Therapeutic Endoscopic Retrograde Cholangiopancreatography without Fluoroscopy in Four Critically Ill Patients Using Wire-Guided Intraductal Ultrasound

• Abstract
• Introduction
• Technique
• Case Reports
• Patient 1
• Patient 2
• Patient 3
• Patient 4
• Discussion
• References

Abstract

Emergent endoscopic retrograde cholangiopancreatography cannot be performed at the bedside in critically ill patients in an intensive care unit because of the requirement for fluoroscopy. Moving such patients to a safe location where fluoroscopy is available can pose practical problems, and can lead to delayed intervention, which may adversely affect the outcome. We report the use of intraductal ultrasound to facilitate therapeutic biliary interventions in four critically ill patients in an intensive care unit. Cannulation was performed endoscopically at the bedside using a sphincterotome and a guide wire. Intraductal ultrasound, rather than fluoroscopy, was then used to confirm the location of the wire within the common bile duct prior to performing endoscopic sphincterotomy or stent placement. This technique was successful in all four patients.

Introduction

The use of endoscopic retrograde cholangiopancreatography (ERCP) without fluoroscopic control has been reported in special clinical situations [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11]. Biliary cannulation was confirmed in these cases by bile aspiration [2] [4] [6] [7] [8] [11] or, less frequently, by transabdominal ultrasound [1] [3] [5]. Although no complications were reported, some authors have questioned the safety of performing therapeutic ERCP without fluoroscopy [12].

We describe a novel nonfluoroscopic bedside ERCP technique using intraductal ultrasound (IDUS) guidance (IDUS-ERCP), which we used in four critically ill patients in an intensive care unit (ICU). This technique adds to a growing number of endoscopic ultrasound applications that can be used as an adjunct to therapeutic ERCP [13].

Technique

ERCP cannulation was performed using a duodenoscope (TJF-160F; Olympus America Inc., Melville, New York, USA), a sphincterotome (Autotome RX; Boston Scientific Corp., Natick, Massachusetts, USA), and a 0.035-inch guide wire (Jagwire; Boston Scientific). After cannulation, as evidenced by unhindered, smooth guide-wire insertion of at least 4 - 5 cm, the sphincterotome was exchanged for a wire-guided 20-MHz IDUS probe (XUM-G20 - 29R probe, UA 192 driver, EU-M30S processor; Olympus America), in order to confirm cannulation of the common bile duct and obtain images of ductal lesions.

Case Reports

Patient 1

A 63-year-old woman was admitted to ICU with severe gallstone pancreatitis complicated by respiratory failure. IDUS-ERCP confirmed that the wire had been inserted into the cystic duct and revealed layering sludge in the common bile duct (Figure [1]). Given the location of the cystic duct takeoff, well upstream of the ampulla, the wire placement was considered adequate for performing endoscopic sphincterotomy. The patient improved after the sphincterotomy and was discharged.

Patient 2

A 72-year-old man with metastatic pancreatic adenocarcinoma presented with cholangitis and leukopenia after chemotherapy. ERCP was performed, with placement of a plastic biliary stent across a malignant stricture. The patient improved but subsequently developed septic shock. IDUS-ERCP performed in ICU showed early stent occlusion by purulent bile and sludge. IDUS confirmed cannulation of the common bile duct and allowed measurement of the length of the stricture (Figure [2]). A metal stent was deployed. Proper stent placement and biliary decompression were confirmed by computed tomography. The patient died 2 weeks later from fungal sepsis.

Patient 3

A 51-year-old man with extensive choledocholithiasis in a massively dilated common bile duct underwent ERCP with endoscopic sphinterotomy and stone extraction. A maximal biliary sphincterotomy was performed, as advocated for complete stone extraction and prevention of re-stenosis or recurrent lithiasis [14]. The patient was admitted to ICU for melena and hypotension shortly after the procedure. Emergent endoscopy revealed bleeding at the sphincterotomy site. A previously placed biliary stent was extracted, endoscopic hemostasis was achieved, and IDUS-ERCP was used to replace the biliary stent, IDUS guiding the placement of a stent upstream of the residual common bile duct stones (Figure [3]). Hemostasis was successful and the patient was discharged.

Patient 4

A 55-year-old man with sickle cell disease, who had undergone a laparoscopic cholecystectomy, a choledochoduodenostomy, and a Billroth II resection, presented in septic shock and multiorgan failure. IDUS-ERCP, performed to investigate suspected cholangitis, revealed thick purulent material emerging from the choledochoduodenostomy. Transpapillary cannulation of the bile duct was confirmed by IDUS, which also provided images of accretions of sludge and stones within a markedly dilated common bile duct. IDUS assisted in the placement of biliary stents of appropriate length. The patient recovered and was discharged.

