ERCP—the first twenty years

GASTROINTESTINAL ENDOSCOPY Editor

BERNARD M. SCHUMAN, MD Associate Editors

CHARLES j. L1GHTDALE, MD STEPHEN E. SILVIS, MD Editorial Assistant

JOYCE M. CAMPBELL Editor Emeritus

WILLIAM S. HAUBRICH, MD Address all editorial correspondence to the Editor Department of Medicine (GI) Medical College of Georgia Augusta, Georgia 30912 Editorial Board

JOSEPH E. GEENEN, MD

Editorials Twenty years have passed since the landmark paper "Endoscopic Cannulation of the Ampulla of Vater: A Preliminary Report" appeared in the Annals of Surgery 1968, 167:752-6. The article is reprinted in part with the permission of the publishers, Lippincott/Harper & Row, Philadelphia, Pennsylvania. I asked Dr. McCune to provide us with his views of the important contributions that have been made in this field since his 1968 publication; his response is the editorial that follows. After World War II, during which he served as Chief of the general surgical section at Walter Reed Army Medical Center, Dr. McCune became Clinical Professor of Surgery at George Washington University School of Medicine, a position he held for 35 years. He is a Fellow of the American and Southern Surgical Associations and a member of the Society for Surgery of the Alimentary Tract. He is now enjoying retirement in Petoskey, Michigan. The Editor

Chairman

THOMAS DENT, MD KENNETH A. FORDE, MD LAWRENCE F. JOHNSON, MD

ERCP-the first twenty years

PAUL A. KANTROWITZ, MD MYRON LEWIS, MD JEROME H. SIEGEL, MD ROBERT G. STRICKLAND, MD SIDNEY j. WINAWER, MD International Editors

MEINHARD CLASSEN, MD Munich, Germany

MICHEL CREMER, MD Brussels, Belgium

L10NELLO GANDOLFI, MD Bologna, Italy

MOISES GUELRUD, MD Caracas, Venezuela

KEIICHI KAWAI, MD Kyoto, japan

ZDENEK MARATKA, MD Prague, Czechoslovakia

PAUL ROZEN, MD Tel-Aviv, Israel

GUIDO TYTGAT, MD Amsterdam, The Netherlands

CHRISTOPHER WILLIAMS, MD London, England

VOLUME 34, NO.3, 1988

In 1928, Baird,l an English scientist, described a revolutionary method for the transmission of light by which images could be projected over multifilamented cables around corners, and even around knots. It was not until 1957, however, that Hirschowitz and his coworkers 2 applied the "fiberoptics" principle to medicine and perfected the Hirschowitz gastroscope. This instrument was quickly accepted because of its maneuverability, and it was inevitable that the fiber tracts would be lengthened. When a track to house a cannula was added, an endoscope capable of visualizing and cannulating the ampulla of Vater resulted. The first endoscope long enough to visualize and cannulate the papilla was an experimental Eder instrument with the cannula strapped to its side. 3 When the feasibility of ERCP had finally been established, instrument makers began to provide better, more maneuverable scopes, and endoscopists learned the new technique. Many capable operators have since found this procedure extremely valuable in the diagnosis and treatment of diseases of the biliary tract and pancreas. Cholelithiasis and obstructive jaundice, in general, as well as strictures of the papilla of Vater, pancreatitis, and tumors of the bile ducts have all been more easily diagnosed and better understood since ERCP became an accepted procedure. The cost of the endoscopic approach must be balanced against that of prolonged hospitalization for surgery. In many cases removal of stones from the common duct by sphincterotomy has obviated the 277

