis | 135 | ||
| ES-Related Hemorrhage | 136 | ||
| ES-Related Perforation | 137 | ||
| ES-Related Cholangitis | 137 | ||
| Long-Term Consequences of ES | 137 | ||
| References | 138.e1 | ||
| 17 Balloon Dilation of the Native and Postsphincterotomy Papilla | 139 | ||
| Technique of Balloon Dilation of the Native Papilla | 139 | ||
| Indications for EPBD | 140 | ||
| Limitations and Recommendation of EPBD | 140 | ||
| Adverse Events of EPBD | 141 | ||
| Endoscopic Papillary Large Balloon Dilation (EPLBD) after Endoscopic Biliary Sphincterotomy (ES) | 145 | ||
| Technique of Large Balloon Dilation of Postsphincterotomy Papilla | 146 | ||
| Adverse Events of EPLBD after ES | 147 | ||
| EPLBD without Preceding Sphincterotomy (ES) | 149 | ||
| Summary | 150 | ||
| References | 151.e1 | ||
| 18 Stone Extraction | 152 | ||
| Indications and Contraindications | 152 | ||
| Indications | 152 | ||
| Contraindications | 153 | ||
| Description of Technique | 153 | ||
| Removal of an Impacted Ampullary Stone | 153 | ||
| Balloon Stone Extraction | 153 | ||
| Basket Stone Extraction | 156 | ||
| Relative Cost of Stone Retrieval Balloons and Baskets | 158 | ||
| Mechanical Lithotripsy | 158 | ||
| Intraductal Lithotripsy | 162 | ||
| Methods of POC | 162 | ||
| Electrohydraulic Lithotripsy | 163 | ||
| Laser Lithotripsy | 163 | ||
| Management of Cystic Duct Stones | 163 | ||
| Adverse Events and Their Management | 163 | ||
| Extraction Balloons | 163 | ||
| Extraction Baskets | 164 | ||
| Mechanical Lithotripsy | 164 | ||
| Intraductal Lithotripsy | 165 | ||
| Summary | 165 | ||
| References | 165.e1 | ||
| 19 Pancreatic Sphincterotomy | 166 | ||
| Endoscopic Pancreatic Sphincterotomy | 166 | ||
| Preparation | 166 | ||
| Equipment | 166 | ||
| The Endoscopic Technique | 167 | ||
| Pull-Type Sphincterotomy | 168 | ||
| Needle-Knife Sphincterotomy | 170 | ||
| Precut Pancreatic Sphincterotomy | 170 | ||
| Indications for Pancreatic Sphincterotomy | 171 | ||
| Pancreatic Sphincterotomy as Primary Therapy | 171 | ||
| Pancreas Divisum and Sphincter of Oddi Dysfunction | 171 | ||
| Chronic Pancreatitis | 173 | ||
| Pancreatic Sphincterotomy as Secondary Therapy | 175 | ||
| Adverse Events of Pancreatic Sphincterotomy | 175 | ||
| The Cost of Pancreatic Sphincterotomy | 176 | ||
| References | 177.e1 | ||
| 20 Minor Papilla Cannulation and Sphincterotomy | 178 | ||
| Indications for Minor Papilla Cannulation and Sphincterotomy | 178 | ||
| Sedation, Supplemental Drugs, and ERCP Accessories | 178 | ||
| Sedation | 178 | ||
| Supplemental Drugs | 179 | ||
| ERCP Accessories | 179 | ||
| Minor Papilla Cannulation (Video 20.1) | 180 | ||
| Cannulating the Minor Papilla in Difficult Cases | 181 | ||
| Minor Papilla Sphincterotomy | 182 | ||
| Techniques for Minor Papilla Sphincterotomy | 182 | ||
| Sphincterotomy with Pull-Type Sphincterotome | 183 | ||
| Sphincterotomy with Needle Knife over Pancreatic Stent | 184 | ||
| Sphincterotomy with Wire-Assisted Needle Knife | 184 | ||
| Pull-Type or Needle-Knife Sphincterotome: Pros and Cons | 184 | ||
| Postprocedural Stenting of the Minor Papilla | 185 | ||
| Precut Sphincterotomy Technique | 185 | ||
