Third Edition
Edited by
Peter B. Cotton, MD, FRCP, FRCS
Digestive Disease Center
Medical University of South Carolina
Charleston, SC, USA
Joseph W. Leung, MD, FRCP, FACP, MACG, FASGE
Department of Gastroenterology and Hepatology
University of California Davis School of Medicine
Sacramento, CA, USA;
Section of Gastroenterology
VA Northern California Health Care System
GI Unit, Sacramento VAMC
Mather, CA, USA
This edition first published 2020
© 2020 John Wiley & Sons Ltd
Edition History
Wiley‐Blackwell (2e, 2015)
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Library of Congress Cataloging‐in‐Publication Data
Names: Cotton, Peter B., editor. | Leung, J. W. C., editor.
Title: ERCP : the fundamentals / [edited by] Peter B. Cotton, MD FRCP FRCS, Professor of Medicine, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, Joseph W. Leung, MD FRCP FACP MACG FASGE, Mr. & Mrs. C.W. Law Professor of Medicine, Department of Gastroenterology and Hepatology, University of California, Davis School of Medicine, Chief, Section of Gastroenterology, VA Northern California Health Care System, GI Unit, Sacramento VAMC Mather, California.
Description: Third edition. | Hoboken, NJ : Wiley‐Blackwell, 2020. | Includes index.
Identifiers: LCCN 2020010927 (print) | LCCN 2020010928 (ebook) | ISBN 9781119601098 (hardback) | ISBN 9781119601067 (adobe pdf) | ISBN 9781119601081 (epub)
Subjects: LCSH: Endoscopic retrograde cholangiopancreatography. | Gastroscopy.
Classification: LCC RC847.5.E53 A38 2020 (print) | LCC RC847.5.E53 (ebook) | DDC 616.36/07572–dc23
LC record available at https://lccn.loc.gov/2020010927
LC ebook record available at https://lccn.loc.gov/2020010928
Cover Design: Wiley
Cover Image: Courtesy of Joseph W. Leung
Lars Aabakken, MD, PhD, BC
Professor of Medicine
Chief of Gastrointestinal Endoscopy
Oslo University Hospital, Rikshospitalet
Oslo, Norway
Majid A. Almadi, MB, BS, MSc, FRC
Division of Gastroenterology
King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
Alan Barkun, MD, CM, MSc, FRCPC
Division of Gastroenterology
Montreal General Hospital, McGill University
Montreal, Quebec, Canada
Todd H. Baron, MD, FASGE
Director of Advanced Therapeutic Endoscopy
Professor of Medicine
Division of Gastroenterology & Hepatology
University of North Carolina
Chapel Hill, NC, USA
Catherine Bauer, RNBS, MSN, MBA, CGRN, CFER
Director of Digestive Health
University of Virginia Medical Center
Charlottesville, VA, USA;
Society of Gastroenterology Nurses and Associate President 2018–2019
Benjamin L. Bick, MD
Indiana University School of Medicine
Indianapolis, IN, USA
Michael Bourke, MD, PhD
Clinical Professor of Medicine
University of Sydney
Sydney;
Director of Gastrointestinal Endoscopy
Westmead Hospital
Westmead, Australia
Gregory A. Coté, MD, MS
Professor of Medicine
Medical University of South Carolina
Charleston, SC, USA
Peter B. Cotton, MD, FRCP, FRCS
Professor of Medicine
Digestive Disease Center
Medical University of South Carolina
Charleston, SC, USA
John T. Cunningham, MD
Professor Emeritus of Medicine
Section of Gastroenterology and Hepatology
University of Arizona School of Medicine
Tucson, AZ, USA
B. Joseph Elmunzer, MD, MSc
The Peter B. Cotton Endowed Chair in Endoscopic Innovation
Professor of Medicine and Endoscopic Innovation
Division or Gastroenterology and Hepatology
Medical University of South Carolina
Charleston, SC, USA
Evan L. Fogel, MD
Indiana University School of Medicine
Indianapolis, IN, USA
Erin Forster, MD, MPH
Department of Medicine
Division of Gastroenterology and Hepatology
Medical University of South Carolina
Charleston, SC, USA
Andres Gelrud, MD, MMSc
Gastro Health and Miami Cancer Institute
Miami, FL, USA
Moises Guelrud, MD
Gastro Health and Miami Cancer Institute
Miami, FL, USA
Sundeep Lakhtakia, MD, DM
Asian Institute of Gastroenterology
Hyderabad, India
John G. Lee, MD
H. H. Chao Comprehensive Digestive Disease Center
University of California at Irvine Medical Center, Irvine, CA, USA
Joseph W. Leung, MD, FRCP, FACP, MACG, FASGE
Emeritus Professor of Medicine
Department of Gastroenterology and Hepatology
University of California Davis School of Medicine
Sacramento, CA;