need for operation, and although brief hospitalization may be necessary for ERCP, it will hardly compare in length with that needed for surgical exploration of the common duct. In 1978, 10 years after the introduction of ERCP, 1,000 endoscopic cannulations of the ampulla were reported from the Manhattan Veterans' Hospital with a 75% diagnostic success rate. 4 By dilation of the sphincter of Oddi or by sphincterotomy with a cautery wire, retained common duct stones were extracted in all six of the cases attempted, and the necessity for laparotomy was avoided. Visualization of the pancreatic drainage system is one of the outstanding achievements of ERCP because changes in the appearance of the pancreatic ducts are so important in the diagnosis of pancreatitis and pancreatic tumors. With this procedure the duct systems have been seen as never before and a diagnosis of carcinoma of the pancreas can be made in 80% of cases. Typically, carcinoma produces an invasive, space-occupying lesion that obstructs branch ducts at its periphery and the main duct within the tumor. In a group of 28 patients with idiopathic pancreatitis,5 endoscopic cholangiopancreatography was diagnostic in 21. Operative lesions were found in 15 of the patients and operative results were excellent. In the last 10 years a method for extracting large stones from the lower end of the common bile duct has been devised. 6 A technique for insertion of a nasobiliary catheter for perfusion of monooctanoin to dissolve retained stones has been developed. 7 In 1986, Riemann et al. 8 described a method of mechanical lithotripsy for the extraction of large stones not removable in a Dormia basket. In the treatment of malignant tumors involving the common duct, Venu et al. 9 reported the endoscopic placement of iridium 192 seeds in an inner tube into the tumor. Marbet et al. lO utilized endoscopic sphincterotomy to empty the distal common duct of debris after side-to-side anastomosis of the common duct to the duodenum in the treatment of the so-called "sump syndrome." In spite of its successes this procedure, like most invasive tests, is not free from complications. As recently as 1986, Saar et al. l l reported five patients that developed duodenal perforations and six clinically significant episodes of pancreatitis among 254 patients undergoing therapeutic endoscopic sphincterotomy and related procedures. Leese et al./ 2 in a group of 394 endoscopic sphincterotomies performed over a 6year period, reported early complications in 41 patients (10.4%); hemorrhage accounted for nearly half of them. Emergency surgery followed endoscopic sphincterotomy in 15 patients, and there were 13 deaths within 1 month (3.3%), three of which were directly attributable to sphincterotomy. The greatest progress in medicine is often made by use of procedures that at first carry considerable morbidity and even mortality, and it is not the purpose of this editorial to discourage the use of ERCP. Rather, 278

it is to encourage its employment by qualified endoscopists in ever-widening spheres of usefulness. Future possible applications are almost limitless. They include, among others, the endoscopic diagnosis of intrahepatic stones, the tissue diagnosis of malignant disease of the biliary and pancreatic ducts, the intraductal perfusion of drugs or chemotherapeutic agents, and the treatment of pancreatic cysts or inflammatory ductal strictures. The curtain has barely risen on an exciting field for endoscopic exploration. William S. McCune, MD Petoskey, Michigan

REFERENCES 1. Baird JL. An improved method of and means for producing optical images. Br Patent Specification 1928;285:738. 2. Hirschowitz BL, Curtis LE, Peters CW, Pollard HM. Demonstration of a new gastroscope, the "fiberscope." Gastroenterology 1958;35:50. 3. McCune WS, Shorb PE, Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report. Ann Surg 1968;167:752-6. 4. Zimmon DS. Endoscopic management of biliary calculi. Hosp Pract 1978;13:103. 5. Katon RM, Bilboa MK, Eidemiller LR, Benson JA Jr. Endoscopic retrograde cholangiopancreatography in diagnosis and management of nonalcoholic pancreatitis. Surg Gynecol Obstet 1978;147:333-8. 6. Witzel L, Hacki W, Halter F. Simple method for removal of gallstones after duodenoscopic sphincterotomy. N Engl J Med 1977;296:1536-7. 7. Witzel L, Wiederholt J, Wolbergs RE. Dissolution of retained duct stones by perfusion with monooctanoin via a Teflon catheter introduced endoscopically. Gastrointest Endosc 1981;27:63-5. 8. Rielliann JF, Seuberth K, Demling L. Mechanical lithotripsy of common bile duct stones. Gastrointest Endosc 1985;31:20710. 9. Venu RP, Geenen JE, Hogan WJ, Johnson GK, Klein K, Stone J. Intraluminal radiation therapy for biliary tract malignancyan endoscopic approach. Gastrointest Endosc 1987;33:236-8. 10. Marbet VA, Stalder GA, Faust H, Harder F, Gyr K. Endoscopic sphincterotomy and surgical approaches in the treatment of "sump syndrome." Gut 1987;28:142-5. 11. Saar MG, Fishman LK, Milligan FD, Siegelman SS, Cameron JL. Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation and management. Surgery 1986;100:461-6. 12. Leese T, Neoptolemos JP, Carr-Locke DL. Successes, failures, and early complications and their management: results in 394 consecutive patients from single center. Br J Surg 1985;72:2159.

Endoscopic Cannulation of the Ampulla of Vater: A Preliminary Report WILLIAM S. MCCUNE, M.D., PAUL

E.

SHORB, M.D., HERBERT

MOSCOVITZ, M.D.

From the Department of Surgery, The George Washington University School of Medicine, Washington, D. C.

IN SPITE of the rapid progress which has been made in the non-operative visualization of almost every organ of the body by the injection of radio-opaque materials, radio-isoGASTROINTESTINAL ENDOSCOPY