“The Road Less Chosen” ERCP in Surgically-Altered Anatomy

ERCP Satellite Seminar

39th NYSGE Annual Course

David L Carr-Locke MA,MD,DRCOG,FRCP,FACG,FASGE,AGAF,NYSGEF

Chief, Division of Digestive Diseases

Associate Chair of Medicine

Mount Sinai Beth Israel Medical Center

Professor, Icahn School of Medicine

The Road Not Taken (1916)

Two roads diverged in a yellow wood, And sorry I could not travel both And be one traveler, long I stood And looked down one as far as I could To where it bent in the undergrowth; Then took the other, as just as fair And having perhaps the better claim, Because it was grassy and wanted wear; Though as for that the passing there Had worn them really about the same,

And both that morning equally lay In leaves no step had trodden black. Oh, I kept the first for another day! Yet knowing how way leads on to way, I doubted if I should ever come back. I shall be telling this with a sigh Somewhere ages and ages hence: Two roads diverged in a wood, and I — I took the one less traveled by, And that has made all the difference.

Robert Lee Frost (1874-1963)

Cannulation

ANATOMY

Abraham Vater (1720)

EA Boyden (1935)

Here it is: Why is it so difficult?

Cannulation

CBD

Intramural Bile Duct (IBD)

CBD

PD

CBD

PD

P

Yes, it really is there

1 Sphincters

2 Intramural

Segment

3 CBD

4 PD

Access to the Bile Duct GW

CBD

PD

Access Papillotomy

Billroth II: Access w Gastro/Colonoscope

Billroth II: Access w Duodenoscope

PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

Surgical Anatomy Requiring NO Special Maneuvers

•Choledochoduodenostomy

•Cholecystojejunostomy

•Some choledochojejunostomy

•Liver transplantation (C-C)

•Puestow/Frey/Duval procedures

•Billroth I partial gastrectomy

Biliary Bypass Surgery

Choledochoduodenostomy

Cholecystojejunostomy

Choledochojejunostomy

Choledochoduodenostomy

Puestow Procedure

Lateral Pancreaticojejunostomy

Liver transplantation - Choledochocholedochotomy

Surgical Anatomy Requiring Special Maneuvers

Papilla Intact

•Partial gastrectomy

•Total gastrectomy

•Gastric bypass

Partial gastrectomy

ROUX-EN-Y

BILLROTH II BILLROTH I

Billroth II Gastrostomy

Billroth II Partial Gastrectomy

BILLROTH II BILLROTH I

ERCP after Partial gastrectomy

ROUX-EN-Y

EUS-guided hepaticogastrostomy (Benias)

EUS-guided hepaticogastrostomy (Benias)

Total Gastrectomy

Gastric Bypass Surgery

For gastric outlet obstruction

For obesity treatment

PROXIMAL

END OF

STENOSIS

4 MM BALLOON

10MM X 6CM FCSEMS

Jejunojejunostomy Anastomosis

Side-to-side

anastomosis

End-to-side

anastomosis

Roux-Y Jejunojejunostomy

Efferent

Blind

Afferent

PB limb

Biliary Access after RYGB

• Peroral ERCP

• PTC

• PEG/dilation access

• Transgastric stent

• Gastrogastric fistula

natural

created

ERCP after RYGB

ERCP after RYGB

ERCP after RYGB

Percutaneous Endoscopic Transgastric Stent Access

Laparoscopy-assisted access for ERCP (Benias)

Surgical Anatomy Requiring Special Maneuvers

No Papilla - Anastomoses

•Pancreaticoduodenectomy

(Whipple/PPPDY)

•Hepaticojejunostomy

Pancreaticoduodenectomy

Pylorus-preserving

pancreaticoduodenectomy Standard (Whipple)

pancreaticoduodenectomy

Endotherapy after pancreatic surgery

11 year (1990-2000) single center review

135 ERCP, 61 patients

pancreaticoduodenectomy 29

lateral pancreaticojejunostomy 11

distal pancreatectomy 21

Farrell J, Carr-Locke D, Garrido T, Ruymann F, Shields S, Saltzman J.

Endoscopy. 2006 Dec;38(12):1246-9.

Endotherapy after pancreatic surgery

Technical Success by Clinical Indications

Jaundice Pain

Pancreaticoduodenectomy 69% 54%

Lateral Pancreaticojejunostomy

100% 87%

Distal Pancreatectomy 100% 86%

Farrell J, Carr-Locke D, Garrido T, Ruymann F, Shields S, Saltzman J.

Endoscopy. 2006 Dec;38(12):1246-9.

Bile Duct Transection with Hepaticojejunostomy

Hepatico-cutaneous-jejunostomy (Hutson-Russell)

Scared?

Desperate? Confused?

Confused?

Scared?

Desperate?

Confused?

Scared?

Desperate?

“The Road Not Taken” ERCP in Surgically-Altered Anatomy

I shall be telling this with a sigh

Somewhere ages and ages hence: Two roads diverged in a wood, and I —

I took the one less traveled by, And that has made all the difference.

Robert Lee Frost (1874-1963)