Chief of Gastroenterology
Section of Gastroenterology
VA Northern California Health Care System
GI Unit, Sacramento VAMC
Mather, CA, USA
Wei‐Chih Liao, MD, PhD
Associate Professor
Department of Internal Medicine
National Taiwan University Hospital
National Taiwan University College of Medicine
Taipei, Taiwan
Phyllis Malpas, MA, RN, CGRN
Digestive Disease Center
Medical University of South Carolina Charleston, SC, USA
Derrick Martin, FRCR, FRCP, Mb, CHb
Radiology Department
Wythenshawe Hospital
Manchester, UK
Robert A. Moran, MD
Medical University of South Carolina
Charleston, SC, USA
Zaheer Nabi, MD, DNB Gastroenterology
Consultant Gastroenterologist
Asian Institute of Gastroenterology
Hyderabad, India
D. Nageshwar Reddy, MD, DM, DSc, FRCP
Chairman and Chief of Gastroenterology
Asian Institute of Gastroenterology
Hyderabad, India
Stuart Ashley Roberts, MD
Radiology Department
University Hospital of Wales
Cardiff, UK
Joseph Romagnuolo, MD, MSc, FRCPC
Department of Medicine
Division of Gastroenterology and Hepatology
Medical University of South Carolina
Charleston, SC, USA
Stuart Sherman, MD
Indiana University School of Medicine
Indianapolis, IN, USA
Paul R. Tarnasky, MD
Digestive Health Associates of Texas
Program Director Gastroenterology
Methodist Dallas Medical Center
Dallas, TX, USA
Shyam Varadarajulu, MD
Center for Interventional Endoscopy
Florida Hospital
Orlando, FL, USA
John J. Vargo, II, MD, MPH
Cleveland Clinic
Cleveland, OH, USA
Hsiu‐Po Wang, MD
Department of Internal Medicine
National Taiwan University Hospital
National Taiwan University College of Medicine
Taipei, Taiwan
Andrew Yen, MD, FACG, FASGE
Chief of Endoscopy and Associate Chief of Gastroenterology
Section of Gastroenterology
VA Northern California Health Care System
GI Unit, Sacramento VAMC
Mather, CA, USA
Attempts at endoscopic cannulation of the papilla of Vater were first reported in 1968. However, the method was put on the map shortly afterward 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 and 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 endoscopic ultrasound [EUS]‐guided cannulation) and improvements in safety (e.g. pancreatic stents, nonsteroidal anti‐inflammatory drugs [NSAIDs], anesthesia, and carbon dioxide [CO2]).
Other important changes in ERCP practice have been driven by improvements in radiology and surgery and the increasing focus on quality.
Imaging modalities for the biliary tree and pancreas have proliferated. High‐quality ultrasound, computed tomography (CT), EUS, and magnetic resonance scanning (with magnetic resonance cholangiopancreatography [MRCP]) have greatly facilitated the noninvasive 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.
There has been substantial and progressive reduction in the risks associated with surgery as a result of 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 and not only when ERCP is unsuccessful.
Another relevant development in this field is the increased participation of patients in decisions about their care. Patients are right in demanding information about their potential interventionists and the likely benefits, risks, and limitations of all of the possible approaches to their problems.
The term ERCP 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,” because 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? Previously, 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.
This is the third edition of this book devoted to ERCP. The first, Advanced Digestive Endoscopy: ERCP was published on gastrohep.com in 2002 and printed by Blackwell in 2006 and again in 2015. This edition owes much to its predecessors, but the title ERCP: The Fundamentals emphasizes our attempt to provide core information for trainees and practitioners, rather than a scholarly review of the (now) massive literature. Note that we have largely separated the technical aspects (how it can be done) from the clinical aspects, to allow the authors of the latter chapters to review the complex questions of when they might be done (and when best not).
We greatly appreciate the efforts of all the contributors and look forward to constructive feedback.