They're very advanced. We're going to show you how to succeed under a wide range of circumstances while minimizing risk of pancreatitis and other complications. We're also going to emphasize how to tailor your technique to the individual patient. For a discussion of data, I refer you to these review articles in GIE. We would like to thank the ASGE for offering us the opportunity to bring you this DVD, and I would like to thank Dr. Kapil Gupta for his great help with this project. I'd also like to acknowledge my expert colleagues, Dr. Oliver Kass and Dr. Tim Kinney, and not to forget the nurses who are so important to making ERCP successful. This DVD is divided into eight chapters. You can go directly to each one if you like. Here's what we're going to cover, introduction, accessories, principles of cannulation, standard techniques, pancreatic guide wire and stent techniques, pre-cut techniques, access in unusual anatomy, and some concluding remarks. Introduction for ERCP. A fundamental principle is to make sure there is a strong indication for therapeutic ERCP and that a fairly determined effort to access the duct is justified. Nowadays, with advanced imaging such as MRCP and EUS widely available, there just isn't any reason for marginally indicated ERCP. Going into a case with a clear goal makes it easier for you to maintain the proper focus and make appropriate decisions. It also seems to protect against many of the disasters that seem to plague marginal indications. ERCP room and setup. It's really important to have a well-setup room for ERCP with a fluoroscopy and video screens next to each other so you and your assistant can see both screens in one view. We use either general anesthesia or MAC for our ERCPs, but many centers use GI nurse sedation. Either way, you need to be able to concentrate on your job while the patient is safely and effectively sedated. If it is available, you may want to consider involving the anesthesia department for selected challenging cases. It's important to have a wide variety of accessories to take on difficult bile duct access. Cannulas, paplatomes, and guide wires. In addition to standard cannulas, we recommend a 543 or 3 French tip cannula for stenotic or difficult to enter papillas. Double or triple lumen paplatomes and at least one kind of needle knife are essential. Rotatable paplatomes can also be very useful. A wide variety of guide wires is available. Standard Teflon coated wound steel wires kink easily and are seldom used anymore. Hybrid wires such as jag wire or tracer wires are used most often combining a hydrophilic tip attached to a polymer coated nitinol body. .035 are most commonly used, but 025 or 021 wires are more flexible and friendly to the pancreatic duct if we get in there or wish to place a pancreatic stent. Fully hydrophilic wires, sometimes generically referred to as glide wires, are slippery when wet. They vary in diameter from 035 down to 020. They're effective for access, but can be unstable and slip out of place during exchanges. 018 non-hydrophilic wires combined with an ultra-flexible platinum tip will fit through a 3 French catheter and are particularly useful in a tortuous pancreatic duct. Unlike hybrid wires, the tips of these wires can be bent into a J or L shape. Roadrunner and Pathfinder are examples. A sidearm adapter allows you to preload a guide wire and pre-flush contrast around the wire without removing it. 450 centimeter or longer wires are the traditional standard, but can get tangled and touch the floor. Many now use 260 centimeter wires, which are best for physician-controlled wire and quick exchange systems. Short wires also work best with torque devices to spin the tip. Pancreatic stents. Pancreatic stents are important to reduce rates of pancreatitis after high-risk ERCP. For this application, you only need to have short stents, such as these 2 centimeter straight stents, and if you like, long stents as well, such as these 3 or 4 French, 8 or 9 centimeter stents without flanges. We'll talk more about choice of stents later. Physician-controlled guide wire devices. Physician-controlled guide wire devices represent a major advance in cannulation technology. By stripping the wire down to the accessory channel, the endoscopist can control the wire during the critical moment of cannulation, which can be done with either catheter or guide wire. It also gives better wire control when placing stents, especially in the pancreas. Rapid Exchange from Boston Scientific, Fusion from Cooke, and Vscope from Olympus are examples of physician-controlled guide wire systems. They all work well and we mix and match between them. In order to cannulate successfully, it's very important to understand basic principles. Biliary and Pancreatic Ductal Anatomy. Here is a cross-sectional view of a normal major papilla. You all know the basic axis of entry for pancreatic duct and bile duct seen from the fluoroscopic point of view. We will emphasize this throughout the video. There are several variations of pancreatic obiliary