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“The Road Less Chosen” ERCP in Surgically-Altered Anatomy ERCP Satellite Seminar 39 th 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 Less Chosen”

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Page 1: “The Road Less Chosen”

“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

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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)

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Cannulation

ANATOMY

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Abraham Vater (1720)

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EA Boyden (1935)

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Here it is: Why is it so difficult?

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Cannulation

CBD

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Intramural Bile Duct (IBD)

CBD

PD

CBD

PD

P

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Yes, it really is there

1 Sphincters

2 Intramural

Segment

3 CBD

4 PD

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Access to the Bile Duct GW

CBD

PD

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Access Papillotomy

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Billroth II: Access w Gastro/Colonoscope

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Billroth II: Access w Duodenoscope

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PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

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PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

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PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

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PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

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PD

C

B

D

ampulla

papilla

duodenum

polyp

CHRONIC

PANCREATITIS

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Surgical Anatomy Requiring NO Special Maneuvers

•Choledochoduodenostomy

•Cholecystojejunostomy

•Some choledochojejunostomy

•Liver transplantation (C-C)

•Puestow/Frey/Duval procedures

•Billroth I partial gastrectomy

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Biliary Bypass Surgery

Choledochoduodenostomy

Cholecystojejunostomy

Choledochojejunostomy

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Choledochoduodenostomy

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Puestow Procedure

Lateral Pancreaticojejunostomy

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Liver transplantation - Choledochocholedochotomy

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Surgical Anatomy Requiring Special Maneuvers

Papilla Intact

•Partial gastrectomy

•Total gastrectomy

•Gastric bypass

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Partial gastrectomy

ROUX-EN-Y

BILLROTH II BILLROTH I

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Billroth II Gastrostomy

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Billroth II Partial Gastrectomy

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BILLROTH II BILLROTH I

ERCP after Partial gastrectomy

ROUX-EN-Y

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EUS-guided hepaticogastrostomy (Benias)

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EUS-guided hepaticogastrostomy (Benias)

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Total Gastrectomy

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Gastric Bypass Surgery

For gastric outlet obstruction

For obesity treatment

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PROXIMAL

END OF

STENOSIS

4 MM BALLOON

10MM X 6CM FCSEMS

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Jejunojejunostomy Anastomosis

Side-to-side

anastomosis

End-to-side

anastomosis

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Roux-Y Jejunojejunostomy

Efferent

Blind

Afferent

PB limb

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Biliary Access after RYGB

• Peroral ERCP

• PTC

• PEG/dilation access

• Transgastric stent

• Gastrogastric fistula

natural

created

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ERCP after RYGB

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ERCP after RYGB

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ERCP after RYGB

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Percutaneous Endoscopic Transgastric Stent Access

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Laparoscopy-assisted access for ERCP (Benias)

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Surgical Anatomy Requiring Special Maneuvers

No Papilla - Anastomoses

•Pancreaticoduodenectomy

(Whipple/PPPDY)

•Hepaticojejunostomy

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Pancreaticoduodenectomy

Pylorus-preserving

pancreaticoduodenectomy Standard (Whipple)

pancreaticoduodenectomy

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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.

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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.

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Bile Duct Transection with Hepaticojejunostomy

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Hepatico-cutaneous-jejunostomy (Hutson-Russell)

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Scared?

Desperate? Confused?

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Confused?

Scared?

Desperate?

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Confused?

Scared?

Desperate?

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“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)