Upload
vuongkien
View
220
Download
2
Embed Size (px)
Citation preview
“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
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)