43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent

Name of the Procedure:

Endoscopic Retrograde Cholangiopancreatography (ERCP) with Stent Placement

Summary

Endoscopic Retrograde Cholangiopancreatography (ERCP) with stent placement is a medical procedure that uses a flexible tube with a camera (endoscope) to examine and treat conditions in the bile ducts and pancreatic duct. A stent, a small tube, may be placed to keep these ducts open. The procedure may include dilation, guiding a wire, and making a cut (sphincterotomy) to ease stent placement.

Purpose

Medical Conditions or Problems Addressed

• Blockages, narrowing, or leaks in the bile or pancreatic ducts.
• Gallstones, tumors, or inflammation causing duct obstruction.

Goals or Expected Outcomes

• Restore the proper flow of bile or pancreatic fluids.
• Relieve symptoms such as jaundice, pain, and infection.
• Prevent complications associated with duct obstructions.

Indications

Specific Symptoms or Conditions

• Light-colored stools, dark urine, jaundice (yellowing skin/eyes).
• Abdominal pain, particularly in the upper right quadrant.
• Recurrent pancreatitis, bile duct stones, or cholangitis.

Patient Criteria

• Patients with suspected or diagnosed bile or pancreatic duct obstruction.
• Patients with ductal tumors or strictures needing stent placement.

Preparation

Pre-Procedure Instructions

• Fasting for at least 8 hours prior to the procedure.
• Informing the healthcare team about all medications and allergies.
• Adjusting or stopping certain medications, such as blood thinners.

Diagnostic Tests

• Blood tests.
• Imaging studies like ultrasound, CT scan, or MRI.

Procedure Description

Step-by-Step Explanation

1. Sedation/Anesthesia: Patient is given sedatives or general anesthesia.
2. Endoscope Insertion: The endoscope is inserted through the mouth, passing through the esophagus, stomach, and into the duodenum.
3. Duct Cannulation: A small tube is threaded into the bile or pancreatic duct.
4. Contrast Injection: Contrast dye is injected to visualize the ducts via X-ray.
5. Guide Wire Passage: A guide wire may be used to navigate through the duct(s).
6. Dilation and Sphincterotomy: If needed, the duct is dilated, and a sphincterotomy is performed to ease stent placement.
7. Stent Placement: A stent is positioned inside the duct to keep it open.
8. Endoscope Removal: The endoscope is carefully removed.

Tools and Equipment

• Endoscope
• Contrast dye
• Guide wire
• Dilation balloons
• Stents
• X-ray equipment

Anesthesia or Sedation

• Intravenous sedation or general anesthesia.

Duration

The procedure typically takes 1 to 2 hours.

Setting

• Hospital endoscopy suite or specialized outpatient endoscopy center.

Personnel

• Gastroenterologist or surgeon specializing in endoscopy.
• Anesthesiologist or nurse anesthetist.
• Endoscopy nurses and support staff.

Risks and Complications

Common Risks

• Sore throat from the endoscope.
• Abdominal discomfort.
• Mild pancreatitis.

Rare Risks

• Perforation of the gastrointestinal tract.
• Significant bleeding.
• Severe pancreatitis.
• Infection.

Management of Complications

• Perforations may require surgical repair.
• Bleeding may necessitate additional endoscopic procedures.
• Pancreatitis and infections are treated with medications and supportive care.

Benefits

Expected Benefits

• Immediate relief of symptoms caused by duct blockages.
• Improved bile flow and pancreatic function.
• Reduced risk of complications from untreated obstructions.

Timeframe

• Benefits typically realized immediately to within a few days post-procedure.

Recovery

Post-Procedure Care

• Observation in the recovery area until sedation wears off.
• Restrictions on eating or drinking for a few hours post-procedure.
• Instructions on signs to monitor, such as fever or intense pain.

Expected Recovery Time

• Typically, 1 to 2 days for minor discomfort.
• Full recovery and return to normal activities usually within a week.

Follow-Up

• Potential follow-up appointments to check stent placement and function.
• Removal of temporary stents in a few weeks to months, if applicable.

Alternatives

Other Treatment Options

• Percutaneous transhepatic cholangiography (PTC).
• Surgical procedures like bile duct exploration or bypass.

Pros and Cons

• ERCP: Minimally invasive, quick recovery, but with potential serious complications.
• PTC: Alternative for patients not eligible for ERCP, but invasive and with its own risks.
• Surgery: Definitive treatment, but involves longer recovery and higher initial risk.

Patient Experience

During the Procedure

• Mild discomfort in the throat and abdomen.
• Limited awareness due to sedation.

After the Procedure

• Throat soreness and bloating are common but temporary.
• Pain management with prescribed medications.
• Most patients feel better within a day or two.

Comfort Measures

• Pain relief medications.
• Instructions on positioning and dietary adjustments to reduce discomfort.