Endoscopic Retrograde Cholangiopancreatography ERCP Technique скачать в хорошем качестве

Endoscopic Retrograde Cholangiopancreatography ERCP Technique

Endoscopic Retrograde Cholangiopancreatography (ERCP) Technique. Insertion of endoscope. With the patient in the prone or semiprone position, the duodenoscope is passed through a self-retaining mouth guard with the tip angled slightly downward to facilitate its movement to the level of the hypopharynx. Once the endoscope has reached this location, the tip is brought back to the neutral position, and gentle pressure is applied until passage into the proximal esophagus is achieved. Care must be taken in passing the endoscope through the esophagus and into the stomach; visibility is limited. If attempts to pass the duodenoscope meet with resistance and no cause is visible, removal of the duodenoscope and subsequent examination with a gastroscope (standard forward-viewing endoscope) should be considered. Gastric examination and duodenal positioning: Once the duodenoscope is in the gastric lumen, it is advanced to a position in which it lies on the mucosa of the greater curvature, allowing visualization of the lesser curvature and the distal stomach. With further advancement of the endoscope, the tip should pass the angular incisure. In this position, upward angulation of the tip should allow examination of the gastric cardia. In the distal stomach, downward angulation of the tip should bring the pylorus into view. When the endoscope reaches the pylorus, the tip should again be placed in the neutral position, with the pylorus visible in the 6-o'clock location (“sun setting” position) as passage into the duodenal bulb is achieved. The duodenoscope is advanced to the distal aspect of the first portion of the duodenum, and the tip is angled to the right and slightly upward. The scope is then carefully withdrawn with slight clockwise torque applied to bring the endoscope into the "short" position. This maneuver should advance the endoscope to the second portion of the duodenum and permit visualization of the major duodenal papilla, which appears as a small pink protuberance at the junction of the horizontal and vertical duodenal folds (see the image below). Cannulation of major papilla: The key to successful cannulation of either the pancreatic or the biliary ductal system is proper scope positioning. With the duodenoscope in the short position in the second portion of the duodenum, the lens should be facing the papilla, with the tip in close proximity to the duodenal wall. For easier cannulation of the common bile duct (CBD), the scope should be positioned so that the image of the papilla is in the upper portion of the video monitor; this allows an upward approach to the papilla, which is more in line with the natural path of the CBD. In contrast, cannulation of the pancreatic duct is more easily achieved via an approach that is more perpendicular to the duodenal wall. If possible, the intraduodenal segment of the CBD should be observed before the initial attempt at cannulation so that the duodenoscope can be lined up with the natural contour of the bile duct. As a rule of thumb, for cannulation of the CBD, the cannulation device should be aimed in a slightly tangential direction to the 10- to 11-o'clock position; for cannulation of the pancreatic duct, the device should be pointed to the 1-o'clock position. The traditional approach to cannulation, termed contrast-guided cannulation, involves passage of the cannulation device tip into the papillary orifice, followed by injection of contrast material to confirm proper positioning. However, there are data to support a wire-guided approach. In the wire-guided approach, a guide wire is passed under fluoroscopy into either the pancreatic duct (see the video below) or the CBD before the injection of contrast. A systematic review and meta-analysis demonstrated a significantly lower incidence of post-ERCP pancreatitis (PEP), higher primary cannulation rates, fewer precut sphincterotomies, and no increase in ERCP-related complications with the wire-guided technique as compared with the contrast-assisted cannulation technique. Therefore, the guide wire–assisted cannulation technique has become the method preferred by most advanced endoscopists.