Endoscopic retrograde cholangiopancreatography (ERCP) (Figure 35–1) is a combined endoscopic and fluoroscopic procedure that was introduced in the early 1970s to allow access to the biliary and pancreatic ductal systems and their openings at the major and minor duodenal papillae. ERCP has evolved from a purely diagnostic technique, performed by a few, into a complex set of procedures integrating diagnosis and therapy for a wide variety of pancreatobiliary disorders offered in all major medical centers. ERCP requires dedicated training in order to acquire the range of techniques that include endoscopic papillectomy, sphincter of Oddi manometry, biliary sphincterotomy, pancreatic sphincterotomy, stone removal, tissue sampling, placement of plastic and metallic stents, and drainage of pancreatic fluid collections. Although it has become a highly successful therapeutic modality, ERCP also carries an overall morbidity of 7% that includes pancreatitis (4%), hemorrhage (1%), cholangitis (1%), perforation (0.5%), and death (0.1%). With the advent of magnetic resonance cholangiopancreatography (MRCP) (Figure 35–2) which safely and noninvasively images the pancreatic and biliary tracts, the need for purely diagnostic ERCP has appropriately diminished considerably while the demands for therapy have grown.
ERCP radiograph showing standard endoscope position and normal biliary and pancreatic ductal systems.
MRCP image showing small distal common bile duct stones during late pregnancy.
Baron T, Kozarek RA, Carr-Locke DL. ERCP. Elsevier Saunders, 2007.
Small intestinal tumors represent 2.4% of all gastrointestinal malignancies and over half of these are found in the duodenum. Duodenal adenomas may occur sporadically or in 50–100% of patients with familial adenomatous polyposis (FAP) and are most commonly in the periampullary location. Papillary adenomas may be detected as an incidental finding during upper endoscopy performed for another indication or may manifest with recurrent pancreatitis, weight loss, or biliary obstruction. The frequency of carcinoma in papillary adenomas ranges from 30% to 65%.
Adenomas of the papilla follow the adenoma–carcinoma sequence similar to that seen in the colon; thus, resection of these lesions is recommended. Traditionally, the approach was surgical resection by pancreaticoduodenectomy because the presence of malignancy could not be completely excluded based on preoperative biopsies. Due to significant morbidity, even with improvements in surgery, endoscopic resection is currently the treatment of choice. Since the first reports of endoscopic resection of the papilla in the early 1990s, endoscopic papillectomy or ampullectomy has gained wider acceptance as a less invasive therapy.
Accurate preoperative diagnosis and staging of papillary lesions is essential. ERCP with biopsies and endoscopic ultrasound are the current accepted approach for diagnosis and staging of local invasion and assessment of lymph node status. Invasive cancer is a contraindication to endoscopic resection. Inoperable ampullary cancer causing biliary obstruction is best treated by sphincterotomy if feasible or by ...