Anesthetic management of ERCP patient tushar chokshi

Anesthetic management of ERCP patient tushar chokshi

1. ANAESTHETIC MANAGEMENT

OF

(EDndoscopie
ADetrosrade
(EDholansie
(PDancreatosraphy

(EDndoscopie

& etrosrade
(ED'holangio
(Pancreatosraphy

Dr. Tushar Chokshi
VADODARA

3. AUDIENCE EC 7

How many of you are giving Anaesthesia in ERCP ?

What is your experience in High Risk Patients ?

|

Are you using Capnography in ERCP Anaesthesia ?

4. LECTURE Outline

Introduction

y
Indications
Contraindications
Procedure Room Layout
Preparation before ERCP

y
Positioning of ERCP Patients

ERCP Procedure
howit is performed

After the Procedure

—> Complications

rn - ee

Soo

u;

v
Monitoring in ERCP Anesthesia

LA
Anesthesia Goals and Different
Anesthetic Techniques

v
Journal Articles/Newer
Gadgets for ERCP Anesthesia

Y
How I manage my High Risk
patients for ERCP anesthesia

LA
Conclusions

Y
Take Home Message and My
Verdict ‘

5. SST #3 «iF o — <e
Endoscopic Retrograde Cholangio Pancreatography

O LÉ CE, a E e

A > « D 4 à « » 4 h
Im Wee The Papill The i itecs
E | Pancreatic a Common Se |

\ Duodenum Of Water Bladder |
\ Duct Bile Duct /
À y À: y

«Y > ~ D D. D. “À

6. ERCP Indications

Diagnostic
Narrowed or blocked bile or
pancreatic ducts
Tumours
Gallstones that form in the
gallbladder and become stuck in
the ducts
Inflammation due to trauma or
illness, such as pancreatitis
Dysfunction of valves in the
ducts, called sphincters
Pseudo-cyst, accumulations of
fluid and tissue debris

Scarring of the ducts (sclerosis)

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Therapeutics

Sphincterotomy
Stone Removal

Stent Placement
Balloon Dilation
Tissue Sampling

Galistones NY

7. ERCP Contraindications

Unstable cardiopulmonary, neurologic, or
cardiovascular status; and existing bowel perforation

Structural abnormalities of the oesophagus, stomach,
or small intestine may be relative contraindications
for ERCP

An altered surgical anatomy

ERCP with sphincterotomy or ampullectomy is
relatively contraindicated in coagulopathic patients

Acute pancreatitis
History of iodinated contrast dye anaphylaxis

8. ERCP Procedure Room Lay Out

9. A- Anesthesiologist
Aa-Anesthesia Assistant
E- Endoscopist
Eu-Endoscopy Nurse 1
Ew-Endoscopy Nurse 2

elsayysouy

ERCP Procedure Room Lay Out

10. Most ERCP procedures in high volume centres are
performed in dedicated fluoroscopic procedure
rooms with a compact layout

ERCP procedures in low-volume centres may be
performed in a radiology suite or in the operating
room using a portable C-arm fluoroscopy
machine

Rooms are compact but must accommodate the
one endoscopist, a technician, one nurse, and an
anaesthesia provider

Anaesthesia personnel usually have an
anaesthesia machine as well as an anaesthesia
cart with all monitoring parameters

Anaesthesia providers are positioned at the
patient’s head

11. The upper Gl tract must be
empty Generally, no eating or
drinking is allowed 8 hours
before ERCP

Removal of any

Smoking and chewing

Gum/ Tobacco Preparation nor
are prohibited during Before contact lenses
NBM period beforehaving an
ERCP ERCP.

urrent medications may need
to be adjusted or avoided.

Most medications can be

continued.as usual

12. Positioning of ERCP

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pu = :

13. Prone Left Lateral Decubitus

21pme
{Head Tilted to Left Side)

14. Prone Position

* Most common position for ERCP since it allows the endoscopist optimal visualization and
access to anatomical structures.

