ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
ROBERTS-THOMSON
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IANC. ROBERTS-THOMSON Departent of Gastroenterology, Royal Melbourne Hospital Endoscopic retrogradecholangiopancreatography (ERCP) involvescannulationof the papllla of Vater followed by contrast radiology of the biiiary and pancreaticducts. With experience,X-ray films of the desired duct@)can be obtained in 90% of patients, with minimal patient discomfort and a low frequency of complicatlons. Retrograde cholangiography accurately assesses the site and cause of biliary tract obstruction. Retrograde pancreatography reveals ductal abnormalities in most patients withchronic pancreatitis and pancreatic cancer, and the nature of the abnormality usually permits differentiationof the two diseases. The diagnostic accuracy of ERCP is enhanced by cytological evaluation of pure pancreatic juice, while endoscopic sphincterotomy is a therapeutic option in selected patients with choiedocholithiasis and papillary stenosis. Current developments include endoscopic aspiration biopsy of the pancreas and endoscopy of pancreatic and biliary ducts, using a miniature endoscope passed down a channel in the parent instrument.
ENDOSCOPIC retrograde cholangiopancreatography (ECRP) was first performed by McCune et alii (1968) and was subsequently developed by a number of workers, particularly Oi (1970) and Kasugai et alii (1971) in Japan. ERCP is now being performed in many medical centres throughout the world (Kasugai, 1975), and its use appears to be increasing in Australia. However, satisfactory results can only be achieved after a considerable period of training, and the procedure involves a commitment of resources which might be inappropriate in smaller hospitals. The purpose of this report is to review briefly the current status of ERCP, with emphasis on the diagnosticsignificance of changes in the pancreatic ducts. TECHNIQUE The diagnostic potential of ERCP can only be fully exploited by close cooperation between an experienced endoscopist and a radiologist with high-quality radiographic equipment. Face-on views of the papilla of Vater are essential for successful cannulation and can only be obtained with a side-viewing endoscope such as the Olympus JFB, Fujinon FD-QB, or A.C.M.I. F5A (Figure 1). Diazepam and pethidine are used for sedation, while atropine and increments of glucagon (1 mg), hyoscine n-butyl bromide (Buscopan 40 mg) or probanthine (30 mg) are used to inhibit duodenal peristalsis. Glucagon is preferred in our Depart ment, as the onset of duodenal ileus is rapid, and
Reprints: Dr Ian C. Roberts-Thomson, M.D , F . R . A . ~ . P, Department of Gastroenterology. Royal Melbourne Hospital, Victoria 3050.
AUST. N.Z. J. SURG.. VOL. 48-No. 3, JUNE, 1978
the effect is rarely prolonged beyond 30 minutes. Glucagon increases blood sugar levels, but rnonit o r i n g is o n l y required i n patients w i t h diabetes mellitus. The major papilla is usually identified on the medial wall of the mid-portion of the second part of the duodenum, but is occasionally located in the first or third part of the duodenum. The papilla hasa transverse semicircular hood, a small glans with an orifice at the apex, and a longitudinal fold which passes distally for one t o four centimetres. Papillary shapes have been classified (Cotton, 1972), but the shape of the papilla does not appear to influence cannulation technique or subsequent results. A small accessory papilla marks thesiteof entry of the duct of Santorini, but cannulation is difficult, even in . patients with rnalfusion of the dorsal and ventral pancreas (Gregg, 1977). Face-on views of the papilla are achieved by a number of manoeuvres, but particularly that of withdrawing the endoscope to straighten its course. A cannula filled with contrast material is passed (or impacted) into the orifice of the papilla, and ducts are opacified using fluroscopy t o control filling and prevent overdistension. Manometric control of the pressure of injection has been advocated by Kasugai et alii (1974), but has not been widely adopted. Radiographs are taken both before and after withdrawal of the endoscope, and positional changes facilitate views of various parts of the biliary system. Meglumine diatrizoate (Urografin 60%) appears to be the most widely used contrast material, but 247
ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
ROBERTS-THOMSON
with biliary-type pain (particularly following cholecystectomy) are a common clinical problem, but as yet there are no firm endoscopic or radiographic criteria for diagnoses such as papillary stenosis. The indications in suspected pancreatic disease include suspicion of cancer or chronic pancreatitis on the basis of pain, weight loss, diabetes mellitus, an abnormal barium meal X-ray examination, or an abnormal pancreatic scan or ultrasound examination. Pancreatography may have a r o l e i n p a t i e n t s w i t h m e t a s t a t i c adenocarcinoma when more common primary sites have been excluded. The relative frequency of the above indications in 250 consecutive studies from our Department is shown in Table 1. FIGURE1 Tip of the Olympus JFB side-viewing endoscope, showing the Teflon cannula which is passed into the orfice of the papilla.