| Repeat Minor Papilla Sphincterotomy | 186 | ||
| Outcomes of Minor Papilla Sphincterotomy | 186 | ||
| Adverse Events | 186 | ||
| References | 187.e1 | ||
| 21 Plastic Pancreaticobiliary Stents and Nasopancreaticobiliary Tubes: | 188 | ||
| Stent Systems | 188 | ||
| Endoscope Requirements | 188 | ||
| Description of Technique: Biliary | 188 | ||
| Distal Biliary Obstruction | 188 | ||
| Stents for Irretrievable Bile Duct Stones | 193 | ||
| Hilar Biliary Obstruction | 194 | ||
| Nasobiliary Tubes | 194 | ||
| Pancreatic Duct Stent Insertion | 196 | ||
| Nasopancreatic Tubes | 196 | ||
| Drainage of Pancreatic Fluid Collections | 196 | ||
| Indications and Contraindications | 197 | ||
| Biliary Indications | 197 | ||
| Pancreatic Indications | 197 | ||
| Adverse Events | 198 | ||
| Relative Cost | 199 | ||
| References | 199.e1 | ||
| 22 Biliary Metal Stent Insertion | 200 | ||
| Indications | 200 | ||
| SEMS versus Plastic Stents | 200 | ||
| SEMS for Benign Biliary Disease | 201 | ||
| Types of SEMS | 201 | ||
| Covered versus Uncovered SEMS | 201 | ||
| Uncovered SEMS | 202 | ||
| Wallstent | 202 | ||
| Wallflex | 202 | ||
| Zilver | 203 | ||
| Niti Stents | 203 | ||
| Flexxus | 204 | ||
| Covered SEMS | 205 | ||
| Wallstent | 205 | ||
| Wallflex | 205 | ||
| Viabil | 205 | ||
| Other SEMS | 205 | ||
| Techniques for SEMS Placement | 206 | ||
| Duodenoscope | 206 | ||
| Cholangiogram | 206 | ||
| Sphincterotomy | 206 | ||
| Dilation | 206 | ||
| Stent Selection | 206 | ||
| Use of Guidewire | 206 | ||
| SEMS Positioning | 206 | ||
| Endoscopic and Fluoroscopic Guidance | 207 | ||
| Deployment | 208 | ||
| Rendezvous Technique | 208 | ||
| Hilar Strictures | 208 | ||
| Duodenal Obstruction | 208 | ||
| Adverse Events and Their Management | 210 | ||
| Relative Cost | 211 | ||
| SEMS versus Plastic | 211 | ||
| Summary | 211 | ||
| References | 211.e1 | ||
| 23 Pancreaticobiliary Stent Removal: | 212 | ||
| Removal of Biliary Stents | 212 | ||
| Indications and Contraindications | 213 | ||
| Time for Stent Removal | 214 | ||
| Techniques | 214 | ||
| Direct Grasping Technique | 215 | ||
| Indirect Grasping Technique | 215 | ||
| Lasso Technique | 215 | ||
| Soehendra Stent Retriever Technique | 215 | ||
| Fogarty Balloon Technique | 215 | ||
| Covered Stent in Uncovered Stent Technique | 216 | ||
| Trimming of SEMS | 217 | ||
| Other Techniques and Variations of the Previous Techniques | 217 | ||
| Adverse Events and Management | 218 | ||
| Relative Costs and Choice of Technique | 218 | ||
| Removal of Pancreatic Stents | 218 | ||
| Indications and Contraindications | 219 | ||
| Time for Stent Removal | 219 | ||
| Techniques | 219 | ||
| Adverse Events and Management | 221 | ||
| Relative Costs and Choice of Technique | 221 | ||
| Summary | 221 | ||
| References | 221.e1 | ||
| 24 Papillectomy and Ampullectomy | 222 | ||
| Treatment Options | 222 | ||
| Considerations in FAP | 222 | ||
| Technique (Box 24.1) | 223 | ||
| Initial Endoscopic Assessment | 223 | ||
| 1. Conventional Endoscopy | 223 | ||
| 2. Endoscopic Ultrasound (EUS) and Intraductal Endoscopic Ultrasound (IDUS) | 224 | ||
| 3. Endoscopic Retrograde Cholangiopancreatography (ERCP) | 225 | ||