* Contraindications for prone position for ERCP include À

--- Significant aspiration risk a

— Advanced pregnancy ean

-— Tense ascites

--- Severe immobilizing cervical spine disease

--- Critically ill patients who cannot be turned prone due to lines/infusions/ongoing
treatments

--- Patients who have marginal cardiopulmonary status

* Prone positioning in conscious patients requires cooperation of patient, who can lie on
their abdomen for at least 5-10 min until adequate sedation is achieved

* Frail, elderly patients may have limited mobility and may require significant assistance to
achieve the correct position. Additionally, arthritic changes in the cervical spine may make
turning of the head difficult to facilitate passage of the endoscope. Pressure and skin injuries
are also more common in frail elderly patients, so extra care must be taken in moving and
positioning

* Post-cholecystectomy patients or patients with any intervention of the anterior abdomen
(e.g. percutaneous trans hepatic biliary drain) may require analgesia prior to positioning

* Anaesthesia providers should ensure IV lines are not inadvertently displaced during

movementand positioning TM 14

15. Supine Position

Reserved for patients who are critically ill where position changes may
lead to unacceptable changes in ventilation or cardiovascular status.

Patients who are actively vomiting, known gastric outlet obstruction
(physical or functional), and patients at high aspiration risk have their
procedure performed in the supine position (e.g. active severe
pancreatitis)

Patients with cervical spine disorders, altered airway anatomy, or
patients at high risk for airway obstruction may benefit from the supine
position

Facilities performing general anaesthesia for ERCP will often maintain
their patients in the supine position to secure the airway

Advanced pregnancy and patients with increased intra-abdominal
pressure due to pathology (tumour, ascites) may benefit from the supine
® with left lateral tilt position to preventaortocaval compression

16. Left Lateral Decubitus Position

This position is only possible in rooms where the

fluoroscope can be rotated to obtain anterior-posterior
views

This is a potential alternative position for patients who
cannot or will not assume the prone position

Endoscopists may find this position less favourable in
terms of visualizing the ampulla and cannulating the bile
ducts

The literature does not seem to support this finding in
deeply sedated patients

17. EPS-30

SURGICAL
Endoscopy Positioning System Rs. 50,000/

Recovery Head Support

Head Support
Mainteins Bevation and y >
prin Head Support Bolsters

Arm/Shoulder Recess
Anterior Lower Quadrant Bolster

Chest Support
Arway Alignment
Posterior Bolster Support

New Endoscopy Positioning
System (EPS 30) for all
types of gastroscopy and
ERCP positions in prone or

17

aware TEST lateral positions

18. Patients

receive a Patients lie on
local i
: == their back
anaesthetic or or side
Sedation/GA

gallstones
removal or other

therapy PROCEDURE

performed

Radio contrast
is injected
to look blockage
or lesion/stones

sphincterotomy
with an
electrified
Wire

flexible camera
(endoscope) is
inserted

Oesophagus
Stomach
Pylorus
Duodenum

Ampulla of
Vater
Cannulated
with
Plastic catheter,

19. AFTER THE PROCEDURE

¢ Patients are monitored in the endoscopy area
for 1-2 hours until the effects of the sedatives

have worn off & observed for complications

+ Eating or drinking is allowed if the throat is
no longer numb and are able to swallow
without choking

+ If a gallstone was removed or placed a stent

during the test, the patient is made to stay in
the hospital overnight

® pr

20. COMPLICATIONS

ERCP is a highly specialized procedure which requires a lot
of experience and skill both in Surgical and Anaesthesia

The procedure is quite safe and is associated with a very
low risk when it is performed by experienced physicians

The success rate in performing this procedure varies from
70% to 95% depending on the experience of the physician

Complications can occur in approximately one to five
percent depending on the skill of the physician and the
underlying disorder

Complications varies from Pancreatitis, Cholangitis,
Bleeding, Perforation, Stroke and Death

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21. Vascular access
always secured
and hydration
with infusion of
Ringer lactate is
must

Ss
Continuous O presence of
Oxygenation Anesthesiolo

Blood
Pressure,
NIBP every
5 minutes

Defibrillatoris
mustin higher
risk patients

v

nea Capnograph
Rate pnography

Anesthesia
work station
with all
emergency
drugs

22. Anesthesia Goals in ERCP

23. ERCP is an uncomfortable
procedure requiring adequate
sedation or general
anaesthesia

The required level of sedation
during these procedures is
oftendeep

The patient cooperationis an
imperative factor for the
success of the procedure
especially, to avoid intra-

operative complications such
as duodenal perforations

presence of an
anaesthetist
without
intubation

cases in high
risk patients

This deep sedation may
compromise the safety of the
upper airways and be a
source of complications,
especially respiratory