junction anatomy which are important when accessing bile or pancreatic duct. Most common is a short millimeter or two segment of common channel. Less common are very long common channel or separate channels. Pancreas divison with a small or vestigial ventral pancreas is another possibility. Concepts for cannulation. There may be a subtle difference between point of entry for the pancreatic duct which is usually lower right and the bile duct which is usually upper left. This may vary between patients. Most important is the axis of entry. In general, the pancreatic duct enters from 1 o'clock and the bile duct enters from 11 o'clock. The bile duct almost always runs up the middle of the papilla. However, its orientation in the endoscopic view can vary. It's useful to visualize the direction of the bile duct before starting to cannulate. This protractor will appear every now and then throughout the DVD to indicate the axis of the bile duct. Sometimes the course of the papilla can be ambiguous. Duodenoscope Maneuvers Everyone knows the importance of the elevator in lifting the catheter and tilting the cannula upwards. Another key concept is to understand the relationship between the big wheel and the axis of approach to the papilla. When the tip of the scope is deflected upwards with the big wheel, not only does this bring you closer to the papilla so you can see it better, but it tips the cannula in a cephalad direction, which is generally towards the bile duct. The small wheel moves the tip of the scope from side to side, which can be combined with rotation of the endoscope to smoothly dial to the left or right. This combined action of rotating the endoscope spins the axis of approach to the papilla. When you push the scope to the papilla, it generally starts out in the long position, which would seem to give you an upwards angle of entry, but it actually can be pretty horizontal. As we pull the scope back into a semi-long position, we can aim a little more upwards. Let's see that from an endoscopic point of view. Then, pulling the scope back to a fully straightened short position, we not only get closer to the papilla, which gives us better control, but also lets us aim more vertically and thus have the best chance for bile duct cannulation. Overview of techniques for biliary access. One of the most important principles for safe and successful cannulation is to use a variety of techniques and choose the ones that seem most appropriate for each individual patient and their anatomy. Here are the techniques we will cover for biliary cannulation. Standard techniques, including paplatomes, guide wire cannulation, and 5-4-3 cannula. Pancreatic guide wire and stent techniques to aid biliary cannulation and protect the pancreas. Needle knife pre-cut from orifice. Needle knife pre-cut fistulotomy. Needle knife pre-cut over pancreatic stent. And trans-pancreatic pre-cut sphincterotomy. Standard techniques include selective cannulation with catheters, paplatomes, and guide wires, including the guide wire cannulation technique. Cannula. With a far-away view of the papilla and the scope tip turned downwards with the big wheel, we are pointing towards the feet. No duct runs that way. Then, raising the scope tip with the big wheel, we enter pancreatic duct. Note the angle of the catheter. Now we push in the scope a bit further to tuck under the papilla, raise the tip of the scope further with the big wheel, and use the upwards curve of the catheter to point cephalad and slide above the septum into the bile duct. Look at the difference in angle of approach in the orientation of the scope determined by the big wheel. Again, no duct, pancreatic duct, and bile duct. Let's see another case which also illustrates the importance of point of entry. This patient might have slightly separated orifices for pancreatic and bile duct. Entering the bottom of the orifice in a straighter direction gives us PD. Notice also the angle on fluoroscopy. Now pushing the scope in, Now pushing the scope in a little further to a more tucked under position, and then lifting the scope tip up with the big wheel, and feeling over the top of the septum, gives us bile duct. Again, notice the vertical angle of entry into the bile duct, aided by the elevator and the big wheel. Paplitome with guide wire. Most endoscopists will start a biliary case with a paplitome and guide wire to facilitate cannulation and therapy. Here is a typical case. With a paplitome partially bowed, we fill pancreatic duct. This is a little more contrast than we would normally inject, but it shows the anatomy. Now increasing tension on the bow to aim more upwards, we pull above the septum and impact into the biliary orifice. However, we're not ready to pass a wire yet, because it would just bang into duct wall and possibly dissect tissue. We're actually compressing the intrapapillary duct. Look at the tortuous course of the duct here. The next task is to straighten this angle out. First manoeuvre is to pull back on the endoscope, which will seat the tip of the