ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

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ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It's a procedure used to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas.

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In an ERCP procedure, an endoscope (a long, flexible, lighted tube) is guided through the patient's mouth and stomach, up into the upper part of the small intestine, called the duodenum. A smaller tube (a catheter) is then inserted through the endoscope and into the bile and pancreatic ducts. A dye is injected, and the ducts are then x-rayed to outline the gallstones, other obstructions, tumors, or abnormalities.

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Besides diagnostic purposes, ERCP can also be used for therapeutic interventions such as removing gallstones from the bile duct or placing a stent (a small tube) to open up a narrowed bile or pancreatic duct

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Endoscopic sphincterotomy, also known as papillotomy, is a procedure often performed during ERCP (Endoscopic Retrograde Cholangiopancreatography).

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In this procedure, a small incision (cut) is made in the opening of the bile duct, known as the papilla, or the pancreatic duct. This procedure is performed to enlarge the opening of the duct so that bile or pancreatic juices can flow more easily, or to allow removal of gallstones lodged in the bile duct.

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Endoscopic sphincterotomy or papillotomy can be a very effective way to treat certain conditions, like gallstones, strictures (narrowing) of the bile duct, or certain tumors.

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Biliary flow from the common bile duct into the duodenum is controlled by the sphincter of Oddi.

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                                                                      Anesthetic Implications for ERCP

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Anesthesia type: General, TIVA

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Airway: Endotracheal tube

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Preoperative:

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• ERCP combines endoscopy with fluoroscopy

• Retrograde refers to the direction in which the contrast dye is injected for visualization of bile ducts and pancreas

• Fluoroscopy/Xray precautions. Use lead aprons and thyroid shields

• Check for allergies. Contrast dye is used during this procedure

• Check the patients cervical range of motion

• Check with the surgeon which side is preferred for ETT taping

• Eye protection should be used in the prone position 

• Local anesthetics can be administered to numb the back of the throat

• A mouthpiece (bite block) is inserted to prevent damage to teeth from biting on scope

• Lowering the chin towards the sternum or jaw thrust can help massage of scope into oropharynx 

• An anticholinergic agent such as Glycopyrrolate can be administered to decrease secretions

• Patients may have pancreatic disease with associated peritoneal and pleural effusions

• Hepatic dysfunction may be associated with coagulopathy and altered drug metabolism

• Liver dysfunction may increase the risk of esophageal varices bleeding 

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Intraoperative:

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• Glucagon may be administered to inhibit intestinal motility and to relax the sphincter of Oddi (decreases biliary pressure)

• Opioids can cause spasms of the sphincter of Oddi

• Position: prone with head turned to the side (towards surgeon)

• Duration: 1-2 hours

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Postoperative:

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• Pain management

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Complications:

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• Post-ERCP pancreatitis

• Bowel or duct perforation

• Aspiration

• Bleeding

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Sources:

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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