ASGE Recognized Industry Associate (ARIA) Training Program for Medtronic | March 2025-Mastering the Gateway

Mastering the Gateway_Cannulation and Sphincterotomy

Pdf Summary

The document authored by Prabhleen Chahal MD, FASGE, is a comprehensive guide focused on the process and considerations involved in Endoscopic Retrograde Cholangiopancreatography (ERCP) cannulation and sphincterotomy. It outlines procedural steps, equipment, and techniques critical for successful ERCP, as well as strategies to mitigate associated risks, particularly post-ERCP pancreatitis (PEP).<br /><br />Before the procedure, clinicians are advised to ensure appropriate indication, perform a thorough history and physical (H&P), obtain informed consent, and verify the availability of necessary imaging such as MRCP (Magnetic Resonance Cholangiopancreatography). The preparation also includes ensuring the readiness of equipment and personnel, assessing patient labs, and managing anticoagulants and antibiotics. Key considerations include patient positioning and appropriate sedation.<br /><br />During the procedure, the document emphasizes the use of Indomethacin, CO2 for insufflation, and the importance of cautious fluoroscopy practices to minimize radiation exposure and enhance imaging. It discusses the pros and cons of wire-guided cannulation versus contrast methods, recommending hydrophilic guidewires to reduce PEP risk.<br /><br />Advanced procedural techniques, such as the double wire technique and precut sphincterotomy, are detailed to improve success rates in complex cases. The document also outlines the merits of various precut methods like papillotomy and fistulotomy, underscoring the need for individualized technique selection based on expertise and patient anatomy.<br /><br />Key prevention strategies against PEP include the use of CO2 over air for insufflation, post-procedural pharmacological prophylaxis with NSAIDs, and consideration of pancreatic stenting, particularly in high-risk cases. The guide concludes with a reminder to adhere to standard care guidelines, recognize personal technical limitations, and consider referrals to advanced centers for complex cases, emphasizing the importance of a well-stocked toolkit and early utilization of techniques like fistulotomy.

Keywords

Endoscopic Retrograde Cholangiopancreatography

ERCP

cannulation

sphincterotomy

post-ERCP pancreatitis

Indomethacin

wire-guided cannulation

precut sphincterotomy

pancreatic stenting

fluoroscopy