Diagnostic ERCP

Technique and Usual Practice

Interventional cardiologists have developed a system for grading the technical difficulty of coronary artery procedures. In comparison, ERCP outcomes are reported in terms of success and complication rates, and there is at present no objective scale for quantifying the technical difficulty of ERCP. Schulz et al. [1] developed this type of grading scale for technical difficulty in ERCP, and evaluated it retrospectively during 1997 then prospectively during 1998. The grading ranges from 1 (simple diagnostic ERCP) to 5 (very advanced ERCP). For example, common bile duct stenting or extraction of more than three common bile duct stones was classified as 4. Removal of one or two small stones was graded 2, and all forms of pancreatic therapy 5. If an ERCP was previously unsuccessful, a B modifier was added to the grade (e. g., a diagnostic cholangiogram after an unsuccessful attempt at another center was graded 1B). Procedures involving more than one intervention received the highest applicable grade. In 1997, Schulz et al. carried out 231 ERCPs [1]. The success rate was 94 % for grades 1 to 4B, and 74 % for grades 5 and 5B (P < 0.05). The morbidity rate was higher in grades 5 and 5B than in grades 1 to 4B (P < 0.05).

In 1998, 187 ERCPs were performed and analyzed prospectively. The success rate was 96 % for grades 1 to 4B and 65 % for grades 5 and 5B. The morbidity rate was higher in grades 5 and 5B (8. 7 %) than in grades 1 to 4B, but the difference was not statistically significant. The authors stated that more prospective studies and also input from expert endoscopists are mandatory before this scale can be adopted for general use. Prior sphincterotomy or stent placement in the desired duct should also be included in the scale. The authors believe that this type of scale could allow meaningful comparisons to be made among endoscopists and centers, and could be helpful for purposes of ERCP training, credentialing, and billing.

The success rate is highly variable from one center to another, depending on the disease entities being treated, the availability of dedicated accessories, well-trained staff, and the skill of the endoscopists concerned. Choudari et al. [2] conducted a prospective study which shows that if an attempt at ERCP is unsuccessful, referral to another center at which there are advanced ERCP skills is a good option. A total of 562 patients were referred to the Indiana University School of Medicine for ERCP after having undergone a previous unsuccessful attempt to inject the clinically relevant duct. The overall success rate for visualizing the desired duct was very high at 96.4 %, although a standard 5-Fr catheter or a manometry catheter was used in 59 % of cases. The main factors possibly contributing to the failure of the prior ERCPs were duodenal diverticulum, overhanging duodenal folds, and Billroth II anatomy. ERCP identified a cause or potential cause for the symptoms in 86 % of patients, but it should be noted that sphincter of Oddi dysfunction and pancreas divisum accounted for 51 % and 14 %, respectively, of the final diagnostic findings. The overall complication rate was 10.1 %, and the mortality rate was 0.2 %. Sphincter of Oddi dysfunction and pancreas divisum are still controversial disease entities in Europe. Despite the high success rate and the fairly low morbidity rate in this series - due to the authors' experience - the use of alternatives such as endoscopic ultrasonography or MRCP should also be an option in these cases. However, as the authors state, this paper emphasizes the role of large referral centers with available resources and expertise.

Whether to use a standard catheter (e. g., a metallic tip catheter) or a sphincterotome as a first-intent accessory to cannulate the common bile duct is still a question. The sphincterotome has a few theoretical advantages: the angle of the end of the catheter can be varied and made more acute by modifying the wire tension, and the stiffness of the sphincterotome allows better directional control. On the other hand, the standard catheter is thinner and floppier. Schwacha et al. [3] conducted a randomized study in 100 consecutive patients to compare the success rate and safety of selective common bile duct (CBD) cannulation using a guide-wire sphincterotome without a guide wire, with a standard catheter. They confirmed the opinion of some experts: the primary success rate of selective common bile duct cannulation was significantly higher with the sphincterotome (84 %) than with the standard catheter (62 %). If CBD cannulation failed even after four or five attempts, it was regarded as unsuccessful, and the alternative technique was then used. Thus, in patients in whom the standard catheter primarily failed, the use of the sphincterotome increased the total success rate to 94 %, while in patients in whom the sphincterotome primarily failed, the use of the standard catheter increased the total success rate to 88 %. The complication rates, and in particular the frequency of pancreatitis, did not statistically differ between the two groups. The authors therefore recommend using the sphincterotome before resorting to precut techniques. More and more frequently, experts are recommending the use of the sphincterotome as the primary accessory for CBD cannulation, as the increasing rate of therapeutic ERCP favors the primary use of the sphincterotome in order to avoid catheter exchange. The authors did not use guide wires in this study, in order to prevent potential trauma to the papilla. However, hydrophilic guide wires could have increased the success rate of selective CBD cannulation in this series, and further prospective studies should be performed with this material. Some experts find guide wires so helpful that they cannulate the bile duct using fluoroscopic rather than endoscopic guidance.