satisfactory skiagrams can be obtained with other media (Cotton, 1972). Urografin 30% is preferred in patients with suspected small biliary calculi, since such calculi may be obscured by denser contrast materials. Antibiotics are mixed with contrast materials in some centres and may minimize infective complications (Kasugai, 1975). Success rates for cannulation. -With experience the clinically relevant duct(s) can be outlined in over 90% of patients (Figure 2). I n some patients difficulty may be encountered in transferring the cannula from the pancreatic to the biliary system, with the result that success rates for the latter system are usually slightly lower. Failure to transfer the catheter to the desired duct should raise the possibility of separate duct openings on the major papilla - an anatomical variation which occurs in 4% to 25% of patients (Cotton, 1972). Papillary cannulation, particularly cholangiography, is difficut after a Polya partial gastrectomy, and in this setting percutaneous cholangiography with a Chiba (skinny) needle is preferred. Duodenal distortion due to pancreatic disease, diverticula, o r inflammatory strictures, may obscure the papilla, although endoscopic evaluation of the region often provides useful diagnostic information. lndications and Contraindications There are four possible indications for ERCP: jaundice with clinical and biochemical features suggesting extrahepatic obstruction, suspected biliary disease without jaundice. suspected pancreatic disease, and evaluation of known pancreatic disease. The indication of biliary disease without jaundice includes patients with abnormal liver function and those with abnormal or equivocal findings on intravenous cholangiography. Patients 248
TABLE1 Indication for ERCP i n 250 consecutive patients studied in our Department Seventeen patients had two indications for the procedure
Indication Jaundice with suspected extrahepatic obstruction Suspected biliary disease without jaundice Suspected pancreatic disease Evaluation of known pancreatlc disease
No of Patients 90 53 70 54 267 -
Pancreatography is contraindicated during the acute and early recovery phases of pancreatitis because of the risk of exacerbation of inflammation, and is rarely indicated in patients with proven pancreatic pseudocysts because of reports of cyst infection (Galvan and Klotz, 1973; Ruppim et ah;, 1974). Cholangitis should be controlled with
FIGURE2: A normal retrograde cholangiogram and pancreatogram in a patient without pancreatic or biliary disease.
AUST N.Z. J. SURG..VOL. 48-No
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ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
appropriate a n t i b i o t i c s cholangiography.
prior t o retrograde
Retrograde Cholangiography Techniques for visualization of the biliary system constitute a major advance in the evaluation of patients with jaundice (Figure 3). Cholangiography prior to surgery avoids unnecessary laparotomy in patients w i t h u n o b s t r u c t e d ducts, p e r m i t s preoperative planning, and frequently shortens operating time. Retrograde cholangiography, like percutaneous cholangiography with the Chiba needle, identifies the site and cause of extrahepatic obstruction in most patients (Vennes et alii, 1974). The relative merits of retrograde cholangiography and percutaneous c h o l a n g i o g r a p h y were studies by Elias et a/;/ (1976) in 60 randomly assigned patients with suspected biliary disease.
FIGURE3 Retrograde cholangiogram in a man, aged 7 7 , with a postoperative biliary stricture (arrow) abovewhich are rnultlple biliary calculi
Both techniques outlined the biliary tree in the majority of patients, and a success rate of 90% was achieved when patients in whom the first procedure was unsuccessful were investigated by the alternative technique. Three patients had complications after percutaneous cholangiography and one after retrograde cholangiography. As results from both techniques appear similar, the procedure of choice in any institution is largely determined by the availability of trained personnel. Retrograde cholangiography involves a prolonged period of training, but additional information may be obtained from duodenal endoscopy, duodenal AUSTN.Z. J. SURG,VOL 48-No
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ROBERTS-THOMSON
biopsy, pancreatography, or . duct cytological examination. Percutaneous cholangiography involves a shorter period of training, but the complication rate appears to be higher, and normal d u c t s may m o t b e visualized. Retrograde cholangiography is the procedure of choice in the p r e s e n c e of c o a g u l a t i o n d i s o r d e r s . B o t h procedures may be used should the first procedure fail or should visualization of the proximal and distal sites of biliary obstruction seem desirable. Comparative studies of retrograde cholangiography and percutaneous cholangiography have not been performed in the absence of jaundice, but retrograde cholangiography is preferred in our Department as dilatation of intrahepatic ducts may be minimal despite biliary disease. Retrograde Pancreatography Pancreatic disease is identified by a critical analysis of changes in the main pancreaticduct and side-branches. The normal main duct tapers from the head of the gland to the tail and usually pursues an ascending course, although considerable variation occurs (Kasugai et alii, 1972). Studies on the dimensions of the normal main duct haveshown some variation, but mean diameters of 3 mm, 2 mm, and 1 mm in the head, body, and tail of the pancreas respectively were observed by Sivak and Sullivan (1976) and Roberts-Thomson (1977). Aging was associated with duct dilatation in one autopsyradiographic study (Kreel and Sandin, 1973), but a significant correlation between age and duct diameter has not been observed in endoscopic studies (Sivak and Sullivan, 1976; RobertsThomson, 1977). Choledocholithiasis hasalso been associated with duct dilatation (Satakeetalii, 1975), perhaps because of coexisting chronic pancreatitis o r papillary oedema w i t h pancreatic duct obstruction. Pancreatic cancer results in main duct changes in over 90% of patients; the most frequent changes being abrupt obstruction, tapered obstruction, and segmental stricture with proximal dilatation (Norton et a///, 1973; Roberts-Thomson, 1977) (Figure 4). Delayed emptying of the main duct has been emphasized by some authors (Belisto et alii, 1973), but almost always coexists with other main duct changes. On rare occasions pancreatic field defects may reveal the presence of a small pancreatic tumour or cyst (Kasugai, 1975). Retrograde pancreatography was compared with pancreatic f u n c t i o n tests, ultrasonography, pancreatic scan, thermography, arteriography, and duodenal cytology, in the evaluation of 70 patients with suspected pancreatic cancer (DiMagno et 249
ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
FIGURE4: Retrograde pancreatogram in a woman.'aged 72, with obstruction of the main pancreatic duct (arrow) due to a carcinoma i n the head of the pancreas.
