ERCP and Gallstone Removal

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Endoscopic retrograde cholangio-pancreatography (ERCP) is often considered one of the most technically challenging procedures for an endoscopy nurse. The procedure, which involves passing an endoscope through the mouth, down the esophagus, through the stomach and into the duodenum, allows doctors to diagnose and remove gallstones in the bile duct in a single procedure. It is simultaneously diagnostic and therapeutic.

While the procedure is often required following a laparoscopic cholecystectomy, this is not always the case. If a patient has gallstones in the gallbladder, he or she will often have them in the common duct, but it is also possible that there are stones in the duct and none in the gallbladder. In these instances, ERCP will be the first therapeutic procedure required.

Because of the level of expertise involved in ERCP and the wide range of equipment options, understanding the procedure and which instruments to use in a given situation is crucial. This is particularly important considering ERCP has a high instance of complications compared to other endoscopic procedures, including pancreatitis, bleeding, infection, and perforation.

While the role of the nurse in an ERCP varies by location, Jeff Barnett, MD, associate director of the Medical Procedures Unit at the University of Michigan, says all nurses should have an understanding of the procedure beyond simply monitoring the patient and handling instruments.

"A one-on-one relationship [between the doctor and the nurse] is possibly more important with ERCP than with any other endoscopic procedure," Barnett says. "The doctor and the nurse really have to learn to work together. A lot of doctors want a nurse to work with them who is really experienced with the procedure."

Most nurses are not exposed to ERCP on a regular basis, which can make gaining proficiency a challenge. Tammy Muncrief, an RN at Citizen's Medical Center in Victoria, Texas, says even though a nurse is constantly under a doctor's direction, he or she needs to have a firm knowledge of the instruments.

"ERCP is probably the hardest procedure for a nurse to learn and actually feel comfortable with, mainly because you have them few and far between, so you don't become familiar with them as quickly," she says. "You have to have an overview of everything to be able to do it. You can't be good in one area and bad in another."

At Citizen's Medical Center, a team of three nurses assists the doctor performing the ERCP. Typically one of the three is responsible for the instruments. It is this nurse's job to assist in instrument selection, ensure instruments are in working order and assist in manipulation of instruments such as guide wires and cannulas.

Instruments

Once the gallstones have been identified, doctors will typically elect to either capture the stones using a basket, or push the stones down into the duodenum with a retrieval, or occlusion, balloon.

Baskets are available in a number of different shapes and sizes. Mike Mangano, global product manager for pancreatic biliary instruments at Boston Scientific, says the four-wire basket is the most common, but facilities will have a variety of sizes and styles available. When selecting an instrument, Mangano says a number of factors are important to consider, including the size of the stone, its location within the duct, dilation of the duct, the patient's anatomy, and the doctor's preference.

Muncrief says nurses at Citizen's Medical Center keep at least two of each size of instrument on hand. Anything that is used during ERCP is circled on the instrument chart and replaced immediately following the procedure. When choosing instruments, Muncrief says the nurses typically look for anything that makes the procedure easier and faster, so the patient does not need to be sedated any longer than necessary.

Mangano says nurses need to make themselves specialists, spending more time understanding the instruments and how they are used in the procedure.

"Most nurses just go and get [an instrument] instead of understanding why that device is being used," he says. "They need to understand the mechanics, the anatomy, and the devices themselves and how the devices specifically function. That is probably the most important part for an ERCP nurse."

Advancements are always in the workings when it comes to ERCP equipment. Mangano says baskets and occlusion balloons improve every year.

Muncrief says the most recent ERCP advancement at her endoscopy unit is the use of rapid exchange, which locks the guide wire into place. Companies are continually looking for ways to simplify the procedure through instrumentation, she adds, as it is fairly difficult to perform.

A number of developments have been made recently in mechanical lithotriptors used to crush stones, according to Barnett. A few institutions are also working with shock wave catheters that fit through the scope and can be used to pulverize the stones in the bile duct.

Researchers are currently looking at the possibility of combining ERCP and endoscopic ultrasound. Barnett says the ultrasound would allow doctors to locate the stone without injecting dye, which he says can increase the risk of pancreatitis. ERCP would then be used to retrieve the stone. He expects it will be at least 5 years before this becomes common practice.

Whenever a new instrument is introduced in a facility, Muncreif says representatives from the medical instrument company will provide presentations and make themselves available to medical staff as cases arise until all are comfortable with the device. Nurses new to ERCP observe several procedures before participating, and Muncrief says two endoscopy RNs are required to be present for all ERCPs.

Nurses interested in becoming proficient in ERCP should focus on both the diagnostic and therapeutic procedures, as it is counterproductive to understand one and not the other.

Overall, ERCP is often considered a safe and successful procedure for diagnosing and treating problems in the bile and pancreatic ducts and, in many cases, is completed without complication. Perhaps the biggest benefit is that patients who undergo therapeutic ERCP avoid the need for major abdominal surgery. Nurses taking an active role in furthering their knowledge of the equipment associated with ERCP will help lower the instance of complication and promote a complementary relationship between doctors and nurses for this challenging procedure.

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