Dilemmas in ERCP
Chapter 3: Difficult Biliary Cannulation
Cannulation of the bile duct over a pancreatic guidewire. This video demonstrates the importance of placing the sphincterotomy at the 11 o’clock position, above and to the left of the pancreatic guidewire.
In this case, deep guidewire access into the pancreas duct could not be achieved due to preferential advancement of the guidewire out a side branch. Thus, a free handle needle knife sphincterotomy is performed to achieve deep biliary access.
Chapter 5: Indeterminate Biliary Strictures
Cholangioscopy of the case patient’s extrahepatic bile duct showing targeted biopsies of areas of abnormal appearing biliary epithelium and neovascularization at the level of the stenosis.
Chapter 13: Cholangioscopy
This video demonstrates the technique of single-operator cholangioscopy and electrohydraulic lithotripsy.
This video demonstrates the technique of single-operator cholangioscopy with direct forceps biopsy of abnormal biliary mucosa.
This video demonstrates cholangioscopy via direct peroral cholangioscopy. The use of cholangioscopy helps direct the wire across a completely obstructed bile duct, which was not able to perform via traditional methods.
Chapter 14: Post-ERCP Pancreatitis
Ampullectomy with PD stent placement. A 12 mm ampullary adenoma is seen at the major papilla. After achieving successful biliary cannulation and completion of biliary sphincterotomy, the 0.025 inch guidewire is passed into the ventral pancreatic duct. The pancreatic duct is deeply cannulated with the sphincterotome and contrast, and methylene blue is injected. Using a 15 mm snare, the major papilla is grasped and then resected using electrocautery. A small residual villous area is noted to be refluxing at the pancreatic duct orifice. After resection, a guidewire is again passed into the ventral pancreatic duct, and a 5Fr by 3 cm plastic pancreatic stent with a full external pigtail and a single internal flap is placed. Biopsies are then obtained of the residual villous area. A guidewire is passed into the bile duct, and a 7Fr by 7 cm plastic biliary stent with a single external flap and a single internal flap is placed with fluid flowing through both stents. Pathologic analysis confirms a diagnosis of ampullary adenoma but unfortunately with residual adenoma at the pancreatic duct orifice.
Minor papilla sphincterotomy. Minor papillotomy is associated with an increased risk of PEP, and therefore prophylactic pancreatic duct stent placement is recommended.
Precut sphincterotomy using a needle knife followed by extension sphincterotomy: In cases of difficult cannulation, early transition to precut sphincterotomy can prevent excessive manipulation of the ampulla and facilitate biliary cannulation. Precut sphincterotomy can be completed with or without a pancreatic duct stent in place. After biliary cannulation is achieved, extension sphincterotomy can be performed.