alii, 1977). The pancreatic function test and ultrasonography proved sensitive for the detection of pancreatic disease (without differentiating pancreatitis from cancer), while retrograde pancreatography was more sensitive and specific than arteriography or duodenal cytological examination in the detection of pancreatic cancer. In chronic pancreatitis the principal main duct changes are dilatation throughout the duct, segmental stricture, and gross distortion (RobertsThomson, 1977). Changes in pancreatic duct branches have been emphasized by some authors (Kasugai, 1975), but should be interpreted with caution unless accompanied by changes in the main duct. In general the degree of ductal change correlates w i t h t h e degree of pancreatic dysfunction (Kasugai et alii, 1974; Nakano et alii, 1974),thus permitting an assessment of theseverity of the disease. Pancreatography also identifies patients in whom surgical drainage of the main pancreatic duct is technically feasible, but its role in patient selection for surgery requires further definition. Retrograde pancreatography has been performed in patients with pancreatic pseudocysts, and the majority have been shown t o communicate with the main pancreatic duct (Silvis et alii, 1974). However, because of the risk of cyst infection the procedure should be restricted to patients with negative or equivocal findings on barium meal X-ray examination and ultrasonography. I n patients with acute and acute relapsing pancreatitis the main pancreatic duct is usually normal (Rohrmann etalii, 1974), but focal acinar opacification may occur in areas of inflammation (Zimmon et alii, 1974).
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ROBERTS-THOMSON
POTENTIAL COMPLICATIONS The complications of ERCP were evaluated in a national survey in the United States (Bilbao et alii, 1976). Pancreatitis (l0/o), cholangitis (O.8%), drug reactions (O.6%),pseudocyst infection (0.3%) and instrumental injury (0.2%) were the most common, with an overall complication rate of 3% and a mortality of 0.2%. Hyperamylasaemia (as distinct from clinical pancreatitis) may occur i n the majority of patients if serum levels are determined within a few hours of the procedure. The factors which influence hyperamylasaemia and pancreatitis are poorly understood, but may include overdistension of ducts (particularly when associated with acinar opacification), prolonged and repeated filling of ducts, and inappropriate studies in patients with pancreatic inflammation (Kasugai, 1975; Bilbao et alii, 1976). Cholangitis almost always occurs in the setting of biliary obstruction and can largely be avoided by early surgical decompression (the preferred method) or the systemic use of antibiotics. The management of an opacified pancreatic pseudocyst remains unclear, but should surgery be deferred, it would seem wise to use systemic antibiotics. PANCREATIC DUCTCYTOLOGY Cannulation of the papilla has permitted a s p i r a t i o n o f p u r e p a n c r e a t i c j u i c e for cytodiagnosis. Malignant cells were identified in 11 of 14 patients with cancer studied by Endo et alii, (1974) and in 11 of 19 patients studied by Hatfield et alii (1975). Duct aspiration is relatively simple, can be performed at the time of ERCP, and appears to be superior to pancreatic cytology using duodenal aspirates. Pure pancreatic juice has also been used for electrolyte, enzyme, protein, and carcinomaassociated antigen assays, but the diagnostic value of such studies has not been determined. Endoscopic Sphincterotomy Endoscopic sphincterotomy is now being performed in selected patients with retained or recurrent common duct stones, papillary stenosis, and choledocholithiasis without cholecystectomy when the risk of operation is high (Safrany, 1977). However, the procedure has resulted in morbidity and mortality, and the period of follow-up is insufficient to exclude long-term complications such as papillary stenosis. CONCLUSION ERCP constitutes a major advance in diagnosisof biliary and pancreatic disease. With experience, skiagrams of the desired duct(s) can be obtained in AUST.N.Z. J. SURG., VOL.48-No.