References

• 1 Schulz S M, Abbott R M. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.  Gastrointest Endosc. 2000;  51 535-539
• 2 Choudari C P, Sherman S, Fogel E L. et al . Success of ERCP at a referral center after a previously unsuccessful attempt.  Gastrointest Endosc. 2000;  52 478-483
• 3 Schwacha H, Allgaier H P, Deibert P. et al . A sphincterotome-based technique for selective transpapillary common bile duct cannulation.  Gastrointest Endosc. 2000;  52 387-391
• 4 Larkin C J, Workman A, Wright R E, Tham T CK. Radiation doses to patients during ERCP.  Gastrointest Endosc. 2001;  53 161-164
• 5 Masci E, Toti G, Mariani A. et al . Complications of diagnostic and therapeutic ERCP: a prospective multicenter study.  Am J Gastroenterol. 2001;  96 417-423
• 6 Testoni A, Bagnolo F. Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis.  Gastrointest Endosc. 2001;  53 33-39
• 7 Martin F, England R E, Rösch T. et al . Diagnostic quality in endoscopic retrograde cholangiopancreatography: comparison between iodixanol and iopromide.  Endoscopy. 2000;  32 783-787
• 8 Matsumoto Y, Fujii H F, Itakura J. et al . Pancreaticobiliary maljunction: etiologic concepts based on radiologic aspects.  Gastrointest Endosc. 2001;  53 614-619
• 9 Koshinaga T, Fukuzawa M. Pancreatic ductal morphological pattern and dilatation in postoperative abdominal pain in patients with congenital choledochal cyst: an analysis of postoperative pancreatograms.  Scand J Gastroenterol. 2000;  35 1324-1329
• 10 Zamora C, Sahel J, Garcia Cantu D. et al . Intraductal papillary or mucinous tumors (IPMT) of the pancreas: report of a case series and review of the literature.  Am J Gastroenterol. 2001;  96 1441-1447
• 11 Yamaguchi T, Hara T, Tsuyuguchi T. et al . Peroral pancreatoscopy in the diagnosis of mucin-producing tumors of the pancreas.  Gastrointest Endosc. 2000;  52 67-73
• 12 Irie H, Honda H, Aibe H. et al . MR cholangiopancreatography: differentiation of benign and malignant intraductal mucin-producing tumors of the pancreas.  AJR Am J Roentgenol. 2000;  174 1403-1408
• 13 Albert J, Schilling D, Breer H. et al . Mucinous cystadenomas and intraductal papillary mucinous tumors of the pancreas in magnetic resonance cholangiopancreatography.  Endoscopy. 2000;  32 472-476
• 14 Kim H J, Kim M H, Lee S K. et al . Mucin-hypersecreting bile duct tumor characterized by a striking homology with an intraductal papillary mucinous tumor (IPMT) of the pancreas.  Endoscopy. 2000;  32 389-393
• 15 van den Hazel S J, Wolfhagen F HJ, van Buuren H R. et al . Prospective risk assessment of endoscopic retrograde cholangiography in patients with primary sclerosing cholangitis.  Endoscopy. 2000;  32 779-782
• 16 Fulcher A S, Turner M A, Franklin K J. et al . Primary sclerosing cholangitis: evaluation with MR cholangiography: a case-control study.  Radiology. 2000;  215 71-80
• 17 Parascher V K, Romain K, Sukumar R, Jordan J. Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis.  Gastrointest Endosc. 2000;  51 401-404
• 18 Jailwala J, Fogel E L, Sherman S. et al . Triple-tissue sampling at ERCP in malignant biliary obstruction.  Gastrointest Endosc. 2000;  51 383-390
• 19 Kaufman D, Widlus D, Lazinger M. et al . Diagnostic accuracy of Simpson atherectomy catheter biopsy in detecting pancreaticobiliary malignancy.  Am J Gastroenterol. 2001;  96 1054-1058
• 20 Myung S J, Kim M H, Kim Y S. et al . Telomerase activity in pure pancreatic juice for the diagnosis of pancreatic cancer may be complementary to K-ras mutation.  Gastrointest Endosc. 2000;  51 708-713
• 21 Queneau P E, Adessi G L, Thibault P. et al . Early detection of pancreatic cancer in patients with chronic pancreatitis: diagnostic utility of a K-ras point mutation in the pancreatic juice.  Am J Gastroenterol. 2001;  96 700-704
• 22 Saurin J C, Joly-Pharaboz M O, Pernas P. et al . Detection of Ki-ras gene point mutations in bile specimens for the differential diagnosis of malignant and benign biliary strictures.  Gut. 2000;  47 347-361
• 23 Itoi T, Shinohara Y, Takeda K. et al . Detection of telomerase activity in biopsy specimens for diagnosis of biliary tract cancers.  Gastrointest Endosc. 2000;  52 380-386
