Endoscopic Sphincterotomy for Choledocholithiasis

Chapter

Abstract

Symptomatic choledocholithiasis commonly presents as biliary colic, with abnormal liver function tests, most notably with conjugated hyperbilirubinemia and elevated alkaline phosphatase levels. Ultrasound or computed tomography (CT) imaging will reveal a dilated common bile duct, and occasionally a stone may be visualized within it. Sometimes, it may present as cholangitis or pancreatitis, which carry a much higher morbidity and will require more immediate attention. Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a pure diagnostic modality to primarily a therapeutic intervention for pancreaticobiliary duct pathologies, which are amenable to endoscopic treatment. It is commonly employed as an option for the management of common bile duct stones. ERCP may also be performed preoperatively, intraoperatively, or post-cholecystectomy for specific conditions. Most ERCPs can be performed safely under moderate sedation. The basic steps of ERCP include inserting and navigating the side-viewing duodenoscope to visualize the ampulla of Vater, cannulating the bile duct, and performing a cholangiogram, followed by a sphincterotomy if necessary. Bile duct cannulation is the most technically challenging part of the procedure, commonly performed using a standard catheter or a sphincterotome, with a guidewire used to assist. Complication rates with ERCP are higher than with most endoscopic procedures; however, the risk for severe or fatal complication is low in experienced hands. The most common complications after ERCP include pancreatitis, bleeding, perforation, and infection. Steps to minimize and prevent complications are discussed here. It is the responsibility of the training program to ensure adequate hands-on training under directed supervision to prepare the next generation of endoscopists to perform ERCP safely and competently. Simulation lab and animal lab courses conducted by experts can be used to augment training in ERCP.

Keywords

Choledocholithiasis ERCP complications and management ERCP in pregnancy Indications for ERCP Accessories for ERCP ERCP for surgeons Basic ERCP technique Training in ERCP 

Supplementary material

Video 12.1

Two examples of sphincterotomy technique are shown (using a sphincterotome or needle-knife) (MP4 97900 kb)

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Varun Kapur
    • 1
  • Victor Sandoval
    • 2
  • Jeffrey M. Marks
    • 3
  1. 1.Department of General SurgeryUniversity Hospitals Case Medical CenterClevelandUSA
  2. 2.Department of General SurgeryUniversity Hospitals of ClevelandClevelandUSA
  3. 3.Department of General SurgeryUniversity Hospitals Cleveland Medical CenterClevelandUSA

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