3, JUNE,1978
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10 to 30 minutes in most patients with minimal patient discomfort and a low frequency of complications. Many procedures can be performed on an outpatient basis, but patients with jaundice, relapsing pancreatitis, or pancreatic pseudocysts should be admitted to hospital because of potential complications. The diagnostic accuracy of ERCP has been enhanced by aspiration of pure pancreatic juice for cytodiagnosis. Endoscopic sphincterotomy is an exciting therapeutic development, but should be restricted to leading centres until early and late complications have been more fully evaluated. Endoscopic aspiration biopsy of the pancreas was recently reported (Tsuchiya et alii, 1977) and may facilitate the diagnosis of cancer and lead to a better understanding of changes i n pancreatic morphology associated with inflammatory disease. Endoscopic visualization of pancreatic and biliary ducts using a miniature endoscope passed down a channel in the parent instrument (Nakajima et alii, 1977) is an extraordinary technical development, but is diagnostic or therapeutic role remains unclear. ACKNOWLEDGEMENTS I am grateful to Professor W.S.C. Hare and other members of the Department of Radiology, Royal Melbourne Hospital, who assisted with the investigation. REFERENCES BELISTOA.A.. CRAMER. G.G. and DICKINSON. P.B. (1973).Amer. J Roentg enol., 119: 109. BILEIAO. M.K., DOTTER. C.T.. LEE.T.G.. and KATON.R.M. (1976). Gastroenterology. 70: 314. COTTON, P.B. (1972), Gut, 13. 1014.
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ROBERTS-THOMSON DIMAGNO,E.P., MALAGELADA. J.R. TAYLOR,W.F. and Go, V.L.W. (1977), New Engl. J. Med. 297: 737. ELIAS.E. HAMLYN, A.N. JAIN, S. LONG, R.G. SUMMERFIELD. J.A. DICK.and SHERLOCK. S.S. (1976). Gastroenterology, 71: 439. ENDO. Y. MORII, T. TAMURA,H. and OKURDA.S. (1974). Gastroenterology. 67: 944. GALVAN. A. and KLOTZ.A.P. (1973). Gastroint. Endosc., 20: 28. GREGG.J.A. (1977), Amer. J. Surg. 134: 639. HATFIELD. A.R.W. SMITHIES, A. WILKINS,R. and LEVI,A.J. (1975), Gut, 16: 405. KASUGAI. T. KUNO.N. AOKI.I. Kizu. M. and KOBAYASHI, S. (1971), Gastrointest. Endosc., 18: 9. KASUGAI, T., KUNO.N. KOBAYASHI. S. and HATTORIK. (1972). Gastroenterology. 63: 217. KASUGAI.T., KUNO.N. and Klzu. M. (1974), Amer. J. dig. Dis., 19: 485. KASUGAI, T. (1975). Digestion, 13: 76. KREEL.L. and SANDIN,B. (1973). Gut, 14: 962. MCCUNE. W.S., SHORE,P.E. and MOSCVITZ. H. (1968). Ann. Surg. 167: 752. NAKAJIMA. M.. AKASAKA. Y. and KAwAl. K. (1977), Gastroint. Endosc., 23: 236. NAKANO. S..HORIGUCHI. Y., TAKEDA. T., SUZUKI.T. and NAKAJIMA. S. (1974), Scand. J. Gastroent., 9: 383. NORTON.R.A., OGOSHI,K., HARA,Y., NIWA.M.. PAUL,R.E.. TOMAS.J. and FAWAZ, K. (1973). Gastroinf. Endosc.,20: 13. 01. I. (1970), Gastrointest. Endosc., 17: 59. ROBERTS-THOMSON. I.C. (1977), Med. J. Aust., 2: 793. ROHRMANN. C.A.. SILVIS. S.E. and VENNES, J.A. (1974). Radiology, 113: 297. RUPPIM,H.,AMON.R., ETTL.W.. CLASSEN. M. and DEMLING,L. (1974), Endoscopy, 6: 94. SAFRANY, L. (1977), Gastroenterology, 72: 338. SATAKI.K., UMEYAMA, K.. KOBAYASHI, K., MITANI,E.. TATSUMI, S.. YAMAMATO. S. and HOWARD. J.M. (1975), Surg. Gynec. Obstet. 140: 439. SILVIS. S.E., VENNES.J.A. and ROHRMANN. C.A. (1974). Amer. J. Gastroent. 61: 542. SIVAK.M.V. and SULLIVAN. B.H. (1976), Amer. J. dig. Dis., 21: 263. TSUCHIYA, R.. HENMI. T., KONDO. N , AKASHI.M. and HARADA. N. (1977). Gastroenterology. 73: 1050. VENNES.J.A., JACOBSON. J . R . ~ ~ ~ S I L V I S . S(1974),Ann. .E. intern. Med., 80: 61. ZIMMON, D.S., FALKENSTEIN. D.B., ABRAMS. R.M., SELIGER, G. and KESSLER, R.E. (1974). Radiology, 113: 287.
