Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography

Anesthesia type	GETA vs deep sedation (risk stratify based on procedure and patient)
Airway	ETT vs native airway (risk stratify based on procedure and patient)
Lines and access	1 PIV sufficient for most procedure, consider extra if unstable or complex procedure
Monitors	Standard ASA monitors, +/- A line depending on hemodynamic instability
Primary anesthetic considerations
Preoperative	Consider aspiration precautions in patient with risk factors. May be asked to give glucagon 0.25-2mg IV 10min prior to procedure to reduce duodenal motility.
Intraoperative	Consider RSI for pt at high risk of aspiration. Intubation increases likelihood of procedural success.
Postoperative	Pain from procedure is typically minimal. Pancreatitis from ERCP most common complication (1-40% quoted)
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Endoscopic retrograde cholangiopancreatography (ERCP) was originally designed as a purely diagnostic modality, but modern usage is typically for therapeutic purposes. Indications for ERCP include pancreatic or common bile duct obstruction and evaluation of pancreatic malignancy. Success, complication rate and speed of the procedure depends on significantly on operator experience.

ERCP consists of passing an endoscope from the mouth through the upper GI tract and into the duodenum, where the papilla of Vater is located. The endoscopist may request glucagon and/or secretin at this time to reduce duodenal motility. A guide wire is passed through the sphincter of Oddi into the common bile duct or pancreatic duct. Contrast is then injected to image the common bile duct and pancreatic duct via fluoroscopy. Brushings, samples, stenting, sphincterotomy and/or stone extraction may then proceed. Overall complication rate ranges widely based off of the final procedures and instrumentation of the common bile and pancreatic ducts, with <5% quoted for simple stone extraction and 20% or more with sphincterotomy.

Preoperative management

Patient evaluation

System	Considerations
Cardiovascular	Elderly patients may have comorbid CAD or CHF, screen appropriately in preop H&P
Pulmonary	Evaluate aspiration risk and ability to protect airway. Airway evaluation should focus on the need for GETA vs MAC.
Gastrointestinal	Patients often present with ileus or obstruction due to underlying pathology causing biliary or pancreatic obstruction. This makes them high aspiration risk.
Hematologic	Underlying malignancy increases the risk of VTE and may cause comorbid anemia
Renal	Many patients presenting for ERCP may have prerenal AKI from severe vomiting and dehydration
Endocrine	Glucagon administration may be requested, which is contraindicated in certain rare endocrine tumors such as pheochromocytoma and insulinomas.

Labs and studies

• Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
• At a minimum, all patients should have a preoperative CBC and CMP prior to case start
• in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation

Operating room setup

• Standard monitors and setup
• Fluoroscopy will be used, ensure adequate radiation safety equipment available (lead apron, lead glasses, lead shield)
• Positioning (lateral vs prone) will depend on proceduralist preference and patient factors, have equipment for prone positioning availabe (prone pillow)
• Endoscopy will require bite block to facilitate scope passage

Patient preparation and premedication

• Endoscopist may request glucagon (0.25-2mg IV) 10 min and/or secretin (0.2mcg/kg IV over 1min) prior to procedure to reduce duodenal motility
• consider aspiration precautions

Regional and neuraxial techniques

• Not typically necessary

Intraoperative management

Monitoring and access

• Standard ASA monitors
• +/- invasive arterial access for hemodynamic monitoring, based off of history and physical
• +/- addition IV access based on current access, though bleeding is typically minimal and operative time is short.
• consider glucose checks if glucagon is administered

Induction and airway management

• If GETA is chosen, RSI induction is often necessary in patient with inadequate NPO time, current abdominal distension/nausea/vomiting, or other risk factors for aspiration. otherwise standard induction
• If GETA is avoided, induction of deep sedation with propofol and topicalization of the airway to facilitate tolerance of endoscope passage in the pharynx can be sufficient
• Consider etomidate induction for hemodynamically unstable patients

Positioning

• Most patients will be prone for this procedure to aid in manipulation of scope into proper placement.
• If patient cannot tolerate the prone position, lateral or supine positioning can be done (increases difficulty for proceduralist).

Maintenance and surgical considerations

• If deep sedation is used, propofol infusion should be titrated to effect, avoiding respiratory depression and loss of protective airway reflexes
• If GETA is used, normal maintenance with volatile or intravenous agents or balanced approach can be used.
• GETA is associated with higher procedure success rate, consider intubation if the procedure is anticipated to be difficult or complex.

Emergence

• The duodenum and stomach are usually decompressed by the endoscopist prior to scope removal
• If obstruction in bile duct is removed, there is a high risk of bile aspiration. Have suction readily available.

Postoperative management

Disposition

• ERCP can be done as an outpatient surgical procedure, with disposition PACU -> home
• however with more complex ERCP procedures or with comorbid conditions, patients will typically go PACU -> medicine/surgical ward.

Pain management

• Not typically a very painful procedure postop since ERCP is an endoscopic method.
• multimodal analgesia with oral regimen

Potential complications

• post-ERCP pancreatitis (most common complication, up to 40%), more common in young patients with preexisting sphincter of Oddi dysfunction
• bowel or duct perforation (rare)
• hemorrhage (rare)
• cholangitis/cholecystitis
• aspiration
• cardiopulmonary complications (MI, PE, respiratory arrest)