Endoscopic retrograde cholangiopancreatography (ERCP) is becoming more popular every year. Nurses and physicians have become proficient in the procedure as demand increases. But not everyone understands all the indications and contraindications for ERCP, as well as the special cleaning challenges this particular scope provides.
Indications
Since it is the least invasive procedure available to correct a number of problems in the hepatobiliary and pancreatic ducts, ERCPs are increasing in number and therapeutic capability annually, says J. Chris Swann, RN, clinical EndoTherapy specialist for Olympus America. “The first ERCP was performed in 1973 and has grown to an estimated 500,000 to 600,000 procedures annually in the United States,” Swann adds. “Most ERCPs are performed in a hospital setting for a variety of reasons. Since patients are often positioned either prone or supine, airway management is a concern, and many institutions utilize an anesthesiologist or nurse anesthetist for sedation and airway management. There is also the matter of fluoroscopy equipment and operators. Either a fluoroscopy table or C-arm unit is required. There should also be accessibility to a surgical suite and team if needed in case of complications such as excessive bleeding, perforation or an impacted stone retrieval device.”
The purpose of the ERCP is to promote drainage of pancreatic juice and bile, which has been blocked or impeded from a disease process, explains Teresa Soldiviero, RN, CRGN, clinical EndoTherapy specialist for Olympus America. However, she says, the indications for an ERCP are extensive and include the following:
- Evaluation of chronic pancreatitis
- Recurrent cholangitis
- Evaluation of possible cancer of the biliary tree and/or pancreas
- Choledocholithiasis (ductal stones)
- Removal of retained bile or pancreatic stones
- Pre- or post-operative cholecystectomy when ductal stones are suspected
- Chronic or acute abdominal pain when bile duct disease is suspected
- Suspected primary sclerosing cholangitis (PSC)
- Evaluation of abnormal biliary system findings from a CT, EUS or MRCP
- Obstructive jaundice
- Dilated CBD (common bile duct)
- Tissue sampling
- Biliary strictures
- Sphincter of Oddi dysfunction
- Palliative or pre-operative stenting of malignant biliary or pancreatic strictures
- Treatment of bile leaks
However, ERCP is not indicated for evaluating abdominal pain in the absence of symptoms, signs, or laboratory findings that suggest biliary tract or pancreatic disease, nor is it indicated for evaluating suspected gallbladder disease without evidence of bile duct disease, adds Kevin J. Kunkler, MD, vice president and medical director of Immersion Medical, Inc. Additionally, he says, ERCP has little value diagnostically when pancreatic cancer has already been demonstrated by ultrasound or CT.
Reprocessing
Reprocessing an ERCP scope — also called a duodenoscope — is slightly different from that of other endoscopes, Kunkler points out, adding, “The only aspect that is different between an ERCP scope and other endoscopes for the gastrointestinal tract is the elevator.”
Paul Garcia, product manager at Fujinon, Inc., says that special attention should be given to the elevator during both bedside cleaning and manual cleaning before disinfection. And, he stresses, “Users should follow the instructions provided with the particular scope being used.”
Jim Slattery, RN, CGRN, a staff nurse at the endoscopy center at Brigham and Women’s Hospital in Boston, Mass., agrees, adding, “The elevator housing on the scope tip is recessed and collects bioburden during use. Care must be taken to manually clean this housing prior to disinfection. The elevator is operated by a connecting wire that runs the length of the scope, through a channel. The channel must be irrigated with high pressure (by hand or by a high pressure attachment in the processing machine),” he says.
The elevator helps to facilitate device entry into the papilla and does come into contact with human excretions, Soldiviero points out. “If the scope has an auxiliary channel, it is exposed to the same excretions. Newer ERCP scopes do not have a separate channel for the elevator control wire. Like EGD and colonoscopy scopes, ERCP scopes should be pre-cleaned in the procedure room following the exam as per manufacturer’s recommendation. At this time, a special auxiliary cleaning adapter should be attached to the auxiliary wire channel and flushed with detergent using a 3 mL or 5 mL syringe followed by flushing with air,” she says.
When the ERCP scope is being processed during the manual cleaning phase, Soldiviero recommends several extra steps:
First, brush in front of and behind the elevator thoroughly, which is achieved by moving the elevator control up and down; second, thoroughly flush the auxiliary wire channel with detergent, clean water and air before disinfecting it manually or using an automated endoscope reprocessor (AER) or dual scope disinfector (DSD), she says.
“Whether an AER, DSD or manual disinfecting is being used to finalize the process, an auxiliary adapter must be attached to the scope for proper reprocessing of the auxiliary wire channel even if it was not used during the procedure,” she explains. “If this is not done, proper disinfecting of the auxiliary channel cannot be guaranteed. Also, when the ERCP scope is in this final stage, the elevator should be placed ‘half-way,’ in a position that is not entirely raised or lowered. Finally, on completion of the disinfecting stage, proper drying (including drying of the auxiliary wire channel) and storage of the scope should be met by following manufacturers’ recommendations. Besides contamination and the risk of passing on infectious diseases, if the elevator or auxiliary wire channel is not properly cleaned or disinfected, one may experience a clogged channel due to the buildup of excretions and radiographic dye. This can lead to not only a costly scope repair but also to the potential for a disease to be passed on.”