25 1
ROBERTS-THOMSON
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IANC. ROBERTS-THOMSON Departent of Gastroenterology, Royal Melbourne Hospital Endoscopic retrogradecholangiopancreatography (ERCP) involvescannulationof the papllla of Vater followed by contrast radiology of the biiiary and pancreaticducts. With experience,X-ray films of the desired duct@)can be obtained in 90% of patients, with minimal patient discomfort and a low frequency of complicatlons. Retrograde cholangiography accurately assesses the site and cause of biliary tract obstruction. Retrograde pancreatography reveals ductal abnormalities in most patients withchronic pancreatitis and pancreatic cancer, and the nature of the abnormality usually permits differentiationof the two diseases. The diagnostic accuracy of ERCP is enhanced by cytological evaluation of pure pancreatic juice, while endoscopic sphincterotomy is a therapeutic option in selected patients with choiedocholithiasis and papillary stenosis. Current developments include endoscopic aspiration biopsy of the pancreas and endoscopy of pancreatic and biliary ducts, using a miniature endoscope passed down a channel in the parent instrument.
ENDOSCOPIC retrograde cholangiopancreatography (ECRP) was first performed by McCune et alii (1968) and was subsequently developed by a number of workers, particularly Oi (1970) and Kasugai et alii (1971) in Japan. ERCP is now being performed in many medical centres throughout the world (Kasugai, 1975), and its use appears to be increasing in Australia. However, satisfactory results can only be achieved after a considerable period of training, and the procedure involves a commitment of resources which might be inappropriate in smaller hospitals. The purpose of this report is to review briefly the current status of ERCP, with emphasis on the diagnosticsignificance of changes in the pancreatic ducts. TECHNIQUE The diagnostic potential of ERCP can only be fully exploited by close cooperation between an experienced endoscopist and a radiologist with high-quality radiographic equipment. Face-on views of the papilla of Vater are essential for successful cannulation and can only be obtained with a side-viewing endoscope such as the Olympus JFB, Fujinon FD-QB, or A.C.M.I. F5A (Figure 1). Diazepam and pethidine are used for sedation, while atropine and increments of glucagon (1 mg), hyoscine n-butyl bromide (Buscopan 40 mg) or probanthine (30 mg) are used to inhibit duodenal peristalsis. Glucagon is preferred in our Depart ment, as the onset of duodenal ileus is rapid, and
Reprints: Dr Ian C. Roberts-Thomson, M.D , F . R . A . ~ . P, Department of Gastroenterology. Royal Melbourne Hospital, Victoria 3050.
AUST. N.Z. J. SURG.. VOL. 48-No. 3, JUNE, 1978
the effect is rarely prolonged beyond 30 minutes. Glucagon increases blood sugar levels, but rnonit o r i n g is o n l y required i n patients w i t h diabetes mellitus. The major papilla is usually identified on the medial wall of the mid-portion of the second part of the duodenum, but is occasionally located in the first or third part of the duodenum. The papilla hasa transverse semicircular hood, a small glans with an orifice at the apex, and a longitudinal fold which passes distally for one t o four centimetres. Papillary shapes have been classified (Cotton, 1972), but the shape of the papilla does not appear to influence cannulation technique or subsequent results. A small accessory papilla marks thesiteof entry of the duct of Santorini, but cannulation is difficult, even in . patients with rnalfusion of the dorsal and ventral pancreas (Gregg, 1977). Face-on views of the papilla are achieved by a number of manoeuvres, but particularly that of withdrawing the endoscope to straighten its course. A cannula filled with contrast material is passed (or impacted) into the orifice of the papilla, and ducts are opacified using fluroscopy t o control filling and prevent overdistension. Manometric control of the pressure of injection has been advocated by Kasugai et alii (1974), but has not been widely adopted. Radiographs are taken both before and after withdrawal of the endoscope, and positional changes facilitate views of various parts of the biliary system. Meglumine diatrizoate (Urografin 60%) appears to be the most widely used contrast material, but 247
ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
ROBERTS-THOMSON
with biliary-type pain (particularly following cholecystectomy) are a common clinical problem, but as yet there are no firm endoscopic or radiographic criteria for diagnoses such as papillary stenosis. The indications in suspected pancreatic disease include suspicion of cancer or chronic pancreatitis on the basis of pain, weight loss, diabetes mellitus, an abnormal barium meal X-ray examination, or an abnormal pancreatic scan or ultrasound examination. Pancreatography may have a r o l e i n p a t i e n t s w i t h m e t a s t a t i c adenocarcinoma when more common primary sites have been excluded. The relative frequency of the above indications in 250 consecutive studies from our Department is shown in Table 1. FIGURE1 Tip of the Olympus JFB side-viewing endoscope, showing the Teflon cannula which is passed into the orfice of the papilla.
