Endoscopic retrograde cholangiopancreatography: Current practice and future research

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Keywords: Cholangiopancreatography, Endoscopic retrograde, Cholangioscopy, Cannulation, Endoscopic ultrasound, Disposable duodenoscopes

Core Tip: Disposable duodenoscopes present a way to eliminate transmission of drug resistant infections. Access to single operator cholangioscopy and panreatoscopy has made complex intraductal assessment and therapy more ubiquitous. Future research will clarify the role of endoscopic ultrasound bile duct access for variant anatomy or failed endoscopic retrograde cholangiopancreatography (ERCP), photodynamic therapy, and indomethacin and pancreas duct (PD) stents in post ERCP pancreatitis prophylaxis.