paplitome deeper in the orifice. Then we relax the bow on the paplitome. We still have a tortuous compressed papilla, though, not ready for wire passage yet. Now for the final manoeuvre. We let down the elevator to straighten out and align the catheter with the distal duct. Finally, with everything lined up, we can pass the wire freely up the duct. Next is a case in which paplitome cannulation is almost mandatory due to extremely short scope position dictated by tumour compression of the duodenum. With a fully bowed paplitome, the catheter tip has begun to enter the bile duct in the papilla. As in the last case, it is very important to use fluoroscopy to line up the cannula with the axis of the duct before starting to pass the guide wire. Limited contrast injection shows we are on the right track. Again, we go through the manoeuvres of pulling back slightly on the scope, relaxing the bow, and then lowering the elevator to achieve optimal orientation for the wire to pass deep into the duct. With unusually oriented papillas, a rotatable paplitome can be useful. The paplitome dialed to 1 o'clock and then 11 o'clock. Alternatively, you can groom the paplitome yourself. Here is how we groom the catheter towards the 11 o'clock direction. Guide wire cannulation technique. With guide wire cannulation, the idea is clarity, and it theoretically reduces risk of pancreatitis. It works best with the physician-controlled wire systems because you have the best feel for tickling the guide wire into the duct. Ideally, the wire flies into the papillary orifice and up the bile duct. Sometimes the wire bounces off the orifice, and you have to seat the paplatome into the orifice first. Then the wire can be passed deeply without injecting any contrast until we're pretty sure it's in the bile duct. As for every good technique, there are a couple of potential problems with the guide wire cannulation. First is that when you're passing the wire deeply without any contrast injection, it's not always clear which duct you're in. Here the wire enters what is probably CBD based on the cholecystectomy clips. This next wire pass looks very similar, but one of these is actually PD. In fact, this one, after we've injected some contrast. Again, let's compare CBD and PD. Pretty subtle difference. The danger is if you pass the wire deeply and it turns out to be PD, without knowing the course of the main duct, you might perforate a pancreatic side branch duct. Probing with the guide wire can also cause intramural dissection, but we can work through this. Here probing with an 035 hybrid wire, it hangs up in the papilla. Limited contrast injection shows we have created a divot or intramural disruption, which can lead to a real mess if we inject too much contrast. Further gentle passage of the guide wire enters PD, stalls for a while, then with careful probing enters deep into the bile duct. Here's another intramural extravasation from guide wire cannulation. This usually won't hurt the patient, but it can make access more difficult. Used carefully, guide wire cannulation can be a very good technique and you will see it applied in combination with other approaches throughout this video. 5-4-3 cannula. Sometimes even an ultra-tapered 3.9 French tip pappletome will not enter the papillary orifice, despite repetitive probing and changing the angle of approach. Our next step is to go to a 5-4-3 cannula, which has a 3 French tip. It is preloaded with an 018 or 021 wire and a sidearm adapter, with contrast pre-flushed so you can alternate injection and advancing the wire. Like the guide wire cannulation technique, the 5-4-3 catheter requires a gentle touch. You need to use this catheter carefully and not push too hard to avoid intramural injection. Look here as we push the catheter firmly without entering a duct and create a large intramural bleb of contrast. Used properly, 5-4-3 cannulation is more like fitting a round peg into a round hole. When it's lined up, it will gently pop into the orifice. Then, limited contrast injection shows the duct. Here, bile duct and an 018 wire is passed deeply into the duct through a malignant stricture. Here's another case where pappletome and guide wire failed, but the 5-4-3 succeeded in entering a tight papilla. We find the 5-4-3 invaluable for difficult cannulation, and it's often our first choice to start a case, especially with a small or tight-appearing papilla. In this chapter, we're going to explore the important concept of using pancreatic guide wires and stents to improve success and safety at biliary access. Overview A major advance in biliary access is the concept of using rather than abusing the pancreatic duct. This includes placing a wire in the pancreatic duct to assist biliary cannulation and placing a stent in the pancreas to reduce risk of post-ERCP pancreatitis. Here's the principle of PD wire-assisted biliary cannulation. With a standard cannula, the papilla often bunches up, so that you either get pancreatic duct or nothing. Passing a wire deep into the pancreatic duct can