satisfactory skiagrams can be obtained with other media (Cotton, 1972). Urografin 30% is preferred in patients with suspected small biliary calculi, since such calculi may be obscured by denser contrast materials. Antibiotics are mixed with contrast materials in some centres and may minimize infective complications (Kasugai, 1975). Success rates for cannulation. -With experience the clinically relevant duct(s) can be outlined in over 90% of patients (Figure 2). I n some patients difficulty may be encountered in transferring the cannula from the pancreatic to the biliary system, with the result that success rates for the latter system are usually slightly lower. Failure to transfer the catheter to the desired duct should raise the possibility of separate duct openings on the major papilla - an anatomical variation which occurs in 4% to 25% of patients (Cotton, 1972). Papillary cannulation, particularly cholangiography, is difficut after a Polya partial gastrectomy, and in this setting percutaneous cholangiography with a Chiba (skinny) needle is preferred. Duodenal distortion due to pancreatic disease, diverticula, o r inflammatory strictures, may obscure the papilla, although endoscopic evaluation of the region often provides useful diagnostic information. lndications and Contraindications There are four possible indications for ERCP: jaundice with clinical and biochemical features suggesting extrahepatic obstruction, suspected biliary disease without jaundice. suspected pancreatic disease, and evaluation of known pancreatic disease. The indication of biliary disease without jaundice includes patients with abnormal liver function and those with abnormal or equivocal findings on intravenous cholangiography. Patients 248
TABLE1 Indication for ERCP i n 250 consecutive patients studied in our Department Seventeen patients had two indications for the procedure
Indication Jaundice with suspected extrahepatic obstruction Suspected biliary disease without jaundice Suspected pancreatic disease Evaluation of known pancreatlc disease
No of Patients 90 53 70 54 267 -
Pancreatography is contraindicated during the acute and early recovery phases of pancreatitis because of the risk of exacerbation of inflammation, and is rarely indicated in patients with proven pancreatic pseudocysts because of reports of cyst infection (Galvan and Klotz, 1973; Ruppim et ah;, 1974). Cholangitis should be controlled with
FIGURE2: A normal retrograde cholangiogram and pancreatogram in a patient without pancreatic or biliary disease.
AUST N.Z. J. SURG..VOL. 48-No
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ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
appropriate a n t i b i o t i c s cholangiography.
prior t o retrograde
Retrograde Cholangiography Techniques for visualization of the biliary system constitute a major advance in the evaluation of patients with jaundice (Figure 3). Cholangiography prior to surgery avoids unnecessary laparotomy in patients w i t h u n o b s t r u c t e d ducts, p e r m i t s preoperative planning, and frequently shortens operating time. Retrograde cholangiography, like percutaneous cholangiography with the Chiba needle, identifies the site and cause of extrahepatic obstruction in most patients (Vennes et alii, 1974). The relative merits of retrograde cholangiography and percutaneous c h o l a n g i o g r a p h y were studies by Elias et a/;/ (1976) in 60 randomly assigned patients with suspected biliary disease.
FIGURE3 Retrograde cholangiogram in a man, aged 7 7 , with a postoperative biliary stricture (arrow) abovewhich are rnultlple biliary calculi
Both techniques outlined the biliary tree in the majority of patients, and a success rate of 90% was achieved when patients in whom the first procedure was unsuccessful were investigated by the alternative technique. Three patients had complications after percutaneous cholangiography and one after retrograde cholangiography. As results from both techniques appear similar, the procedure of choice in any institution is largely determined by the availability of trained personnel. Retrograde cholangiography involves a prolonged period of training, but additional information may be obtained from duodenal endoscopy, duodenal AUSTN.Z. J. SURG,VOL 48-No
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ROBERTS-THOMSON
biopsy, pancreatography, or . duct cytological examination. Percutaneous cholangiography involves a shorter period of training, but the complication rate appears to be higher, and normal d u c t s may m o t b e visualized. Retrograde cholangiography is the procedure of choice in the p r e s e n c e of c o a g u l a t i o n d i s o r d e r s . B o t h procedures may be used should the first procedure fail or should visualization of the proximal and distal sites of biliary obstruction seem desirable. Comparative studies of retrograde cholangiography and percutaneous cholangiography have not been performed in the absence of jaundice, but retrograde cholangiography is preferred in our Department as dilatation of intrahepatic ducts may be minimal despite biliary disease. Retrograde Pancreatography Pancreatic disease is identified by a critical analysis of changes in the main pancreaticduct and side-branches. The normal main duct tapers from the head of the gland to the tail and usually pursues an ascending course, although considerable variation occurs (Kasugai et alii, 1972). Studies on the dimensions of the normal main duct haveshown some variation, but mean diameters of 3 mm, 2 mm, and 1 mm in the head, body, and tail of the pancreas respectively were observed by Sivak and Sullivan (1976) and Roberts-Thomson (1977). Aging was associated with duct dilatation in one autopsyradiographic study (Kreel and Sandin, 1973), but a significant correlation between age and duct diameter has not been observed in endoscopic studies (Sivak and Sullivan, 1976; RobertsThomson, 1977). Choledocholithiasis hasalso been associated with duct dilatation (Satakeetalii, 1975), perhaps because of coexisting chronic pancreatitis o r papillary oedema w i t h pancreatic duct obstruction. Pancreatic cancer results in main duct changes in over 90% of patients; the most frequent changes being abrupt obstruction, tapered obstruction, and segmental stricture with proximal dilatation (Norton et a///, 1973; Roberts-Thomson, 1977) (Figure 4). Delayed emptying of the main duct has been emphasized by some authors (Belisto et alii, 1973), but almost always coexists with other main duct changes. On rare occasions pancreatic field defects may reveal the presence of a small pancreatic tumour or cyst (Kasugai, 1975). Retrograde pancreatography was compared with pancreatic f u n c t i o n tests, ultrasonography, pancreatic scan, thermography, arteriography, and duodenal cytology, in the evaluation of 70 patients with suspected pancreatic cancer (DiMagno et 249
ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY
FIGURE4: Retrograde pancreatogram in a woman.'aged 72, with obstruction of the main pancreatic duct (arrow) due to a carcinoma i n the head of the pancreas.
