Endoscopy Master Videos: ERCP Cannulation & sphincterotomy @ www.gastroliver.com.sg

Cannulation of a "virgin" papilla remains the most difficult step in ERCP. Without selective cannulation of the desired duct, ERCP fails. Difficulty with cannulation of a virgin papilla results in unwanted pancreatic duct injections and subsequent pancreatitis. To minimise pancreatitis, contrast should never be injected unless one is certain of deep cannulation of the bile duct (unless one intends to cannulate the pancreatic duct for therapy). This can be confirmed by noting the direction of the catheter in the bile duct, on fluoroscopy which usually (but not always) crosses the ERCP scope shaft, or by the aspiration of bile. Precut techniques should be applied selectively and appropriately and should not be a substitute for good cannulation technique. The papilla is positioned at the upper half of the screen and the cannula directed towards the 11 o'clock position, the direction of the bile duct. Cannulation proceeds in a right-to-left-and-upward direction. Anti-clockwise torque on the duodenoscope, anti-clockwise turn on the small knob and anti-clockwise turn of the big knob "up" tends to bring the scope closer to the papilla. In patients with small build, the space in the duodenum is more limited and it may be more difficult to achieve the ideal position. When the scope is too close to the papilla, the cannula points away from the 11 o'clock direction. When the scope is pushed deeper in the duodenum to get further from the papilla, it disappears above the top of the screen. In this situation, a trade off has to be made. The cannula is engaged at the papilla orifice, and the small knob turned anti-clockwise to obtain a maximum lift of the roof of the papilla and hopefully into the bile duct. Sphincterotomy is performed using a pull-type sphincterotome with a "free hand" technique or over a guide-wire to maintain secure access in situations with difficult anatomy. Short controlled incisions are made in the 11 o'clock direction. The papilla opens up like the pages of a book. The salmon pink mucosa indicates the common channel is exposed. The upper limit of the cut is the transverse mucosa fold or where the papilla bulge meets the duodenum wall if the fold is not obvious. The sphincterotome is bowed and pulled back to assess the intra-duodenum portion of the sphincter. I personally make a 90% incision, keeping a margin of safety to avoid perforation. A 100% cut is often advocated, but unnecessary. This is because big stones can be treated by lithotripsy and the papilla orifice can be stretched during the extraction process, or by using biliary dilator balloons.

Category:

Science & Technology

Tags:

• ERCP
• cannulation
• sphincterotomy
• Singapore
• gastroenterologist
• endoscopy
• ultrasound
• dave
• project
• international
• gastroenterology