Discussion

The logistics and safety considerations associated with moving critically ill ICU patients in need of ERCP to an operating room or other critical-care setting with facilities for fluoroscopy are formidable [2] [4] [11]. The coordination of nurses, respiratory technicians, gastroenterologists, anesthesiologists, and house staff that is required often leads to delays that may adversely affect patient outcome, and cogent arguments have therefore been made for performing emergency ERCP without fluoroscopy at the bedside in these patients [1] [2] [3] [4]. This technique has also been suggested for pregnant women who require ERCP, because of concerns about fetal exposure to radiation [5] [6] [7] [8] [11], and is used in institutions where fluoroscopy is unavailable [9] [10] [11]. Finally, the staggering annual medical costs associated with biliary disease [15] provide a further incentive for the development of more cost-effective techniques to manage resource-intensive biliary emergencies.

In the majority of reports of ERCP procedures performed without fluoroscopic control, biliary cannulation was confirmed by bile aspiration, a technique of uncertain accuracy [2] [4] [6] [7] [8] [11]. This method cannot distinguish the cystic duct from the common bile duct, which increases the risk of placing the stent in the cystic duct, with failure of biliary decompression and potential obstruction or perforation of the cystic duct. The possibility of looping of the guide wire, leading to improper placement of the stent, has also been suggested [12], especially for obstructive lesions of the proximal common bile duct, where a failure rate close to 50 % has been reported [11]. Less commonly, transabdominal ultrasound has been used for confirmation of biliary cannulation [1] [3] [5]. This method is not readily reproducible [11], requires the operator to coordinate with a radiologist, and has limited accuracy in obese patients.

We report the use of intraductal ultrasound to confirm common bile duct cannulation in ERCP without fluoroscopy. IDUS offers high-resolution images [16] [17] [18] [19] that allow differentiation of the pancreatic duct, the common bile duct, and the cystic duct (Figure [4]), and provide detailed diagnostic information, on such features as the presence of microlithiasis in the common bile duct [20] [21] or the length and nature of a stricture of the common bile duct [22] [23].

Three recent innovations have greatly facilitated the application of this technique: a compact IDUS processor which is easily transportable to the bedside of ICU patients; a ”monorail” wire-guided IDUS probe which allows rapid and easy intraductal ultrasound [16] [17] [18]; and a similar monorail system for ERCP catheters which allows rapid, single-operator exchange of catheters over a short anchored wire. In IDUS-guided ERCP, multiple exchanges may be required in difficult cannulations, in which the pancreatic duct is cannulated repeatedly prior to successful cannulation of the common bile duct. This technique can be cumbersome and time-consuming in such procedures when using traditional long wire systems, which would also increase the risk of complications because the wire is not controlled by the endoscopist and is not safely anchored during accessory exchanges. With advances in probe technology, it may be possible to design and engineer an ERCP cannula with IDUS capability, including three-dimensional duct reconstruction, and this would obviate the need for cannula-probe exchanges. At present, however, rapid exchange systems are superior to traditional long wire systems.

The cases described in this report illustrate a new technique of IDUS-guided cannulation that makes it possible to perform emergent therapeutic biliary endoscopy at the bedside of critically ill patients in the intensive care unit setting.

References

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S. N. Stavropoulos, M. D.

Columbia University Medical Center · Department of Medicine · Division of Digestive and Liver Diseases

