Endoscopic retrograde cholangiopancreatography: Current practice and future research

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Prevention of post-ERCP pancreatitis: current strategies and novel perspectives

“…Appropriate indications for ERCP are biliary obstruction as a result of symptomatic choledocholithiasis, pancreatic cancer, unresectable cholangiocarcinoma, indeterminate or benign biliary strictures, as well as bile duct injury after cholecystectomy and liver transplantation, and symptomatic pancreatic strictures as it occurs in chronic pancreatitis. 48 …”

ERCP and EUS in Management of Pancreatitis

“…Pancreatic strictures can be diagnosed radiologically by CT and MRI/MRCP with supplementation with Endoscopic Ultrasound, secretin-enhanced MRCP, pancreatic function tests especially in the early stages with limited structural changes [27]. ESGE recommends treating painful dominant main pancreatic duct (MPD) strictures with insertion of a single stent across the dominant MPD stricture for one uninterrupted year.…”

Endoscopic palliation of malignant biliary obstruction

“…PDT utilizes a photosensitizing agent (which is activated by laser light) to ablate tumor tissue via apoptosis, necrosis, and an immunomodulatory effect[ 105 ]. The porphyrin phototoxic substance is given intravenously 3-4 d prior to the procedure to allow for preferential accumulation in the malignant tissue-during this period patients are advised to stay in a darkened room to avoid an accidental inflammatory reaction in normal tissue if exposed to light[ 106 , 107 ].…”