alii, 1977). The pancreatic function test and ultrasonography proved sensitive for the detection of pancreatic disease (without differentiating pancreatitis from cancer), while retrograde pancreatography was more sensitive and specific than arteriography or duodenal cytological examination in the detection of pancreatic cancer. In chronic pancreatitis the principal main duct changes are dilatation throughout the duct, segmental stricture, and gross distortion (RobertsThomson, 1977). Changes in pancreatic duct branches have been emphasized by some authors (Kasugai, 1975), but should be interpreted with caution unless accompanied by changes in the main duct. In general the degree of ductal change correlates w i t h t h e degree of pancreatic dysfunction (Kasugai et alii, 1974; Nakano et alii, 1974),thus permitting an assessment of theseverity of the disease. Pancreatography also identifies patients in whom surgical drainage of the main pancreatic duct is technically feasible, but its role in patient selection for surgery requires further definition. Retrograde pancreatography has been performed in patients with pancreatic pseudocysts, and the majority have been shown t o communicate with the main pancreatic duct (Silvis et alii, 1974). However, because of the risk of cyst infection the procedure should be restricted to patients with negative or equivocal findings on barium meal X-ray examination and ultrasonography. I n patients with acute and acute relapsing pancreatitis the main pancreatic duct is usually normal (Rohrmann etalii, 1974), but focal acinar opacification may occur in areas of inflammation (Zimmon et alii, 1974).
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POTENTIAL COMPLICATIONS The complications of ERCP were evaluated in a national survey in the United States (Bilbao et alii, 1976). Pancreatitis (l0/o), cholangitis (O.8%), drug reactions (O.6%),pseudocyst infection (0.3%) and instrumental injury (0.2%) were the most common, with an overall complication rate of 3% and a mortality of 0.2%. Hyperamylasaemia (as distinct from clinical pancreatitis) may occur i n the majority of patients if serum levels are determined within a few hours of the procedure. The factors which influence hyperamylasaemia and pancreatitis are poorly understood, but may include overdistension of ducts (particularly when associated with acinar opacification), prolonged and repeated filling of ducts, and inappropriate studies in patients with pancreatic inflammation (Kasugai, 1975; Bilbao et alii, 1976). Cholangitis almost always occurs in the setting of biliary obstruction and can largely be avoided by early surgical decompression (the preferred method) or the systemic use of antibiotics. The management of an opacified pancreatic pseudocyst remains unclear, but should surgery be deferred, it would seem wise to use systemic antibiotics. PANCREATIC DUCTCYTOLOGY Cannulation of the papilla has permitted a s p i r a t i o n o f p u r e p a n c r e a t i c j u i c e for cytodiagnosis. Malignant cells were identified in 11 of 14 patients with cancer studied by Endo et alii, (1974) and in 11 of 19 patients studied by Hatfield et alii (1975). Duct aspiration is relatively simple, can be performed at the time of ERCP, and appears to be superior to pancreatic cytology using duodenal aspirates. Pure pancreatic juice has also been used for electrolyte, enzyme, protein, and carcinomaassociated antigen assays, but the diagnostic value of such studies has not been determined. Endoscopic Sphincterotomy Endoscopic sphincterotomy is now being performed in selected patients with retained or recurrent common duct stones, papillary stenosis, and choledocholithiasis without cholecystectomy when the risk of operation is high (Safrany, 1977). However, the procedure has resulted in morbidity and mortality, and the period of follow-up is insufficient to exclude long-term complications such as papillary stenosis. CONCLUSION ERCP constitutes a major advance in diagnosisof biliary and pancreatic disease. With experience, skiagrams of the desired duct(s) can be obtained in AUST.N.Z. J. SURG., VOL.48-No.