630 West 168th Street · P & S 10-508 · New York · NY 10032 · USA

Fax: +1-212-305-6443

Email: sns10@columbia.edu

References

• 1 Lin X Z, Chang K K, Shin J S. et al . Endoscopic nasobiliary drainage for acute suppurative cholangitis: a sonographically guided method.  Gastrointest Endosc. 1993;  39 174-176
  PubMedSearch in Google Scholar
• 2 Siegel J H, Rodriquez R, Cohen S A. et al . Endoscopic management of cholangitis: critical review of an alternative technique and report of a large series.  Am J Gastroenterol. 1994;  89 1142-1146
  PubMedSearch in Google Scholar
• 3 Schorn T F, Jahns U, Vollmer C, Gugler R. Ultrasound-guided emergency endoscopic retrograde biliary drainage without radiography.  Endoscopy. 1997;  29 232-233
  PubMedSearch in Google Scholar
• 4 Wang H P, Huang S P, Sun M S. et al . Urgent endoscopic nasobiliary drainage without fluoroscopic guidance: a useful treatment for critically ill patients with biliary obstruction.  Gastrointest Endosc. 2000;  52 741-744
  CrossrefPubMedSearch in Google Scholar
• 5 Parada A A, Goncalves M O, Tafner E. et al . Endoscopic papillotomy under ultrasonographic control.  Int Surg. 1991;  76 75-76
  PubMedSearch in Google Scholar
• 6 Zagoni T, Tulassay Z. Endoscopic sphincterotomy without fluoroscopic control in pregnancy.  Am J Gastroenterol. 1995;  90 1028
  PubMedSearch in Google Scholar
• 7 Llach J, Bordas J M, Gines A. et al . Endoscopic sphincterotomy in pregnancy.  Endoscopy. 1997;  29 52-53
  PubMedSearch in Google Scholar
• 8 Berger Z. Endoscopic papillotomy without fluoroscopy in pregnancy.  Endoscopy. 1998;  30 313
  PubMedSearch in Google Scholar
• 9 Misra S P, Dwivedi M. A new time-saving technique of inserting multiple biliary endoprostheses without fluoroscopy.  Endoscopy. 1997;  29 58
  PubMedSearch in Google Scholar
• 10 Misra S P, Dwivedi M. Endoscopic sphincterotomy without image intensification.  Endoscopy. 1997;  29 886-887
  PubMedSearch in Google Scholar
• 11 Misra S P, Dwivedi M. Should therapeutic ERCP be conducted in special circumstances without fluoroscopy? Pro.  Endoscopy. 1998;  30 306-307
  PubMedSearch in Google Scholar
• 12 Venu R P, Brown R D. Should ERCP be conducted in special circumstances without fluoroscopy? Contra.  Endoscopy. 1998;  30 308-310
  PubMedSearch in Google Scholar
• 13 Fusaroli P, Caletti G. Endoscopic ultrasonography.  Endoscopy. 2003;  35 127-135
  Thieme ConnectPubMedSearch in Google Scholar
• 14 Costamagna G, Tringali A, Shah S K. et al . Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis, and risk factors for recurrence.  Endoscopy. 2002;  34 273-279
  Thieme ConnectPubMedSearch in Google Scholar
• 15 Fogel E L, Sherman S, Park S H. et al . Therapeutic biliary endoscopy.  Endoscopy. 2003;  35 156-163
  Thieme ConnectPubMedSearch in Google Scholar
• 16 Menzel J, Domschke W. Intraductal ultrasonography (IDUS) of the pancreato-biliary duct system: personal experience and review of literature.  Eur J Ultrasound. 1999;  10 105-115
  CrossrefPubMedSearch in Google Scholar
• 17 Tamada K, Nagai H, Yasuda Y. et al . Transpapillary intraductal ultrasound prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma.  Gastrointest Endosc. 2001;  53 300-307
  CrossrefPubMedSearch in Google Scholar
• 18 Chak A, Isenberg G, Kobayashi K. et al . Prospective evaluation of an over-the-wire catheter US probe.  Gastrointest Endosc. 2000;  51 202-205
  PubMedSearch in Google Scholar
• 19 Levy M J, Vazquez-Sequeiros E, Wiersema M J. Evaluation of the pancreaticobiliary ductal systems by intraductal US.  Gastrointest Endosc. 2002;  55 397-408
  CrossrefPubMedSearch in Google Scholar
• 20 Das A, Isenberg G, Wong R C. et al . Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones.  Gastrointest Endosc. 2001;  54 31-36
  CrossrefPubMedSearch in Google Scholar
• 21 Tseng L J, Jao Y T, Mo L R, Lin R C. Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis.  Gastrointest Endosc. 2001;  54 720-723
  CrossrefPubMedSearch in Google Scholar
• 22 Vazquez-Sequeiros E, Baron T H, Clain J E. et al . Evaluation of indeterminate bile duct strictures by intraductal US.  Gastrointest Endosc. 2002;  56 372-379
  CrossrefPubMedSearch in Google Scholar
• 23 Farrell R J, Agarwal B, Brandwein S L. et al . Intraductal US is a useful adjunct to ERCP for distinguishing malignant from benign biliary strictures.  Gastrointest Endosc. 2002;  56 681-687
  CrossrefPubMedSearch in Google Scholar

S. N. Stavropoulos, M. D.

Columbia University Medical Center · Department of Medicine · Division of Digestive and Liver Diseases

630 West 168th Street · P & S 10-508 · New York · NY 10032 · USA

Fax: +1-212-305-6443

Email: sns10@columbia.edu