FRCA Notes

Endoscopic Retrograde Cholangiopancreatography

Resources

  • ERCP is increasingly used for a variety of interventions, including (but not limited to):
    • Direct visualisation of biliopancreatic ducts in conjunction with EUS
    • Management of choledocholithiasis in patients unfit for surgery or who have previously had a cholecystectomy
    • Pancreatitis/cholangitis requiring drainage
    • Stenting in inoperable malignancy causing obstructive jaundice
    • Biliary manometry for sphincter of Oddi dysfunction
    • Management of other post-operative complications

General considerations

Patient considerations

  • High proportion of patients are heavily comorbid (>60% have an ASA grade ≥3)
  • May be having ERCP as deemed too unfit for other surgical procedure
  • High rates of:
    • Respiratory disease such as COPD (13%)
    • Cardiovascular disease such as IHD (20%), heart failure (8%) and AF (7%)
    • Metastatic cancer (18%)
    • Diabetes (18%)
    • Renal disease (9%)

Intra-operative care

  • Patients positioned prone as makes it technically easier, though may not be possible in the morbidly obese, those with large ascites or physiologically unstable patient
  • Antispasmodics may be required to help cannulation of the biliary ducts e.g. hyoscine, glucagon

Post-operative care

  • Multimodal analgesia with simple analgesics and opioids
    • Most opioids cause sphincter of Oddi contraction (except pethidine)
  • Typically a day-case procedure

Sedation

  • Moderate (conscious) sedation can be delivered by endoscopists, but fails in up to 14% of patients and a growing number of patients require deep sedation
Advantages of deep sedation Disadvantages
↓ recovery time (vs. GA) ↑ aspiration risk
↑ ERCP success (vs. moderate sedation) ↑ rates of oversedation with endoscopist-delivered sedation
↑ patient satisfaction (vs. moderate sedation) ↑ rates of hypoxia
May be better for those at ↑ risk of GA-associated adverse events such as COPD or OSA Other risks (see table below)

  • Rates of adverse events:
    • Do not differ significantly between moderate and deep sedatio
    • Are linearly related to procedure duration
    • Are higher if there is oversedation
    • Are higher if bolus sedation is used (vs. TCI)
  • HFNO reduces the incidence of hypoxia and the need for airway manoeuvres when compared to other oxygenation modalities (BJA, 2021)
Risk Incidence Patient risk factors
Loss of airway
± airway manoeuvres 		3.5 - 29.2% COPD
BMI >30
ASA ≥3
Hypoxia (<85%)
Hypoxia (<92%)		 6.7-15%
70-80%		 Difficult airway
COPD
BMI >30
ASA ≥3
Aspiration <1% Ileus
Ascites
EtOH excess
Conversion to GA 4.7 - 10% OSA
COPD
BMI >30
ASA ≥3
Hypotension req. vasopressor ~14% CV disease
Severe acute illness
Older age
ASA ≥3
Arrhythmia 2.5 - 14% CV disease
Severe acute illness

General anaesthesia

  • Is the technique used in up to 10% of ERCP patients (anecdotally higher)
  • Indicated where:
    • Procedural sedation has previously failed
    • There is a higher risk of sedation-related adverse events
    • Where the procedure is likely to be long, complex or painful
Advantages of GA Disadvantages of GA
Lower risk of aspiration Hypotension (up to 59%; BJA, 2020)
No need for airway manoeuvres Prolonged hospital stay
More suitable for complex or long procedures ↑ mortality
↑ hospital costs


  • Post-procedural
    • Pancreatitis (3 - 10%)
    • Cholangitis (0.5 - 3%)
    • Cholecystitis (<0.5%)
  • Haemorrhage (0.3 - 2%)
  • Perforation, pancreaticobiliary or duodenal (0.1 - 0.6%)
  • Venous air embolus (<2.4%)