| Endoscopic Papillectomy | 225 | ||
| 1. Snare Excision | 225 | ||
| 2. Electrosurgical Currents: Cutting versus Coagulation | 226 | ||
| 3. En Bloc versus Piecemeal Resection | 226 | ||
| 4. Role of Submucosal Injection | 227 | ||
| 5. Infrequently Performed Novel Techniques | 227 | ||
| 6. Specimen Retrieval and Preparation | 227 | ||
| 7. Pre-Resection Sphincterotomy | 227 | ||
| 8. Postpapillectomy Sphincterotomy | 227 | ||
| 9. Postpapillectomy Stents: Pancreatic and Biliary | 228 | ||
| 10. Adjunctive Therapy and Thermal Ablation | 228 | ||
| Postpapillectomy Surveillance | 229 | ||
| Indications and Contraindications (Box 24.2) | 229 | ||
| Adverse Events and Their Management (Boxes 24.3 and 24.4) | 230 | ||
| Success | 231 | ||
| Relative Cost Savings | 232 | ||
| Subepithelial Lesions | 232 | ||
| Summary | 233 | ||
| References | 233.e1 | ||
| 25 Pancreatoscopy | 234 | ||
| Description of Technique | 234 | ||
| Equipment | 234 | ||
| Pancreatoscope | 234 | ||
| Light Source and Image Processor | 235 | ||
| Endoscopic Procedure | 236 | ||
| Indications | 236 | ||
| Differentiation of Stenosis of the Main Pancreatic Duct (Benign or Malignant) | 236 | ||
| Intraductal Papillary Mucinous Neoplasm (IPMN) | 237 | ||
| Further Investigation and Management of Chronic Pancreatitis | 237 | ||
| Video Pancreatoscopic Findings in Various Types of Pancreatic Diseases | 238 | ||
| Normal Case | 238 | ||
| Chronic Pancreatitis | 238 | ||
| Ductal Stenosis | 238 | ||
| IPMN | 239 | ||
| New Trends in Peroral Pancreatoscopy | 241 | ||
| Adverse Events | 242 | ||
| Relative Costs | 242 | ||
| Conclusion | 242 | ||
| References | 242.e1 | ||
| 26 Cholangioscopy | 243 | ||
| Introduction | 243 | ||
| Videocholangioscopy | 244 | ||
| Videocholangioscopy Using the Mother-Baby System | 244 | ||
| Description of the Technique | 244 | ||
| Technique: Diagnostic and Therapeutic | 245 | ||
| Adverse Events and Limitations | 246 | ||
| Videocholangioscopy by the Direct Insertion System | 246 | ||
| Description of the Technique | 246 | ||
| Technique: Diagnostic and Therapeutic | 247 | ||
| Adverse Events and Limitations | 247 | ||
| Acknowledgement | 248 | ||
| Single-Operator Cholangiopancreatoscopy Using the Spyglass Direct Visualization System | 248 | ||
| Equipment | 248 | ||
| Technique | 248 | ||
| Clinical Use and Efficacy (Figs. 26.10 to 26.12) | 248 | ||
| Intraductal Lithotripsy | 248 | ||
| Difficult Biliary Stones Using SOC-S | 248 | ||
| Pancreatic Stone Therapy Using SOC-S | 249 | ||
| SOC-S Evaluation of Indeterminate Biliary Strictures | 250 | ||
| Reimbursement and Limitations | 252 | ||
| Adverse Events | 252 | ||
| Summary | 253 | ||
| References | 253.e1 | ||
| 27 ERCP in Children | 254 | ||
| Description of Technique (Box 27.1) | 254 | ||
| Procedure Setting | 254 | ||
| Endoscopist | 254 | ||
| Sedation | 254 | ||
| Fluoroscopy | 254 | ||
| Supplemental Medications | 255 | ||
| Endoscopic Equipment | 255 | ||
| Technique | 255 | ||
| Indications and Contraindications (Box 27.2) | 257 | ||
| Diagnostic and Therapeutic Indications | 257 | ||
| Biliary Indications | 257 | ||
| Neonatal Cholestasis | 257 | ||