straighten out the common channel, hold down the pancreatic duct, and allow a cannula or second guide wire to slide over the septum into the bile duct. This is a great technique for biliary cannulation that we use frequently. The pancreatic wire also provides access for placement of a pancreatic stent to reduce risk of pancreatitis if that is desired. Pancreatic guide wire placement Atriomatic placement of a guide wire deep into main pancreatic duct can be easy or difficult, but it's quite different than placing a biliary wire. There is tremendous variation in normal pancreatic duct anatomy ranging from large and straight to tiny and twisty. PD has many side branches. Aggressive instrumentation of the pancreatic duct with a guide wire can cause significant injury including ductal edema and side branch perforation, possibly causing pancreatitis that is anything from mild to severe, especially if it isn't followed by pancreatic stent placement. O3-5 hybrid wires are most commonly used but can be a bit stiff for pancreatic access. We recommend O2-5 or even more flexible O1-8 wires as they will go around tortuous turns better. Here's an example of an O2-5 jag wire in a fairly straight duct. Notice how the tip of the wire hangs up at the genu before passing to the tail Note that we've injected just enough contrast to see the outline of the main pancreatic duct. Here is a more difficult case. Also, using an O2-5 hybrid wire through a tapered tip pappletone, we deeply cannulate pancreatic duct. Again, we periodically inject just enough contrast to make sure we can see the course of the main PD. Here the wire hangs up at the genu, so we form an alpha loop to flip it into the body. Once in the body, we form another loop to make a knuckle to the tail. All this has to be done very carefully without too much force so as not to perforate a side branch duct. Here is an O3-5 hybrid jag wire in a tortuous but normal pancreatic duct. Our typical experience with O3-5 wires is that the tip often exits side branches and won't follow main duct. In most cases for pancreatic duct access and a small or tortuous duct, we prefer 018 nitinol wires. Here even the soft tip Roadrunner wire won't make it around the turn and is exiting a side branch. We can take the catheter out of the scope and bend the tip of the wire into a J, which is only possible with such a deformable tipped wire. Now when we cannulate PD, a knuckle forms which stays in the main PD and advances all the way to the tail. An important concept is that only a few centimeters of wire needs to be placed in the pancreatic duct to place a short stent. Typically it's difficult or impossible to pass a wire all the way around a tight ansa turn. In that case, we push the straight or looped end of an 018 wire around the first turn in the duct and leave it there until the bile duct is cannulated or we place a PD stent. Here is a Roadrunner wire in another ansa loop. This technique will usually only work with this type of wire as standard hybrid or glide wires are unstable and slip out of position. Pancreatic guide wire assisted biliary cannulation. Now let's get to the main reason for pancreatic wire placement in this presentation, which is biliary access. Once the guide wire is in the pancreatic duct, bile duct can be accessed using a pappletome. Notice that we're passing the pappletome above the pancreatic wire and aiming to 10 o'clock. We don't have to inject contrast to see where we are. Here is another similar case, but notice how much we are using the big wheel to cannulate, bending the tip of the scope upwards rather than pushing the pappletome or wire. This gives us that upwards angulation so important to biliary cannulation. If our scope position isn't as tucked under as in the previous cases, we can also bow the pappletome to angulate above the septum into the bile duct, as in this case referred from outside after failed attempts at the usual methods. With a PD wire in place, we can also use the guide wire cannulation technique to access bile duct, varying the angle of entry with a pappletome bow. The first wire pass goes up PD along the PD wire, but we don't have to inject any contrast to see that. Then, with further bowing and repositioning, we find bile duct. This is purely fluoroscopic navigation. This final case of PD wire assisted cannulation involves a patient with jaundice due to unresectable pancreatic cancer. We're going to access PD first with a 543 cannula. Knuckle a roadrunner wire to just below the malignant pancreatic stricture and work our way into the biliary sphincter with a 543 catheter. Again, notice the 10 o'clock orientation of the catheter relative to the pancreatic guide wire. Once we're in the bile duct, the wire is passed through the malignant biliary stricture. In this last case of pancreatic malignancy, we won't place a pancreatic stent because the duct is completely obstructed by cancer. Pancreatic Stent Placement In patients at high risk, placing pancreatic stents has been shown to reduce risk of post ERCP pancreatitis