What is the recommended approach for patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP)?

From the Guidelines

The recommended approach for patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) is to prioritize careful patient preparation, appropriate sedation, and antibiotic prophylaxis, with a focus on minimizing complications and ensuring successful diagnostic and therapeutic outcomes, as supported by the most recent and highest quality study 1.

Key Considerations

• ERCP is an invasive procedure that requires careful patient preparation, including fasting for at least 6-8 hours prior to the procedure.
• Antibiotic prophylaxis should be administered for patients with biliary obstruction, using a single dose of a broad-spectrum antibiotic such as ciprofloxacin 400mg IV or ceftriaxone 1g IV 30-60 minutes before the procedure, as suggested by 1.
• Conscious sedation typically involves midazolam (2-5mg IV) combined with fentanyl (50-100mcg IV) or propofol (initial bolus of 0.5-1mg/kg followed by 25-75mcg/kg/min) administered by an anesthesia provider.
• Patients taking anticoagulants may need to temporarily discontinue these medications, with warfarin stopped 5 days before and direct oral anticoagulants 48 hours before the procedure.

Minimizing Complications

• Post-procedure, patients should be monitored for complications such as pancreatitis, bleeding, or perforation for at least 2 hours.
• Rectal indomethacin (100mg) or diclofenac (100mg) administered immediately after ERCP can reduce the risk of post-ERCP pancreatitis, particularly in high-risk patients, as recommended by 1.
• The risks of ERCP, including pancreatitis, cholangitis, and hemorrhage, should be weighed against the potential benefits of the procedure, as discussed in 1 and 1.

Special Considerations

• In patients with primary sclerosing cholangitis (PSC), ERCP should be undertaken by experienced pancreaticobiliary endoscopists, and the risks of ERCP should be carefully weighed against the potential benefits, as suggested by 1 and 1.
• Magnetic resonance cholangiography (MRC) should be preferred over ERCP as the primary diagnostic modality for PSC, as recommended by 1.

From the Research

Recommended Approach for Patients Undergoing ERCP

The recommended approach for patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) involves several considerations, including the patient's condition, the presence of choledocholithiasis, and the availability of endoscopic expertise.

• ERCP is a therapeutic procedure used to manage hepatobiliary and pancreatic diseases, including choledocholithiasis, pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks 2.
• The procedure can be performed using various techniques, including endoscopic sphincterotomy, balloon dilation, and stenting 3, 4.
• In cases where ERCP is not successful, open surgical exploration of the common bile duct (CBD) or biliary-enteric anastomosis may be necessary 3.
• Single-stage management of choledocholithiasis using intraoperative ERCP or laparoscopic common bile duct exploration (LCBDE) can be effective, with low rates of morbidity and mortality 5.
• Stenting can be used as a temporizing or therapeutic measure for choledocholithiasis, allowing for biliary drainage and preventing the need for urgent surgical intervention 4.
• A combined single inpatient procedure involving ERCP and cholecystectomy can be safe, efficacious, and cost-efficient, with a shorter length of hospital stay and reduced total cost of care compared to separate-session procedures 6.

Considerations for ERCP

• The choice of approach depends on various factors, including the patient's condition, the presence of choledocholithiasis, and the availability of endoscopic expertise.
• ERCP can be performed using various techniques, including endoscopic sphincterotomy, balloon dilation, and stenting.
• The use of stenting can be effective in managing choledocholithiasis, but may require repeated ERCP procedures for stone clearance.
• Single-stage management of choledocholithiasis using intraoperative ERCP or LCBDE can be effective, but may require careful patient selection and expertise.
• A combined single inpatient procedure involving ERCP and cholecystectomy can be safe and efficacious, but may require careful consideration of the patient's condition and the availability of resources.