| Cholelithiasis and Choledocholithiasis | 257 | ||
| Choledochal Anomalies | 259 | ||
| Biliary Strictures and Leaks | 260 | ||
| Unusual Biliary Infections | 261 | ||
| Sphincter of Oddi Dysmotility | 261 | ||
| Pancreatic Indications | 262 | ||
| Acute Pancreatitis | 262 | ||
| Persistent, Recurrent, and Chronic Pancreatitis | 262 | ||
| Adverse Events | 263 | ||
| Relative Costs | 263 | ||
| References | 263.e1 | ||
| 28 ERCP in Pregnancy | 264 | ||
| Indication | 264 | ||
| Alternative Diagnostic Imaging Modalities | 264 | ||
| Timing | 265 | ||
| Radiation Exposure during ERCP | 266 | ||
| Positioning, Sedation, and Medications | 266 | ||
| Techniques | 267 | ||
| Outcomes after ERCP during Pregnancy | 268 | ||
| Summary | 268 | ||
| References | 269.e1 | ||
| 29 ERCP in Surgically Altered Anatomy | 270 | ||
| Surgery That May Affect the Performance or Interpretation of ERCP | 270 | ||
| Esophageal Resection | 270 | ||
| Gastric Resection | 270 | ||
| Billroth I | 270 | ||
| Billroth II | 270 | ||
| Roux-en-Y Gastrectomy | 275 | ||
| Total Gastrectomy | 276 | ||
| Upper GI Bypass Surgery without Resection | 277 | ||
| Gastrojejunostomy | 277 | ||
| Duodenal Bypass | 278 | ||
| Bariatric Surgery | 278 | ||
| Malabsorptive-Jejunoileal Bypass | 278 | ||
| Biliopancreatic Diversion and Duodenal Switch | 278 | ||
| Restrictive Surgery | 279 | ||
| Gastric Bypass | 280 | ||
| Pancreatic Resection | 281 | ||
| Conventional Whipple Procedure | 281 | ||
| Pylorus-Preserving Whipple Procedure | 283 | ||
| Pancreaticogastrostomy | 283 | ||
| Other Pancreatic Resective Surgery | 283 | ||
| Pancreatic Duct Drainage Procedures | 283 | ||
| Puestow Procedure | 283 | ||
| Frey’s Procedure | 283 | ||
| Duval Procedure | 283 | ||
| Biliary Surgery | 284 | ||
| Choledochoduodenostomy | 284 | ||
| Roux-en-Y Hepaticojejunostomy | 284 | ||
| Cholecystojejunostomy | 284 | ||
| Liver Transplantation | 284 | ||
| Hepaticocutaneous Jejunostomy | 286 | ||
| Endoscopic Techniques Commonly Employed for ERCP in Surgically Altered Anatomy | 287 | ||
| Performing a Rendezvous Procedure | 287 | ||
| Choosing an Intestinal Anastomotic Opening to Enter | 287 | ||
| Navigating through the Small Intestine | 287 | ||
| ERCP Accessories | 288 | ||
| Summary | 288 | ||
| References | 288.e1 | ||
| 30 Echoendoscopic Ultrasound–Guided Biliary Drainage | 289 | ||
| Equipment | 289 | ||
| Interventional Echoendoscopes | 289 | ||
| Needles and Accessories for Drainage | 289 | ||
| EUS-Guided Rendezvous Technique (Fig. 30.2) | 290 | ||
| EUS-Guided Choledochoduodenostomy | 290 | ||
| Technique of Left Hepaticogastrostomy under EUS Guidance (HGE) (Fig. 30.3) | 291 | ||
| Place of the Biliodigestive Anastomosis Guided by EUS in Comparison with ERCP | 291 | ||
| Choledochoduodenostomyl | 291 | ||
| Hepaticogastrostomy | 293 | ||
| Cost Comparisons | 293 | ||
| Summary | 293 | ||
| References | 293.e1 | ||
| 31 Endoscopic Ultrasound–Assisted Access to the Pancreatic Duct | 294 | ||
| Description of Technique | 294 | ||
| Preprocedure Considerations | 294 | ||
| Equipment Selection | 294 | ||
| Nomenclature | 295 | ||
| Techniques | 295 | ||
| Transpapillary/Transanastomotic Approach (with Retrograde Stent Placement) | 295 | ||