Desaturation remains the
most observed adverse event

Oxygenationis must

Anaesthesia and
Analgesia are important
elements for the realization
of interventional endoscopic

procedures

24. Anaesthesia with
special Gastro Local Spray
Laryngeal Tube with IV

or Special Mouth Different Sedation

Guard Anaesthesia

Techniques

Anaesthesia with Local Spray and IV
Oral/Nasal Anaesthesia Agents

(TIVA) with

Endotracheal intermittent dose or
tube " with TCI

25. Journal Articles

26. Anaesthetic considerations for endoscopic retrograde

cholangio-pancreatography procedures.
Review article

Garewal D, et al. Curr Opin Anaesthesiol. 2013

SUMMARY:

, administered by
personnel, can be used as an alternative
CITE RECUEIL a select group of patients

undergoing ERCP procedure

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27. Outpatient endoscopic retrograde
cholangiopancreatography: Safety and efficacy of

anaesthetic management with a natural airway in 653
consecutive procedures
Basavana G Goudra, Preet Mohinder Singh Ashish C Sinha

Conclusions:

ERCP] In presence of vigilant apnoea monitoring and
careful dose titration of maintenance anaesthetics with

airway conduits, general anaesthesia, emergency
intubations, and procedure interruptions can be avoided

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28. Propofol Sedation for ERCP Procedures: A Dilemma?
Observations from an Anaesthesia Perspective
Davinder Garewal and Pallavi Waikar
Department of Anaesthesia, St. George’s Hospital, London
SW1700QT, UK

Conclusion
Sedation for ERCP proceduresis a challenging area for clinicians,

where there is an overlap between anaesthetic and nonanesthetic
practice. ropofolcanb t f

rely safelyfor
opic proc However, itis

difficult to envisage a future without significant anaesthesiology
involvement in this controversial area. Cooperation and discussion
between gastroenterologists and anaesthesiologists may pave the
way to a realizable solution. The final outcome will undoubtedly be
determined by a mixture of financial, political, and scientific debate
and may well differ internationally

29. General endotracheal anaesthesia preferred for

high-risk patients undergoing ERCP
Smith ZL, et al. Gastrointest Endosc. 2018;doi:10.1016/j.gie.2018.09.001

anaesthesia rather than monitored anaesthesia according to
research published in Gastrointestinal Endoscopy

Fig Te 29

30. Deep Sedation or General Anaesthesia for
ERCP?

Nirav Thosani, Subhas Banerjee

LÉEUMAendoscopists in collaboration with dedicated

anaesthesiologists

to determine optimal sedation strategies for ERCP based

on the grade of complexity of the procedure as well as on

EMULE This may bring us closer to
achieving the perfect balance of patient comfort, safety,
and endoscopy unit efficiency.

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31. Anesthesia for ERCP
Rajiv R. Doshi and Mary Ann Vann

Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel
Deaconess Medical Centre, 330 Brookline Ave, Boston, MA 02215, USA

optimization of the patient, positioning of the patient, and utilization of

anaesthetic agents and airway adjuncts will aid the anaesthesia provider to

= deliver a safe and comfortable anaesthetic, 31

32. ®

Anaesthetic Considerations during Endoscopic
Retrograde Cholangiopancreatography
S.J. MARTINDALE*
Department of Anaesthesia, Sir Charles Gairdner Hospital,
Nedlands, Perth, Western Australia

CONCLUSION
Enormous progress has been made in techniques of therapeutic
biliary endoscopy, which has contributed to the rapid expansion of
this field and the improving success rate of procedures.

in therapeutic ERCP but there is a lack of data in the anaesthetic

literature regarding techniques and potential pitfalls. It is hoped that
increasing understanding and awareness of this evolving field will
stimulate further research, especially with regard to morbidity
resulting from cardiopulmonary complications. 32

33. Safe anaesthesia for ERCP
A. Toner, D. Garewal, P. Keelin

Our experience across two hospitals during a 10-year period
(approximately 3000 upper endoscopy procedures) is that the

If there are residual gastric contents they can usually be suctioned by the
operator, and if not, the endoscope is removed and we performtracheal
intubation following rapid sequence induction of anaesthesia

Thc 33

34. Improved Sedation in Diagnostic and Therapeutic
ERCP: Propofol is an Alternative to Midazolam
M.Jung!, C. Hofmann?, R. Kiesslich 1, A. Brackertz 2
Endoscopy 2000; 32(3): 233-238
DOI: 10.1055/s-2000-96