by about two-thirds and nearly eliminate risk of severe pancreatitis. The concept is to protect the pancreatic sphincter from mechanical and thermal injury and to preserve pancreatic juice drainage. However, as for every technique, there are upsides and downsides and need to master details of the technique. Since only a minority of cases are high risk, it can be difficult to decide which ones warrant placement of a pancreatic stent. In an article mentioned earlier, we reviewed data that might help with that decision. The decision should incorporate patient and procedure-related risk factors and the feasibility of technical success at placing the stent. In general, pancreatic stents can be suggested in the following settings. Difficult cannulation in high risk patients, prior to pre-cut sphincterotomy, history of post ERCP pancreatitis, possible sphincter of OD dysfunction, pancreatic sphincterotomy, endoscopic ampulectomy, and balloon dilation of an intact sphincter. Pancreatic stents are usually not necessary in lower risk patients when the pancreatic duct is not injected with contrast or if there's doubtful feasibility of successful pancreatic wire access and stent placement. We must be aware of the potential problems with pancreatic stents, including failure to place the stent after aggressive manipulation, stent migration into the duct, and ductal injuries resulting from the stent, which are thought to be increased with larger caliber stents, impaction of the tip into the duct wall, hard flanges, and longer duration of stent retention. So let's talk about how to place pancreatic stents safely and effectively. There are many sizes and shapes of pancreatic stents, but in general, for normal ducts, you either want a very short stent that goes just through the sphincter or a very long 8 to 10 centimeter, 3 or 4 French stent that ends up in the body or even tail. We don't usually want to use intermediate length stents, such as 4 to 6 centimeters, as they often poke into the turn at the genu. The tips of polyethylene stents are particularly prone to cause ductal injuries and strictures here, which can be a serious problem. To avoid these kinds of problems, we suggest choosing stents carefully. For short stents, we generally recommend a 2 centimeter straight stent with two outside flanges, which is either 4 French, Hobbs, or 5 French, Cook. Either of these stents will go over any wire, including a standard 035 wire. Some endoscopists remove both of the relatively hard inner flanges of 5 French Cook stents to reduce duct injury and allow the stent to fall out on its own within a couple of weeks. The downside being risk of the stent falling out within a few hours, which can result in delayed onset post ERCP pancreatitis. My current preference is to use 4 French, 2 centimeter stents with a soft inner flange, especially in higher risk patients where we want the stent to stay in for a couple of days. The other approach is to use long stents, 8 to 10 centimeters, that are unflanged with a single pigtail in the duodenum. These must be very small caliber, either 3 French, Cook, or 3 to 4 French, soft material, as from Hobbs. Advantages are that they almost always fall out after a few weeks and are really easy to see on x-ray. Limitations include that they require placement of a wire and stent all the way to the tail, which may be traumatic or impossible, and that 3 French stents only fit over an 018 wire. Whether you place a long or short stent depends on a number of factors, including the patient's ductal anatomy, type of wire you use, and preference. Available data show no advantage to one over the other. Let's see some examples of long pancreatic stents. Here is a 4 French, 9 centimeter Hobbs stent placed mid-body of pancreatic duct. and a three French eight centimeter cook stent over an 018 Roadrunner wire. Note the mark we added at the beginning of the pigtail and the very large diameter of the pigtail on this stent. In either of these cases, a short stent could have been placed. Here are some different cases, including short stent placement in difficult pancreatic anatomy, which require that technique for knuckling an 018 wire just to the first turn in the duct. Using this technique makes PD stent placement possible in the five to 10% of cases that will fail with standard wire techniques. Here is a four French three centimeter soft stent in another ansa duct. To better control the wire, we are using the rapid-exchange pappletome as a push catheter with physician controlling this minimally inserted wire. For high-risk cases, before biliary therapy, we will access PD with a wire so that a pancreatic stent can be placed. It can be very hard to find a pancreatic duct after biliary sphincterotomy. You must document pancreatic stent passage or perform endoscopic removal within a few weeks to minimize duct injury. It can be very hard to see short stents over the spine. Can you see the stent here? No, but you can on this rotated view of the same patient, so multiple x-ray views are required to