ERCP and EUS: A Case-Based Approach
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Papillary adenomas may be detected as an incidental finding during upper endoscopy performed for another indication or may manifest with recurrent pancreatitis, weight loss, or biliary obstruction. Adenomas of the papilla follow the adenoma—carcinoma sequence similar to that seen in the colon; thus, resection of these lesions is recommended.
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Traditionally, the approach was surgical resection by pancreaticoduodenectomy because the presence of malignancy could not be completely excluded based on preoperative biopsies. Due to significant morbidity, even with improvements in surgery, endoscopic resection is currently the treatment of choice. Since the first reports of endoscopic resection of the papilla in the early s, endoscopic papillectomy or ampullectomy has gained wider acceptance as a less invasive therapy.
Accurate preoperative diagnosis and staging of papillary lesions is essential. ERCP with biopsies and endoscopic ultrasound are the current accepted approach for diagnosis and staging of local invasion and assessment of lymph node status.
Invasive cancer is a contraindication to endoscopic resection. Inoperable ampullary cancer causing biliary obstruction is best treated by sphincterotomy if feasible or by placement of a self-expanding metal stent. The technique of ampullectomy involves inspection of the papilla with a side-viewing duodenoscope, and ERCP to define any intraductal tumor extension and to opacify the ducts with contrast to aid in identifying the ductal orifices after the procedure is completed. Most experts resect the papilla and some surrounding normal mucosa en bloc with an electrocautery polypectomy snare and retrieve the specimen for histologic examination.
Residual adenomatous tissue at the margins of the resection site can be ablated with contact thermal or noncontact argon plasma coagulation. After resection, a short polyethylene pancreatic stent is placed to minimize the risk of post-procedural pancreatitis, and many endoscopists also place a biliary stent if a sphincterotomy has not been performed Plates 88, 89, The stents are endoscopically removed about 1 month later, and the site is inspected for residual adenoma.
Surveillance endoscopy with a duodenoscope is offered every 6—12 months. The sphincter of Oddi is a complex muscular structure that surrounds the distal pancreatic duct, bile duct, and ampulla of Vater. This sphincter mechanism lies mostly within the duodenal wall and measures 6—10 mm in length. Functionally, the sphincter of Oddi is independent from the duodenal smooth muscle system. It serves to prevent reflux of duodenal contents into the ductal system and controls the flow of bile and pancreatic juice into the duodenum. Sphincter of Oddi dysfunction SOD describes an abnormality within the sphincter, either motility related dyskinesia or spasm or structural stenosis , and can involve the biliary sphincter, the pancreatic sphincter, or both.
In pancreatic-type SOD, patients typically present with episodic pancreatic-type epigastric pain radiating to the back with pancreatic enzyme abnormalities or frank acute pancreatitis. The more common biliary-type SOD occurs postcholecystectomy and patients experience abdominal pain similar to the preoperative pain of suspected biliary origin. Each type of SOD has three subtypes:.
ERCP and EUS - A Case-Based Approach | Linda S. Lee | Springer
Biliary-I patients have biliary-type pain, abnormal liver enzyme values greater than twice normal documented on one occasion, and dilated common bile duct greater than 10 mm diameter. Biliary-II patients have biliary-type pain but only one or two of the preceding criteria. Pancreatic-I patients have recurrent pancreatitis or typical pancreatic pain, elevated pancreatic enzymes two times the upper limit, and dilated pancreatic duct greater than 5 mm.
Sphincter function can be evaluated by noninvasive methods that include hepatobiliary scintigraphy, ultrasound assessment of pancreatic and bile duct after secretin or cholecystokinin stimulation, and secretin-stimulated MRCP. The gold standard diagnostic test for SOD, however, is manometric assessment of basal sphincter pressure by SOM, which involves the use of solid state or perfusion low-compliance catheters that can measure the biliary and pancreatic sphincter pressures through ports located at the distal end.
Multiple station pull-throughs are performed and graphic recording of the pressures are displayed on a dedicated workstation. The patient must be sedated for the procedure, but narcotics and smooth muscle relaxants are usually avoided as they may interfere with the recordings. A basal sphincter pressure greater than 40 mm Hg above duodenal pressure is considered to be abnormal, and sphincterotomy incision of the intraduodenal portion of the common bile duct or pancreatic duct sphincter muscle is the current standard treatment of choice for SOD in the appropriate clinical setting.
Thus, manometry is not required for this group of patients. In biliary type III SOD patients, not only does manometry not predict response to treatment, but also sphincterotomy does not perform better than sham as seen from a recent randomized sham controlled trial. The risk of pancreatitis is reduced by temporary stenting of the pancreatic duct with or without administration of rectal indomethacin.
Patients may present with abdominal pain of biliary origin, cholangitis see Chapter 54 on Biliary Emergencies , jaundice, pancreatitis, transient elevation of transaminases, or filling defect with or without biliary ductal dilation on imaging studies such as transabdominal ultrasound, computed tomography CT , and MRCP. When choledocholithiasis is suspected, therapy is directed toward extraction of the stones from the biliary tree to minimize serious complications such as severe pancreatitis, sepsis, and death. Stone extraction can be achieved endoscopically, surgically, or by the transhepatic approach radiologically.
Endoscopic removal of bile duct stones is the treatment of choice in centers with expertise in this technique Figure 36—3. Since the first descriptions of endoscopic sphincterotomy in , the role of ERCP in the management of bile duct stones has undergone tremendous growth.
Endoscopic Retrograde Cholangiopancreatography
The standard techniques of stone extraction require access to the bile duct by deep cannulation. Once stones are identified on a cholangiogram, a biliary sphincterotomy is usually performed under direct endoscopic guidance to the maximum extent of endoscopic landmarks using a bow-type sphincterotome, a catheter carrying a cutting electrosurgical wire at its distal end.
An attempt at stone extraction should always be made after biliary sphincterotomy except in urgent, unstable situations. The most commonly used accessories for this purpose are balloon catheters and metal wire baskets see Figure 36—3. Valuable insights on the basics of cytopathology relevant to the endosonographer are summarized.
The classic indication for EUS of staging luminal cancers is examined in detail while pancreaticobiliary indications are discussed highlighting newer adjunctive technologies including elastography and contrast-enhanced EUS. Although in its infancy, the brave new world of therapeutic EUS is explored with a focus on endoscopic necrosectomy, EUS-guided biliary and pancreatic access as well as the exciting possibilities of EUS-guided radiofrequency ablation and injection of anti-tumor agents.
It provides a concise yet comprehensive summary of the current status of ERCP and EUS that will help guide patient management and stimulate clinical research. Linda S.
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