[These data demonstrate that sedation with propofol is suitable for use}
in ERCP, and offers advantages over midazolam aaa Re
shorter, making it possible to reduce the postendoscopic monitoring
phase. The examination conditions are improved for both endoscopist
and patient. Complications and adverse reactions seldom occur and, if
they do, are of brief duration. Nevertheless, close monitoring of the
sedated patient during diagnostic and therapeutic ERCP seems to be

if mandatory Tuc

34

35. ERCP is safe and effective in patients 80 years of age and
older compared with younger patients

Eva Fritz MD, Andreas Kirchgatterer MD, Dietmar Hubner MD, Maximilian
Hinterreiter MD, Peter Knoflach MD
Gastrointestinal Endoscopy
Volume 64, Issue 6 December 2006, Pages 899-905

Conclusion

ERCP is a safe and effective intervention in the elderly because complication
and early mortality rates are comparable to those of younger patients,

im ria 5

36. Sedation for High-Risk ERCPs: Monitored
Anaesthesia Care or General Anaesthesia?
Douglas G. Adler, MD, FACG, AGAF, FASGE reviewing Smith ZL
et al. Gastrointest Endosc 2018 Sep 11

COMMENT

Although there is a trend in many U.S. centres to use
MAC when performing ERCP, this study suggests that GA
is overall a safer alternative in patients at high risk. In my
practice as a high-volume ERCP provider, | strongly favour

GA over MAC, as | feel this provides the highest level of
safety and protection for the patient, recognizing the
increased cost involved

Tc

37. Lung India

Year: 2014 | Volume : 31 | Issue : 4 | Page : 331-335

Utility of noninvasive ventilation in high-risk
patients during endoscopic retrograde
cholangiopancreatography

Miguel Angel Folgado, Carlos De la Serna, Alfonso Llorente, SJ Rodríguez, Carlos Ochoa, Salvador
Diaz-Lobato

Our preliminary results demonstrate that in
high-risk patients undergoing ERCP,
hypercapnia and respiratory acidosis are
frequent. NIV prevents the appearance of
these complications.

38. Gastroenterology

Diclofenac reduces the incidence of acute pancreatitis

after endoscopic retrograde cholangiopancreatography
June 2003 Volume 124, Issue 7, Pages 1786-1791

Bill Murray, Ross Carter, Clem Imrie, Susan Evans, Criostoir O'suilleabhain

This trial shows that rectal diclofenac given
immediately after endoscopic retrograde
cholangiopancreatography can reduce the
incidence of acute pancreatitis.

39. Newer ERCP Anesthesia Gadgets

40. VBM ENDOSCOPY MASK

APPLICATION

Fiberoptic Intubation
Bronchoscopy
Gastroenterology
Transesophageal Echocardiography

https://www.youtube.com/watch?v=uZrVsAu_v4c

Thc 42

41. Pennine’s Mouth Guard for ERCP Anaesthesia

Position of lips Face'L' Port's’ Oxygen attachment

Port'B" Capnography attachment

Face'T Position of teeth

® TMC a

42. https://www.youtube.com/watch?v=wWnvA3gmAW.

LMA’ Gastro“ Airway > Adjustable holder
A acai and strap
with Cuff Pilot™ Technology

Maintains the device in
a neutral position during

+ endoscope manipulation

Endoscope channel
Enables an endoscope to be passed
through the device under vision +. Integrated bite block
Reduces the potential for damage to,
or obstruction of, the airway tube or

+++ endoscope due to biting

Yellow zone Green zone
0-40 em H,0 40-60 em H,0

Silicone airway
tube and cuff
Designed for smooth insertion ° Cuff Pilot” Technology
and patient comfort ‘An integrated, single-use cuff
pressure indicator that constantly ¿ Clear zone

monitors cuff pressure À 60-70cmH,0 «

Red zone
+ 70+em H,0

TMC 43

43. OXYGUARD® Oxygenating Mouthguard

- Unique oxygen nasal port
- Easy and safe to use
> - Delivers oxygen to both the mouth
and nose

- Saves time and effort

- Improves patient comfort

- Disposable — single use

- Two sizes - standard and small *

0

44. Gastro-Laryngeal Tube G-LT

Extraglottie Tube with ventilation- and endoscopy lumen for control of Airway patency during
‘gastrointestinal endoscopic procedures.