prove that a stent has gone. It is debatable whether every endoscopist should be able to place a pancreatic stent to reduce risk of post-ERCP pancreatitis. My personal opinion is yes, especially in high-risk patients. Severe post-ERCP pancreatitis is very unfortunate and can pretty much be prevented by properly placing a pancreatic stent. On the other hand, you should be cautious about trying to wire and stent difficult pancreatic ducts, especially at first, because failure may be worse than no attempt. Pre-cut or access papillotomy is a technique that should be used wisely. There's a big difference between a bulging papilla with an impacted stone and a small flat papilla. Before you get out the needle knife or other pre-cut technique, make sure there is a clear indication, favorable anatomy, and that you have adequate experience to do the job. Needle knife pre-cut from orifice. The traditional technique is to start at the orifice and cut upwards. This is the safest and easiest with impacted stones, which you see here. With a minimal incision, the stones pretty much deliver themselves and the bile duct opens up. Here is a tougher situation with a previously failed cannulation elsewhere in this patient with a bile leak after cholecystectomy. This is a longer and farther away scope position than usual, but lifting the needle knife, starting at the top of the orifice and cutting straight up the middle by lifting the elevator proceeds rather quickly. Look how the bile duct appears as a nipple representing the circular muscle fibers around the biliary sphincter. Watch as the retracted needle knife pops right into the bile duct. This nipple appearance of exposed bile duct is sometimes not recognized as such. Here is a bit more usual technique for biliary access pre-cut in a patient with papillary stenosis in whom the pancreatic duct couldn't be found. You can see here a slight upwards bend we have made to the needle knife tip. We are placing it in the orifice and lifting gently with the elevator by pulling back on the endoscope to load the knife. Brief pulses of electrocautery will do the work and usually neither the elevator nor the endoscope itself have to be moved. Notice how we cut in layers until we think we have exposed the bile duct. Finding the bile duct can be difficult. You usually don't get a rush of gold bile with arrows and flashing signs pointing to a cavernous duct. Instead, it is a potential space, usually right in the middle of the papilla, which can be entered with a cannula. We don't prefer to probe with guide wires after pre-cuts as they can easily cause false tracks through the incised tissue. Look at this wire tracking around the bile duct. Sometimes the bile duct is really hard to find and spraying methylene blue can help find the duct. Needle knife pre-cut fistulotomy. Another approach to pre-cutting is to start above the orifice and cut upwards, or start at the top and cut downwards. The idea is to stay away from the orifice and avoid pancreatic instrumentation. This is a nice technique for prominent papillas, but not for small papillas. In a very large bulging papilla in a patient with acute cholangitis, we are starting the incision well above the orifice. This is ideal anatomy for this fellow's first needle knife case. Now we encounter a little bleeding, which we can deal with at the end of the case. After we have established biliary drainage with two double pigtail stents, here we are injecting epinephrine. Here is another fistulotomy case with a smaller papilla and bile duct, which is not so easy. We couldn't inject either duct through the orifice. After a deep but confident incision, the bile duct is apparent. Needle knife pre-cut over pancreatic stent. Needle knife over a pancreatic stent is our backup plan for bile duct access if we've placed a wire in the pancreatic duct but can't cannulate the bile duct beside the wire. The PD stent serves a number of purposes. It reduces risk of post ERCP pancreatitis, serves as an anatomic guide as to where to cut with a needle knife, and is a fluoroscopic aid to find bile duct without injecting contrast in the PD. Here is a patient with a post-operative biliary stricture and previously failed biliary cannulation at an outside facility who got post ERCP pancreatitis. We specifically intend to access PD first with a guide wire in this high-risk case, but we still couldn't cannulate the bile duct beside the wire. Now we are placing a nine-centimeter four-french in the pancreatic stent and starting our incision over the stent. Since we're not exactly sure where the bile duct will be, we unroof quite a bit of common channel, possibly including some of the pancreatic sphincter as well. With the PD stent in, this will be pretty safe. Then, using a 543 cannula, we probe in the direction of the CBD to 10 o'clock, and voila. Note the normal 10 o'clock location of the bile duct relative to the pancreatic stent. The next cases show variation in the location of the bile duct relative to the pancreatic stent. Here, the bile duct is