• 24 Kim H J, Kim M H, Lee S K. et al . Characterization of primary pure cholesterol hepatolithiasis: cholangioscopic and selective cholangiographic findings.  Gastrointest Endosc. 2001;  53 324-328
• 25 Kim H J, Kim M H, Lee S K. et al . Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture.  Gastrointest Endosc. 2000;  52 635-638
• 26 Seo D H, Lee S K, Yoo K S. et al . Cholangioscopic findings in bile duct tumors.  Gastrointest Endosc. 2000;  52 630-634
• 27 Wang H P, Chen J H, Wu M S. et al . Application of peroral cholangioscopy in an endemic area with high prevalence of hepatocellular carcinoma and choledocholithiasis.  Hepatogastroenterology. 2000;  47 1555-1559
• 28 Aymerich R R, Prokash C, Aliperti G. Sphincter of Oddi manometry: is it necessary to measure both biliary and pancreatic sphincter pressures?.  Gastrointest Endosc. 2000;  52 183-186
• 29 Blaut U, Sherman S, Fogel E, Lehman G A. Influence of cholangiography on biliary sphincter of Oddi manometric parameters.  Gastrointest Endosc. 2000;  52 624-629
• 30 Wehrmann T, Schmitt T, Schönfeld A. et al . Endoscopic sphincter of Oddi manometry with a portable electronic microtransducer system: comparison with the perfusion manometry method and routine clinical application.  Endoscopy. 2000;  32 444-451
• 31 Utsunomiya N, Tanaka M, Ogawa Y. et al . Pain associated with phase III of the duodenal migrating motor complex in patients with postcholecystectomy biliary dyskinesia.  Gastrointest Endosc. 2000;  51 528-534
• 32 Cicala M, Habib F I, Fiocca F. et al . Increased sphincter of Oddi basal pressure in patients affected by gall stone disease: a role for biliary stasis and colicky pain?.  Gut. 2001;  48 414-417
• 33 Tanner A R, Dwarakanath A D, Tait N P. The potential impact of high-quality MRI of the biliary tree on ERCP workload.  Eur J Gastroenterol Hepatol. 2000;  12 773-776
• 34 Tang Y, Yamashita Y, Arakawa A. et al . Pancreaticobiliary ductal system: value of half-Fourier rapid acquisition with relaxation enhancement MR cholangiopancreatography for postoperative evaluation.  Radiology. 2000;  215 81-88
• 35 Soto J A, Alvarez O, Munera F. et al . Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography and MR cholangiography.  AJR Am J Roentgenol. 2000;  175 1127-1134
• 36 Soto J A, Barish M A, Alvarez O, Medina S. Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single and multisection half-Fourier rapid acquisition with relaxation enhancement sequences.  Radiology. 2000;  215 737-745
• 37 Kondo H, Kanematsu M, Shiratori Y. et al . MR cholangiography with volume rendering: receiver operating characteristic curve analysis in patients with choledocholithiasis.  AJR Am J Roentgenol. 2001;  176 1183-1189
• 38 Hirao K, Miyazaki A, Fujimoto T. et al . Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography.  AJR Am J Roentgenol. 2000;  175 713-720
• 39 Adamek H E, Albert J, Breer H. et al . Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study.  Lancet. 2000;  356 190-193
• 40 Merkle E M, Boll D T, Weidenbach H. et al . Ability of MR cholangiography to reveal stent position and luminal diameter in patients with biliary endoprostheses.  AJR Am J Roentgenol. 2001;  176 913-918
• 41 Nanashima A, Yamaguchi H, Fukuda T. et al . Evaluation of pancreatic secretion after administration of secretin: application of magnetic resonance imaging.  J Gastroenterol Hepatol. 2001;  16 87-92
• 42 Cappeliez O, Delhaye M, Devière J. et al . Chronic pancreatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation.  Radiology. 2000;  215 358-364
• 43 Manfredi R, Costamagna G, Brizi M G. et al . Pancreas divisum and ”santorinicele”: diagnosis with dynamic MR cholangiopancreatography with secretin stimulation.  Radiology. 2000;  217 403-408
• 44 van Steebergen W, van Aken L, Volders W, Kesteloot K. Cost analysis of ERCP in a university hospital.  Gastrointest Endosc. 2001;  53 152-160
• 45 Fahlke J, Ridwelski K, Manger T. et al . Diagnostic workup before laparoscopic cholecystectomy: which diagnostic tools should be used?.  Hepatogastroenterology. 2001;  48 59-65
• 46 Menges M, Lerch M, Zeitz M. The double duct sign in patients with malignant and benign pancreatic lesions.  Gastrointest Endosc. 2000;  52 74-77