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10 to 30 minutes in most patients with minimal patient discomfort and a low frequency of complications. Many procedures can be performed on an outpatient basis, but patients with jaundice, relapsing pancreatitis, or pancreatic pseudocysts should be admitted to hospital because of potential complications. The diagnostic accuracy of ERCP has been enhanced by aspiration of pure pancreatic juice for cytodiagnosis. Endoscopic sphincterotomy is an exciting therapeutic development, but should be restricted to leading centres until early and late complications have been more fully evaluated. Endoscopic aspiration biopsy of the pancreas was recently reported (Tsuchiya et alii, 1977) and may facilitate the diagnosis of cancer and lead to a better understanding of changes i n pancreatic morphology associated with inflammatory disease. Endoscopic visualization of pancreatic and biliary ducts using a miniature endoscope passed down a channel in the parent instrument (Nakajima et alii, 1977) is an extraordinary technical development, but is diagnostic or therapeutic role remains unclear. ACKNOWLEDGEMENTS I am grateful to Professor W.S.C. Hare and other members of the Department of Radiology, Royal Melbourne Hospital, who assisted with the investigation. REFERENCES BELISTOA.A.. CRAMER. G.G. and DICKINSON. P.B. (1973).Amer. J Roentg enol., 119: 109. BILEIAO. M.K., DOTTER. C.T.. LEE.T.G.. and KATON.R.M. (1976). Gastroenterology. 70: 314. COTTON, P.B. (1972), Gut, 13. 1014.
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ROBERTS-THOMSON DIMAGNO,E.P., MALAGELADA. J.R. TAYLOR,W.F. and Go, V.L.W. (1977), New Engl. J. Med. 297: 737. ELIAS.E. HAMLYN, A.N. JAIN, S. LONG, R.G. SUMMERFIELD. J.A. DICK.and SHERLOCK. S.S. (1976). Gastroenterology, 71: 439. ENDO. Y. MORII, T. TAMURA,H. and OKURDA.S. (1974). Gastroenterology. 67: 944. GALVAN. A. and KLOTZ.A.P. (1973). Gastroint. Endosc., 20: 28. GREGG.J.A. (1977), Amer. J. Surg. 134: 639. HATFIELD. A.R.W. SMITHIES, A. WILKINS,R. and LEVI,A.J. (1975), Gut, 16: 405. KASUGAI. T. KUNO.N. AOKI.I. Kizu. M. and KOBAYASHI, S. (1971), Gastrointest. Endosc., 18: 9. KASUGAI, T., KUNO.N. KOBAYASHI. S. and HATTORIK. (1972). Gastroenterology. 63: 217. KASUGAI.T., KUNO.N. and Klzu. M. (1974), Amer. J. dig. Dis., 19: 485. KASUGAI, T. (1975). Digestion, 13: 76. KREEL.L. and SANDIN,B. (1973). Gut, 14: 962. MCCUNE. W.S., SHORE,P.E. and MOSCVITZ. H. (1968). Ann. Surg. 167: 752. NAKAJIMA. M.. AKASAKA. Y. and KAwAl. K. (1977), Gastroint. Endosc., 23: 236. NAKANO. S..HORIGUCHI. Y., TAKEDA. T., SUZUKI.T. and NAKAJIMA. S. (1974), Scand. J. Gastroent., 9: 383. NORTON.R.A., OGOSHI,K., HARA,Y., NIWA.M.. PAUL,R.E.. TOMAS.J. and FAWAZ, K. (1973). Gastroinf. Endosc.,20: 13. 01. I. (1970), Gastrointest. Endosc., 17: 59. ROBERTS-THOMSON. I.C. (1977), Med. J. Aust., 2: 793. ROHRMANN. C.A.. SILVIS. S.E. and VENNES, J.A. (1974). Radiology, 113: 297. RUPPIM,H.,AMON.R., ETTL.W.. CLASSEN. M. and DEMLING,L. (1974), Endoscopy, 6: 94. SAFRANY, L. (1977), Gastroenterology, 72: 338. SATAKI.K., UMEYAMA, K.. KOBAYASHI, K., MITANI,E.. TATSUMI, S.. YAMAMATO. S. and HOWARD. J.M. (1975), Surg. Gynec. Obstet. 140: 439. SILVIS. S.E., VENNES.J.A. and ROHRMANN. C.A. (1974). Amer. J. Gastroent. 61: 542. SIVAK.M.V. and SULLIVAN. B.H. (1976), Amer. J. dig. Dis., 21: 263. TSUCHIYA, R.. HENMI. T., KONDO. N , AKASHI.M. and HARADA. N. (1977). Gastroenterology. 73: 1050. VENNES.J.A., JACOBSON. J . R . ~ ~ ~ S I L V I S . S(1974),Ann. .E. intern. Med., 80: 61. ZIMMON, D.S., FALKENSTEIN. D.B., ABRAMS. R.M., SELIGER, G. and KESSLER, R.E. (1974). Radiology, 113: 287.
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