found directly to the left of the stent. And in this case, even farther around to the right of the stent. These cases show the potential danger of assuming where the pancreatic duct is. Caveats of Needle Knife. Caveats of Needle Knife include posterior CP pancreatitis and bleeding. But to me, the most worrisome complication is perforation. Here, an advanced endoscopy fellow is performing a needle knife over a pancreatic stent in a patient with malignant hilar obstruction. The incision jumps to the left a bit, but seems pretty reasonable. However, after repeated cannulation attempts, an extra luminal space is apparent. With retroperitoneal air. And the bile duct can't be accessed. This was treated by emergency percutaneous pilary drainage, with an internal-external drain crossing the papilla. Note that there was no demonstrated contrast leak at the sphincterotomy site, and the patient did well without any abdominal pain. If you do get access to the bile duct, but suspect a perforation, you can consider closing the perforation with clips, or leaving a nasobiliary drain, placing an NG tube to suction, and following the patient very carefully. In retrospect, the patient we showed with a perforation might have been a better candidate for a trans-pancreatic precut. Trans-pancreatic precut sphincterotomy. Trans-pancreatic precut is a newer technique for accessing the bile duct. The idea is to seat a standard papillotome in the pancreatic duct, and open the common channel, and perhaps the septum as well. It can work quite well, especially in patients with poor landmarks for a needle knife. The downsides of this technique include delivering a partial pancreatic sphincterotomy, which is undesirable in young patients with benign disease, and the possibility of causing significant pancreatitis in such patients if a pancreatic stent isn't placed afterwards. Here is a trans-pancreatic precut in a patient with unresectable pancreatic cancer in double duct obstruction. This is a pretty safe setting. Note the distal pancreatic duct stricture with upstream dilation. We place a wire into PD, perhaps unnecessary in this type of patient, and perform a pancreatic sphincterotomy. This opens up the common channel, and allows us to probe for the bile duct with a 543 cannula. Note that the first pass tracks into PD besides the wire. The bile duct is found at 10 o'clock. Here, we are removing the pancreatic guide wire. In this type of patient, a PD stent is unnecessary as the patient is at low risk for post ERCP pancreatitis and because we want to place a metal biliary stent. In most other trans-pancreatic pre-cuts in a normal pancreas, we would leave a pancreatic stent. Here is another trans-pancreatic pre-cut in a high-risk patient. We have placed an 018 Roadrunner wire to the pancreatic tail in a patient with sphincter of OD dysfunction. We perform a small wire-guided pancreatic sphincterotomy to open up the common channel. Leaving the pancreatic wire in place, we probe for bile duct with a 543 catheter. The first pass goes along the PD wire. Probing at 10 o'clock, we find the bile duct confirmed by contrast. Before proceeding any further, we place a pancreatic stent, which is mandatory in this high-risk case. Now we are going to talk about ERCP in difficult and altered anatomy. Difficult to find papilla Major papilla can be difficult to find with an edematous duodenum. To help find it, use a paplatome or other blunt-tip device to lift up folds and search without causing scratches. Use fluoroscopy to show that you are in the right zone. Here is the papilla under a fold. Be sure it really is major papilla. This papilla inside a large diverticulum fooled the referring endoscopist and then us as well. We cut the sphincter and placed a pancreatic stent trying to find bile duct before we realized the major papilla was down here and that the thing we had been working on was minor papilla. Periampulary diverticulum If the papilla is inside a diverticulum, it can be difficult to reach and to see. With periampulary diverticula, the papilla is not often at the top of the tick. This was a red herring. More often, it is along the edge of the tick as we see here. If it is pointing inwards, we can roll back the edge of the papilla with a paplatome, then line up and cannulate. You can use one catheter to hold down the fold while you cannulate with a second catheter or even clip the edge of the tick down, but such maneuvers are usually unnecessary. Sometimes the papilla is completely hidden within a diverticulum. Here, we can't see the papilla until we retract the left wall of the tick. Then we see that the bile duct runs towards nine o'clock, which requires a rotatable or a groomed pappletome, which we make point in the nine o'clock direction. Only with a radical leftwards angle will cannulation succeed. When these techniques don't work, we fall back on our usual tricks that we've already covered. In this patient with a previously failed cannulation by a highly experienced endoscopist, we use a 543 catheter and a roadrunner