ERCP Bootcamp: Cutting Edge Comprehensive Training for the Team

Advani_Understanding ERCP
Pdf Summary
The presentation explains how modern pancreatobiliary care now uses ERCP mainly as a therapeutic procedure rather than a diagnostic one. Because ERCP carries risks such as pancreatitis, bleeding, perforation, and cholangitis, patient selection has become crucial.<br /><br />For suspected choledocholithiasis, the key concept is risk stratification. Patients with high-risk features—such as a stone seen on imaging, ascending cholangitis, or marked bilirubin elevation with a dilated common bile duct—should usually go directly to ERCP. Patients at intermediate risk should generally have EUS or MRCP first. EUS is often favored because it is highly sensitive, especially for small stones or sludge, and can prevent unnecessary ERCP in many patients. Studies show that EUS-first strategies reduce complications without increasing missed stones.<br /><br />The talk also emphasizes that even some “high-risk” patients may benefit from EUS first if imaging is negative, bilirubin is improving, or spontaneous stone passage is suspected. MRCP remains useful when a noninvasive test is preferred, but EUS is more sensitive overall.<br /><br />For biliary strictures and suspected malignancy, EUS and ERCP are complementary: EUS helps diagnose, sample, and stage disease, while ERCP provides drainage and stenting. In many cases, same-session EUS plus ERCP offers the best efficiency, reducing anesthesia, admissions, delays, and cost.<br /><br />The lecture also highlights scenarios where ERCP should come first, such as acute cholangitis, septic patients needing urgent decompression, postoperative bile leaks, or established stones requiring immediate therapy. Conversely, EUS should come first for indeterminate ductal dilation, occult stones, suspected pancreatic cancer, negative MRCP with persistent concern, or idiopathic pancreatitis.<br /><br />Finally, when ERCP fails or is not possible, therapeutic EUS can provide biliary drainage through techniques like hepaticogastrostomy, choledochoduodenostomy, or cholecystoduodenostomy. Overall, the message is to choose the least invasive effective test first and integrate EUS and ERCP for optimal patient-centered care.
Keywords
ERCP
EUS
MRCP
choledocholithiasis
biliary stricture
pancreatobiliary care
risk stratification
therapeutic endoscopy
biliary drainage
cholangitis