Our ERCP book. New edition
I take a pause from spilling beans on royal and famous patients to let y’all know that Joseph Leung and I have just published the 3rd edition of our ERCP book. For anyone interested I am pasting the introduction.
|Developments in ERCP over 50 years|
Attempts at endoscopic cannulation of the papilla of Vater were first reported in 1968. However, the method was put on the map shortly afterwards by Japanese gastroenterologists, working with instrument manufacturers to develop appropriate long side-viewing instruments. The name “ERCP” (Endoscopic Retrograde CholangioPancreatography) was agreed at a symposium at the World Congress in Mexico City in 1974. The technique gradually became established worldwide as a valuable diagnostic technique, although some were skeptical about its feasibility and role, and the potential for serious complications soon became clear. It was given a tremendous boost by the development of the therapeutic applications, notably biliary sphincterotomy in 1974, and biliary stenting 5 years later. It is difficult for most gastroenterologists today to imagine the diagnostic and therapeutic challenges of pancreatic and biliary medicine 50 years ago. There were no scans. The pancreas was a black box, its diseases diagnosed only at a late stage. Biliary obstruction was diagnosed and treated surgically, with substantial operative mortality. The period of 20 or so years from the mid 1970s was a ‘golden age’ for ERCP. Despite significant risks, it was quite obvious to everyone that ERCP management of bile duct stones, strictures and leaks was easier, cheaper, and safer than available surgical alternatives. Percutaneous transhepatic cholangiography (PTC) and its drainage applications were also developed during this time, but were used (with the exception of a few units) only when ERCP failed or was not available. The situation has evolved progressively in many ways during recent decades. There are some new techniques (such as expandable and biodegradable stents, simpler cholangioscopy, balloon sphincteroplasty, pseudocyst debridement, and laparoscopic- and EUS-guided cannulation) and improvements in safety (pancreatic stents, NSAIDs, anesthesia, CO2).
Other important changes in ERCP practice have been driven by improvements in radiology and surgery, and the increasing focus on quality. Radiology. Imaging modalities for the biliary tree and pancreas have proliferated. High quality ultrasound, computed tomography, endoscopic ultrasonography, and MR scanning (with MRCP) have greatly facilitated the non-invasive evaluation of patients with known and suspected biliary and pancreatic disease. As a result, ERCP is now almost exclusively used for treatment of conditions already documented by less invasive techniques. There have also been some improvements in interventional radiology techniques in the biliary tree, which are useful adjuncts when ERCP is unsuccessful, or impractical. Surgery. There has been substantial and progressive reduction in the risks associated with surgery, due to minimally invasive techniques, and better perioperative and anesthesia care. It is no longer correct to assume that ERCP is always safer than surgery. Surgery should be considered as a legitimate alternative to ERCP, not only when ERCP is unsuccessful. Patient empowerment. Another relevant development in this field is the increased participation of patients in decisions about their care. Patients are rightly demanding information about their potential interventionists, and the likely benefits, risks, and limitations of all of the possible approaches to their problems. The Quality imperative. The name Endoscopic Retrograde CholangioPancreatography is now inaccurate. It was invented to describe a method for obtaining radiographs of the biliary and pancreatic trees. It is now a broad therapeutic platform, like laparoscopy. It may be better remodeled as “Ensuring Really Competent Practice”, since quality is now the main challenge. We have to make sure that the right things are done and in the right way. There is increasing attention on who should be trained, and to what level of expertise. How many ERCPists are really needed? In earlier days, most gastroenterology trainees did some ERCP, and continued to dabble in practice. Now the focus is on ensuring that there is a smaller cadre of properly trained ERCPists with sufficient numbers to maintain and enhance their skills, and to be able to address the more complex cases. These issues come into clearest focus where the role of ERCP is still not firmly established, e.g. in the management of recurrent acute and chronic pancreatitis, and of possible sphincter of Oddi dysfunction. Such issues are being addressed by increasingly stringent research.