wire to access the PD and pass a wire to the tail. See how the pancreatic guide wire lifts up the common channel towards us. Using the guide wire cannulation technique with a bowed pappletome, we enter CBD and find the bile duct stone. We leave a long, unflanged PD stent before proceeding with biliary therapy. We're not certain it's necessary here, but it will fall out on its own within a few days. Instead of pancreatic wire-assisted cannulation, we could have performed a needle knife, but freehand needle knife in this setting can be quite tricky and risky. Billroth's 2 gastrectomy. Altered surgical anatomy can present a tremendous challenge to ERCP. Billroth's 2 gastrectomies are becoming less prevalent in bariatric surgery, such as gastric bypass with Roux-en-Y, more common, which makes for an even bigger challenge. With B2, getting a duodenoscope to the papilla can be tricky. Afferent limb is usually the most difficult one to access. Here is efferent, then afferent limb. Fluoroscopy helps us determine that we are heading towards right upper quadrant. Then when we get there, what we are expecting to see is actually turned 180 degrees upside down. It's kind of like standing on your head. This is very unnatural for ERCP. Catheters naturally point upwards in your endoscopic view. But that corresponds to downwards anatomically, and thus generally oriented towards the pancreatic duct. One way to overcome this is to pull back the scope as far below and away from the papilla as possible. Of course, the natural tendency is to move closer to the papilla, but this moves you above it, so that cannulation is impossible. Instead, from a far away position, use an absolutely straight cannula with a stiff guide wire and try to float it into the bile duct. This often works, but may fail or enter pancreatic duct anyway. A trick for getting the cannula to point towards 6 o'clock is to groom it into a T-spout configuration. That's also inconsistently effective. Here a rotatable papillotome is turned upside down and converts this case into a standard cannulation. Watch the papillotome flip upside down and point towards the bile duct. Wiring PD and then placing a pancreatic stent. Here a pancreatic stent is placed in anticipation of a needle knife pre-cut. The needle knife incision starts at the stent and cuts downwards instead of upwards. We are unroofing the papilla carefully and in layers. Here we actually get a blush of bile. As before, cannulating CBD works best with a stiff wire through a straight catheter to get that six o'clock access. Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is increasingly common these days. We generally only try a retrograde ERCP if the patient has had surgery done more than 10 to 15 years ago when roux limbs were shorter. Now they are impossibly long. If we're going to attempt ERCP, we usually first explore the anatomy with a forward-viewing pediatric colonoscope. Here we are looking at the jejunal anastomosis in an elderly lady with cholangitis. We pick one limb and explore it, but it turns out to be the wrong one. We take the colonoscope out and switch to a diagnostic flexible duodenoscope, working our way up the long afferent limb. Here is the papilla on the edge of the diverticulum. Remember that papilla is usually on the bottom of a tech, but since we are upside down, as in a Billroth II, it appears to be on the top of the diverticulum. We are lucky to get into any duct, so we place a Roadrunner 018 wire into PD, which straightens out the common channel. Then we can use the guide wire cannulation technique to find CBD. Now, we have wires in both ducts and look at the bizarre upside down angles of entry. In patients with a standard very long limb Roux-en-Y gastric bypass, you need a totally different route for access. We have our surgeons place a laparoscopic sutured gastrostomy for immediate intraoperative ERCP through the gastrostomy. We need to have a plan if cannulation fails. So you've tried everything you're comfortable with and you're not getting anywhere. One choice is persisting, which may not be a good idea unless the procedure is critical. If it is, maybe you can call a more experienced partner to help out. You can also stop and try again another day. Often the best option is to refer the patient to a more advanced center where access is almost always going to be feasible. Another choice is PTC with rendezvous ERCP, but this has additive complications of both procedures. A new approach that we and others are using in selected cases is EUS guided rendezvous to provide biliary access for subsequent ERCP. In this DVD, we've reviewed a lot of techniques from basic to very advanced. You will need to use judgment as to which of these are appropriate for you and your patients in your own practice. We hope that this DVD has helped you in your goal to better serve your patients.

ERCP

bile duct issues

pancreatic duct issues

complications

therapeutic ERCP

advanced imaging techniques

ERCP room setup

guide wires

pancreatic stents

cannulation failure