12 autoclavable up 10 134°C
= Material: Silicone, latex-tree

u Be

vane >» ee
ores
ET

lo lan and eetaton
‘lot ets

Rs. 22000/

Discussion:

In conclusion, GLT is a safe effective altemative to ETT for airway management during ERCP. GLT is
associated with less hemodynamic stress response, shorter extubation time with less incidence of
‘cough and higher endoscopist satisfaction scores compared to ETT.

44

45. Gastro-Laryngoal Tubo G-LT

‘The G-LT is designed for obtaining and maintaining contol of airway patency during medium to long term complex
‘gastrointestinal endoscopic procedures performed on adults under deep sedation or general anaesthesia while maintaining
‘Spontaneous or assisted venation,

+ Diagnostic ERC (Endoscopic Retrograde Cholangiograptiy)

* Diagnostic and therapeutic ERCP (Endoscopic Retrograde Crolangiopancreatography)
{for pancreatic and bilary disease:

Brush cytology and biopsy
- Endosonografc gastrointestinal diagnosis
= Removal of be and pancreatic duct stones
+ Papilotomy or duodenal ampulta ciation

+ Treatment ofbilary stictures. “
(endoprosthesis. stent placement)

= Paliation of malignancy: obstructive jaundice
(erainage decompression)

+ Enteroscopy
+ Percutaneous Endoscopic Gastrostomy (PEG). particularly in neurologic patients.

‘The G-LT can also be used for performing shor term or minor duodenal and oesophageal gastric endoscopies whenever the
‘patent has particular high isk factors or refuses conscious sedaton/anxiolys's and asks for deep sedation or anaestnesia,
‘orwhenever there are specific indications.

Advantages

+ Prevention and control of hypoventilation and desaturation (supragiotic obstruction caused by the duodenoscope, gasto
¡duodenal gaseous distention, respiratory depression dueto over-sedatin, ic.)

+ Greater stability of the sedation or anaesthesia plan and a reduction in cardio circulatory Instability

+ Faster endoscopic procedures and fewer interruptions due lo intolerance or agitation (under-sedabion)

+ Faciiates the oesophageal insertion ofthe duodenascopes, especialy when the manoeuvres repeated, without impeding
mobility and handling

+ ls positioning does net requio direct laryngoscopy or muscle relation

+ Substitutes endotracheal intubation, preventing associated ansesthesiological problems and dificuities arising in the
‘execution af tne endoscopic procedure

+ Enables clinical checks and instrumental monitoring (eapnometry and capnography) of the sufficiency and adequacy al
lung vention

+ Enables exygen supply and venblatory support of spontaneous respiration wih manual or instrumental techniques without
‘interrupting and intertring with the encascopic procedure

+ Less use of anaesthetic drugs
* Protects he airways rom gast oesophageal eur ao upaladon of gost content

+ Enables suction of secretions in the upper airways using a small size catheter (max, CH10) inserted in the ventilation
tube (consider lubrication)

as

46. Pediatrics ERCP

Experience with ERCP in
paediatric population is limited

the

ERCP in the paediatric population
performed by adult
gastroenterologists with standard
duodenoscopes

Post ERCP pancreatitis was the most
common complication

The higher complexity and duration
of the procedure in paediatric
patients with a smaller anatomy
always requires monitored
anaesthesia care or general
anaesthesia with intubation

Use of standard adult
duodenoscopes recommended for
performing ERCP in children who
weigh at least 10 kg

+ Indications of ERCP in paediatrics

are 1) Suspected
choledocholithiasis, 2) Post-liver
transplantation anastomotic
biliary strictures, 3) Post-surgical
bile duct injury, 4) Choledochal,
Recurrent or chronic pancreatitis
and 5) Trauma

ERCP in new-borns and_ infants
also can be safely performed
with high technical and clinical
success in tertiary care centres
The most common complication
of procedure and anesthesia in
pediatric patients are
desaturation and bradycardia, so
post procedure ERCP is also most
important phase of monitoring:

47. How | manage
My
High Risk patients
For
ERCP Anesthesia

48. My ERCP Anesthesia History

High risk patients for ERCP
means ASA 2 with active
symptoms, ASA 3 and ASA
4

Most of the patients were
more than 50 years age and
youngest was 18 year old

In last 28 years completed
more than 500 ERCPs
Started from Radiology
Room with IITV to
dedicated Endoscopy
Procedure Room with C-
arm and complete
anesthesia machine with
monitors

+ My ERCP anesthesia in high

risk patients were in three

different phase

1) First 8 years (Conscious
Sedation + Buscopan)

2) Second 10 years (Propofol
Sedation + Buscopan)