| Transpapillary/Transanastomotic Approach (with Antegrade Stent Placement) | 295 | ||
| Transluminal Access and Drainage | 295 | ||
| Technical Success and Outcome | 298 | ||
| Indications and Training | 299 | ||
| Indications | 299 | ||
| Training and Experience | 299 | ||
| Technical Difficulties, Adverse Events, and Their Management | 299 | ||
| Relative Cost | 300 | ||
| Summary | 300 | ||
| References | 300.e1 | ||
| III Approach to Clinical Problems | 301 | ||
| 32 Pancreas Divisum, Biliary Cysts, and Other Congenital Anomalies | 302 | ||
| Ampullary Anomalies | 302 | ||
| Ectopic Major Papilla | 302 | ||
| Anomalous Pancreaticobiliary Junction | 302 | ||
| Biliary Anomalies | 302 | ||
| Variations of Bile Duct Anatomy | 302 | ||
| Biliary Cysts | 305 | ||
| Pancreatic Anomalies | 308 | ||
| Pancreas Divisum | 308 | ||
| Embryology and Terminology | 308 | ||
| Diagnosis | 308 | ||
| Association with Pancreatitis | 308 | ||
| Incomplete Pancreas Divisum | 312 | ||
| Annular Pancreas | 312 | ||
| References | 312.e1 | ||
| 33 Approach to the Dilated Bile Duct and Pneumobilia | 313 | ||
| The Dilated Bile Duct | 313 | ||
| Background | 313 | ||
| Defining Dilated Bile Ducts | 313 | ||
| Etiology | 314 | ||
| Evaluation | 315 | ||
| Clinical Evaluation | 316 | ||
| Biochemical Evaluation | 316 | ||
| Imaging | 316 | ||
| Ultrasound | 316 | ||
| Computed Tomography | 316 | ||
| Magnetic Resonance Imaging | 317 | ||
| Endoscopic Ultrasound | 318 | ||
| Cholangiography | 318 | ||
| Biliary Scintigraphy | 319 | ||
| Approach to the Dilated Duct | 319 | ||
| Pneumobilia | 320 | ||
| Background | 320 | ||
| Defining Pneumobilia | 320 | ||
| Etiology | 321 | ||
| Evaluation | 321 | ||
| Imaging | 321 | ||
| Clinical Evaluation | 321 | ||
| Approach to the Patient with Pneumobilia | 322 | ||
| References | 322.e1 | ||
| 34 The Dilated Pancreatic Duct | 323 | ||
| Evaluation | 323 | ||
| Clinical | 323 | ||
| Laboratory Evaluation | 324 | ||
| Imaging and Endoscopy | 324 | ||
| Treatment | 326 | ||
| Medical Therapy | 326 | ||
| Endoscopic Therapy | 326 | ||
| Surgical Therapy | 329 | ||
| Conclusions | 329 | ||
| References | 329.e1 | ||
| 35 Ampullary Neoplasia | 330 | ||
| Symptoms and Signs | 330 | ||
| Diagnostic Workup and Evaluation | 330 | ||
| Endoscopy | 330 | ||
| ERCP | 332 | ||
| Forceps Biopsy | 332 | ||
| Transabdominal Ultrasound, CT, and MRI | 332 | ||
| Endoscopic Ultrasound (EUS) | 332 | ||
| Intraductal Ultrasound (IDUS) | 333 | ||
| Colonoscopy | 334 | ||
| Pathology | 334 | ||
| Adenoma | 334 | ||
| Carcinoma | 335 | ||
| Neuroendocrine Tumors | 336 | ||
| Lymphoma | 336 | ||
| Gastrointestinal Stromal Tumor (GIST) | 336 | ||
| Ampullary Adenomas and FAP Syndrome | 336 | ||
| Pathogenesis of Ampullary Adenoma and FAP Syndrome | 337 | ||
| Treatment | 337 | ||
| Adenomas | 337 | ||
| Carcinomas | 338 | ||
| Conclusions | 338 | ||
| References | 341.e1 | ||
| 36 Malignant Biliary Obstruction: | 342 | ||
| Epidemiology | 342 | ||
| Natural History | 343 | ||
| Clinical Features | 344 | ||
| Differential Diagnosis of Distal Biliary Malignancies and Imaging Techniques | 344 | ||