Training and Technical Challenges
It is very important that nurses understand the equipment and have knowledge of the special products used during an ERCP — for example, the rapid exchange system — observes Susan Sargent, RN, CGRN, a staff nurse at Saints Street Endoscopy in Lafayette, La.
There are three key areas of proficiency necessary for the ERCP assistant, adds Swann. “First, the assistant should have a good working knowledge of the anatomy of the hepatobiliary and pancreatic ductal systems and their appearance under fluoroscopy to help them clearly understand the goal of the procedure as it relates to each specific patient and condition. A patient with choledocholithiasis could require different instruments or devices than a patient with a stricture of the common bile duct. Basic technical skills include an understanding of the tools, such as sphincterotomes, balloons, stone retrieval baskets, lithotripters, manometry catheters, plastic stents, and metal stents. Included in technical skills is the ability to manipulate a guidewire within the devices used, and completing device exchange while leaving the guidewire in place,” Swann says.
Inventory is one of the biggest challenges, agrees Slattery. “Also, there are many steps in instrument exchanges. One of the more difficult techniques that the assistant nurse or tech may need to learn is instrument exchanges over a guidewire,” he adds.
One of the largest learning curves for any endoscopist involves using a side viewing scope such as the duodenoscope, rather than a straight (forward) viewing scope, says Kunkler. “Many novices feel uncomfortable inserting a tube without direct visualization,” he says. “There are aspects of the navigation that almost are entirely based on feel: intubating the upper esophageal sphincter or intubating the pylorus. The next most challenging aspect is the use of the elevator, which requires two additional axes of motion compared to regular scopes: up/down, and the bowing of the sphincterotome (from non-bowed to fully bowed). Cannulation of the major, and especially the minor, papilla is not easy at first.”
Lastly, ERCP uses fluoroscopy and contrast instillation, so one has to be careful of using too much radiation and instilling too much contrast into the ducts, especially the pancreatic duct, Kunkler observes.
To counteract these difficulties, medical simulators that replicate the sight, sound, and feel of ERCP are now being used for training. Immersion Medical offers the Endoscopy AccuTouch® System, which is designed to deliver realistic, procedure-based content for both cognitive and motor skills training. The system consists of a PC, an interface device with interchangeable anatomy, proxy endoscopes, and software modules for a wide range of training scenarios.
Contraindications
There are several contraindications to ERCP. The risk of sedation, Sargent says, is the biggest. “ERCPs are pretty much always done because they are indicated for conditions that need immediate attention and resolution,” she observes.
Other contraindications include a recent myocardial infarction and perforated viscus, says Kunkler. “The patient should not eat or drink for six hours before the procedure, to empty the stomach and duodenum. If the patient has recently ingested barium, an X-ray should be obtained to ensure that the barium is not superimposed on the areas of interest,” he adds.
Additionally, ERCP with IVCS is contraindicated in patients who cannot cooperate or are obstreperous. These patients may require deep sedation with an anesthesiologist, Slattery points out.
Relative contraindications are based on the patient’s needs vs. the patient’s current condition, says W. Mark McClure, RN, CGRN, clinical EndoTherapy specialist for Olympus America. “A patient may be clinically unstable due to an infection but would improve dramatically if the ERCP were performed to remove the stone that is obstructing his common bile duct and causing the infection in the first place. As with any procedure, there has to be a risk/benefit analysis for that particular patient,” he adds.
Technology
Scopes have advanced over the years, and every year sees new additions to the offers. For example, Olympus has developed the V-Scope. In this scope, Slattery says, the elevator is notched in a “V” configuration to aid in stabilization of the guidewire. Overall, he adds, “The resolution of all duodenoscopes has improved (Olympus, Fujinon, Pentax), and the latest ‘new’ tech for ERCP is the Spyglass system by Boston Scientific, which allows direct view of the bile ducts and direct access for target biopsies of biliary lesions.”
Fujinon recently introduced a new ERCP scope called ED-530XT with improved performance in several areas. A proprietary CCD chip, SuperCCD™, provides improved image quality, higher resolution, and improved optical alignment to the elevator, Garcia adds.
“The insertion tube was made slightly stiffer to aid insertion to the duodenum and positioning at the papilla in both long and short scope positions. A new video connector locking mechanism provides greater ease of use for the nurse or tech during set-up and reprocessing. New electronics in the light guide and video connector provide digital signal output from the scope to the processor,” he says.
ERCP is one of the most technical procedures in GI, and continues to expand in capability, says McClure. “The newest generation scopes have amazing images with wider angle of view and near high definition quality. With so many instruments that have very specific uses, it is imperative that nurses become more skilled to effectively assist the physician. ERCPs are very exciting and are only to become more exciting as innovation and technology reveal new techniques and practices to improve patient health,” he adds.