3) Third 8 years and
continuing (KPD only)

In all three phase | have used
different techniques, anesthetic
agents and monitoring

49. My Standard Protocols

I do full pre anesthetic check up in all my high risk patients
in details at least 10 to 30 minutes before procedure

I discuss with my colleague gastroenterologist about
procedure details and timing

I always tell patient relatives and patient himself about
anesthesia and procedure related complications and take
special written consent

| prepare my patient for prone position except in some
contraindication from patient’s history and some high risk

| always keep one assistant with me in my procedure room
My patients are always coming with IV infusion RL

All high risk patients are transferred in procedure room with
stretcher only ri

50. Continued.....

Everything is prepared in procedure room before
patientis transferred

Patient first put in supine position with all monitoring
parameters and nasal oxygen 3-5 liters given

First conscious sedation is given in supine position only
and | put Nasal Airway under lubrication of lidocaine
jelly

Now patient is turned in prone position with oral
mouth guard and head tilted to endoscopist side

When Endoscope passes through first part of
duodenum and after seeing ampulla of water, | give
more sedation with KPD mixture according to patient’s
need intermittently

KPD mixture is combination of Ketamime + Propofol +
Dexmedetomidine in 1:1:1 dose

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51. Continued.....

Now a days | hardly give any buscopan to my ERCP patients

All high risk patients are monitored continuously and nasal oxygen
given throughout procedure

In some more high risk patients having cardiopulmonary
symptoms and obesity ERCP is done in supine position

Average time duration of ERCP is from 15 to 75 minutes for whole
procedure

Almost 20 % cases, | found desaturation where SpO2 goes below
90, and in some cases we have abandoned the procedure

Ihave never intubated any high risk patient in my practice

The main problem for ERCP patients are uncomfortability in prone
position and time duration

All patient | observed at least 10 to 20 minutes post procedure
on ERCP table only then transferred to ward

In most high risk cases we continue post procedure nasal oxygen
and monitoring

There is no major morbidity and not a single mortality in all cases
till now un E

52. Lesson learned in High Risk patients

Do complete PA check up

Discuss with your Gastroenterologist

ERCP position and procedure is uncomfortable but not
painful like surgical incision

Patients require conscious sedation to deep anesthesia
with tailor made plan according to time-space-situation
Continuous monitoring with oxygenation is gold
standard

If require then intubation is safe for high risk patient
Always give broad spectrum antibiotic before
procedure

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53. Contain

Deep Sedation technique is the most practiced
anaesthetic technique in most published series

Propofol + SOS Narcotics are the most used drugs in this
indication

Anaesthesia reduces procedure time and improves the
level of comfort and intra-operative amnesia

During ERCP, the use of TCI mode allows better
optimization of the general anaesthesia, with a shorter
recovery time, decreased demand for antispasmodics
and less peri-operative complications compared to
standard anaesthetic technique

54. ww
* Take
Aome mesSage
Because of patient’s high ASA status and
procedure difficulties, the choice of the
anaesthetic technique presents a real challenge.
Many techniques have been proposed with
sedation used mostly. However, it carries some
risks, and the use of general anaesthesia (with or
without intubation) may be necessary in some
high risk patients. Because of co-morbidities in
patients undergoing ERCP, the optimization of
general anaesthesia for this technique is

necessary. Tan =

55. ow S

The need for patient comfort while
maximizing patient safety and
optimizing procedural conditions for
ERCP success has made anaesthetic
considerations critical to the success of
these complex procedures in high risk
patients

®

56. MRCP VERSUS ERCP

MR cholangiopancreatography is non-invasive and safe,
because it does not require anaesthesia or injection of
intraductal or intravenous contrast agent

MRCP is useful in patients after incomplete or

unsuccessful ERCP In some patients, such as those who
have undergone surgery with biliary enteric anastomosis

or Billroth Il, it may not be possible to perform ERCP
Unlike ERCP, MRCP produces images of the ducts in their
natural state, because it does not involve distention of the
ducts by injected contrast medium

Drawback of MRCP is that there no direct therapeutic
interventional procedures that may be performed

MRCP is gradually replacing ERCP as a primary diagnostic
imaging modality to evaluate the biliary system and
pancreatic duct

57. Endoscopic stone removal

ERCP procedure and Anesthesia
should not be like this

TMC

58. ERCP procedure and Anesthesia
should be like this

TMC

58

59. Thank You