| Ampullary Carcinoma | 344 | ||
| Pancreatic Cancer | 344 | ||
| Cholangiocarcinoma | 346 | ||
| Metastatic Disease | 346 | ||
| An Approach to the Management of Patients with Distal Biliary Malignancies | 346 | ||
| Curative Surgery | 347 | ||
| Palliation | 348 | ||
| Endoscopic Stenting | 348 | ||
| Background | 348 | ||
| Indications for Biliary Stenting | 348 | ||
| Plastic Stents | 348 | ||
| Self-Expandable Metal Stents | 350 | ||
| Stent Choices for Palliation of Malignant Biliary Obstruction | 352 | ||
| Percutaneous Approach to Biliary Drainage | 353 | ||
| Surgical Palliation | 354 | ||
| Adjuvant Chemotherapy | 354 | ||
| Summary | 355 | ||
| References | 355.e1 | ||
| 37 Malignant Biliary Obstruction of the Hilum and Proximal Bile Ducts | 356 | ||
| Cholangiocarcinoma | 356 | ||
| Anatomy of Bile Ducts | 356 | ||
| Segmental Liver Anatomy | 356 | ||
| Bismuth-Corlette Classification | 357 | ||
| Clinical Presentation | 357 | ||
| Diagnostic Evaluation in Patients with Hilar and Proximal Biliary Obstruction | 358 | ||
| Laboratory Studies | 358 | ||
| Routine Blood Work | 358 | ||
| Tumor Markers | 358 | ||
| Radiographic Evaluation | 359 | ||
| Endoscopic Evaluation | 359 | ||
| EUS | 359 | ||
| ERCP | 359 | ||
| Intraductal Ultrasound (IDUS) | 359 | ||
| Cholangioscopy | 359 | ||
| Confocal Laser Endomicroscopy (CLE) | 360 | ||
| Narrow Band Imaging (NBI) and Chromoendoscopy | 360 | ||
| Tissue Diagnosis | 360 | ||
| Cytology | 361 | ||
| Pathology | 361 | ||
| Management | 361 | ||
| Surgical Resection | 361 | ||
| Preoperative Biliary Drainage | 361 | ||
| Biliary Drainage in Patients with Hilar or Proximal Biliary Obstruction | 361 | ||
| Surgical Drainage | 361 | ||
| PTC versus ERCP | 361 | ||
| EUS-Guided Biliary Drainage | 362 | ||
| Image-Guided Biliary Drainage | 362 | ||
| General Principles | 362 | ||
| Technique of ERCP | 362 | ||
| SEMS versus Plastic Stents | 363 | ||
| Local Ablative Techniques | 363 | ||
| Photodynamic Therapy (PDT) | 364 | ||
| Radiofrequency Ablation (RFA) | 364 | ||
| Conclusion | 364 | ||
| References | 364.e1 | ||
| 38 Indeterminate Biliary Stricture | 365 | ||
| Historical Features | 365 | ||
| Laboratory Features | 365 | ||
| Noninvasive Cross-Sectional Imaging | 366 | ||
| Invasive Imaging Techniques | 368 | ||
| Tissue Acquisition and Pathologic Investigations | 371 | ||
| Brush Cytology | 371 | ||
| Intraductal Transmucosal Fine-Needle Aspiration | 372 | ||
| Intraductal Forceps Biopsies | 373 | ||
| Confocal Laser Endomicroscopy | 374 | ||
| Ancillary Techniques | 374 | ||
| References | 377.e1 | ||
| 39 Combined Biliary and Duodenal Obstruction | 378 | ||
| Background and Overview | 378 | ||
| Comparison of Surgical versus Endoscopic Palliation | 378 | ||
| Type 1-2-3 System | 379 | ||
| Endoscopic Treatment of Type 1 Obstruction | 379 | ||
| Endoscopic Treatment of Type 2 Obstruction | 379 | ||
| Endoscopic Treatment of Type 3 Obstruction | 381 | ||
| Additional Scenarios | 381 | ||
| Clinical Trials Regarding Endoscopic Treatment of Combined Biliary and Duodenal Obstruction | 381 | ||
| Adverse Events | 382 | ||
| Conclusion | 382 | ||
| References | 382.e1 | ||
| 40 Benign Biliary Strictures | 383 | ||
| Clinical Features | 383 | ||
| Diagnosis | 383 | ||
| Management | 383 | ||
| Endoscopic Technique | 384 | ||
| Negotiating the Stricture | 384 | ||
| Dilation of the Stricture | 384 | ||
| Outcomes of Endotherapy | 385 | ||
| Plastic Stents | 385 | ||
| Self-Expandable Metal Stents | 386 | ||
| Adverse Events | 387 | ||
| Conclusions | 388 | ||
| References | 388.e1 | ||
| 41 Biliary Surgery Adverse Events Including Liver Transplantation | 389 | ||
| Physiological Basis of ERCP Techniques in the Treatment of Biliary Surgery Adverse Events | 389 | ||
| Decreasing Intrabiliary Pressure | 389 | ||
| Bypassing Bile Flow | 389 | ||
| Sealing the Leak | 389 | ||
| Stricture Dilation | 389 | ||
| ERCP for Management of Biliary Adverse Events Following Laparoscopic Cholecystectomy (LC) | 391 | ||
| Nature and Magnitude of Biliary Injury | 391 | ||
| Flow through the Leak | 392 | ||
| Time to Diagnosis | 392 | ||
| Treatment of Infected Biliary Collections and Related Infectious Adverse Events | 392 | ||
| Surgical Risk | 392 | ||
| ERCP and Bile Leaks after Hepatic Resection | 392 | ||
| Retained Common Bile Stones | 394 | ||
| Biliary Adverse Events of T-Tubes | 394 | ||
| Sump Syndrome | 395 | ||
| Postcholecystectomy Syndrome | 396 | ||
| Endoscopic Treatment of Biliary Disorders through a Subcutaneously Placed Afferent Limb of a Choledochojejunostomy | 396 | ||
| Biliary Adverse Events in Patients with Surgically Altered Anatomy | 396 | ||
| Special Considerations for Liver Transplant Patients | 397 | ||
| Bile Leaks and Fistulae after Liver Transplantation | 398 | ||
| Biliary Strictures Following Liver Transplantation | 399 | ||
| Filling Defects and the Biliary Cast Syndrome | 399 | ||
| Endoscopic Management of Recurrent Biliary Disease after Liver Transplantation | 400 | ||
| Miscellaneous Transplant ERCP | 400 | ||
| Summary | 401 | ||
| References | 401.e1 | ||
| 42 ERCP for Acute and Chronic Adverse Events of Pancreatic Surgery and Pancreatic Trauma | 402 | ||
| Pancreaticoduodenectomy (Whipple Operation) with and without Pylorus Preservation | 402 | ||
| Anatomy | 402 | ||
| Role of Endoscopy in the Management of Adverse Events | 402 | ||
| Biliary Obstruction | 404 | ||
| Bilioenteric Anastomotic Stricture | 404 | ||
| Afferent Limb Obstruction | 404 | ||
| Miscellaneous | 404 | ||
| Other Treatment Options for Biliary and Pancreatic Ductal Obstruction | 404 | ||
| Interventional Radiology (IR) and ERCP | 405 | ||
| Endoscopic Ultrasound (EUS) and ERCP | 405 | ||
| Distal and Central Pancreatectomy | 406 | ||
| Anatomy | 406 | ||
| Adverse Events | 406 | ||
| Role of Endoscopy in Patients with Distal Pancreatectomy | 406 | ||
| Puestow or Longitudinal Pancreatojejunostomy | 407 | ||
| Anatomy | 407 | ||
| Index | 513 | ||
| A | 513 | ||
| B | 514 | ||
| C | 515 | ||
| D | 517 | ||
| E | 518 | ||
| F | 519 | ||
| G | 519 | ||
| H | 519 | ||
| I | 520 | ||
| J | 520 | ||
| K | 521 | ||
| L | 521 | ||
| M | 521 | ||
| N | 522 | ||
| O | 522 | ||
| P | 522 | ||
| Q | 525 | ||
| R | 525 | ||
| S | 526 | ||
| T | 527 | ||
| U | 528 | ||
| V | 528 | ||
| W | 528 | ||
| Z | 528 | ||
| Endsheet 7 | IBC1 |