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Chapter 32 / Endoscopy in HPB Surgery Including ERCP and EUS 401
larger diameter (8 to 10mm as opposed to 7 to 10 Fr for plastic) and are thus
less likely to occlude prematurely (median patency rates of 6 to 9 months for
SEMS as compared to 3 months for plastic stents).
In patients with locally advanced or metastatic PDAC, the goals of
biliary drainage are palliation of symptoms and to permit systemic che-
motherapy with a normal or near-normal serum bilirubin. e treatment
of jaundice will undoubtedly relieve pruritus (if present) and may improve
other symptoms such as anorexia and indigestion. For cases of unresect-
able disease, an endoscopic approach is safer than is surgical bypass but
with reduced durability. Long-term patency of SEMS is superior to that
of plastic stents due to their larger diameter; SEMS should be placed in
patients having a life expectancy of greater than 3 months. e majority
of patients in the United States with potentially resectable periampul-
lary malignancy undergo preoperative biliary drainage despite a lack
of evidence that it reduces postoperative complications. is practice
may be explained in part by a delay in surgical consultation and concern
for higher risk of perioperative complications in the setting of jaundice.
Older studies suggest jaundice may be a predictor of postoperative infec-
tion and renal and nutritional complications. Experimental studies dem-
onstrate improved nutritional status and immune function and reduced
endotoxinemia after biliary decompression. Prospective studies evaluat-
ing the role of preoperative biliary drainage have excluded patients with
deep jaundice (serum total bilirubin ≥10 to 15 mg/dL), where the ben-
ets of drainage are expected to be the highest. Furthermore, the duration
between preoperative biliary drainage and surgery is often less than 4 weeks
despite evidence suggesting normalization of hepatocyte function after
6 weeks of decompression.
Treatment of Gastric Outlet Obstruction
Duodenal obstruction from pancreatic cancer typically is not present at
diagnosis but may develop in 15% to 20% of patients. To avoid this compli-
cation, many surgeons create a prophylactic palliative gastrojejunostomy
with a biliary bypass in those who are deemed to be unresectable at explo-
ration. Endoscopic placement of a self-expandable, gastroduodenal metal-
lic stent has lower morbidity compared to surgical gastrojejunostomy and
comparable short-term ecacy but lower long-term (>3 to 6 months) e-
cacy due to tumor ingrowth within the interstices of the stent. In a study
comparing patients who underwent surgical gastrojejunostomy with endo-
scopic stenting, patients who underwent endoscopic palliation had similar
median survival (94 vs. 92 days) but shorter hospitalization (4 vs. 14 days),
which led to overall lower cost ($9,921 vs. $28,173).
ERCP IN THE SETTING OF CHRONIC PANCREATITIS
ERCP has evolved from a diagnostic to a therapeutic tool for patients
with CP as a result of advances in magnetic resonance cholangiopancrea-
tography (MRCP), computed tomography (CT), and EUS. Pancreatic duc-
tal changes on ERCP can be classied by the Cambridge classication as
equivocal (type I), mild to moderate (type II), and severe (type III). e
classication has been shown to correlate with the severity of exocrine
insuciency. However, some patients with early CP have a normal pancrea-
togram. Achieving a denitive diagnosis in this population is challenging
and requires the incorporation of other imaging and pancreatic function
testing.
Pain from CP is probably multifactorial, although one suggested mech-
anism is pancreatic ductal hypertension due to pancreatic duct obstruction
Section IV / Multidisciplinary HPB Care402
from a stricture or stone. erapeutic ERCP can alleviate pain and recur-
rent pancreatitis ares with serial dilation of pancreatic duct strictures or
stone extraction. Similar to the treatment of benign bile duct strictures,
pancreatic duct strictures are managed with serial dilation and placement
of one or more plastic stents until the stricture is obliterated. is usually
requires three or more ERCPs occurring every 2 to 4 months for up to 1 year.
Pancreatic stones are more easily removed if they are small, few in number,
closer to the head of the pancreas, and not impacted. For either stricture
or stone management, a pancreatic sphincterotomy is usually required.
Stones upstream to the tail from a pancreatic duct stricture require stric-
ture dilation before extraction. Other options for stone removal include
direct pancreatoscopy, electrohydraulic lithotripsy, and extracorporeal
shock wave lithotripsy (ESWL). Notably, ESWL alone may be as eec-
tive as ESWL combined with ERCP for therapy of pancreatic duct stones.
Although studies have shown endoscopic therapy may improve pain, in CP,
the short- and long-term ecacy of endoscopic treatment are inferior to
surgical interventions aimed at relieving obstruction and achieving pain
relief.
ERCP IN THE SETTING OF ACUTE PANCREATITIS
e role of ERCP in the early management of patients with acute pancre-
atitis is limited. In patients with gallstone pancreatitis, urgent ERCP (to be
performed within 72 hours of presentation) is indicated only in the setting
of concomitant acute cholangitis or severe acute pancreatitis with biliary
obstruction. e benets of early ERCP remain controversial. One meta-
analysis concluded early ERCP reduced complications but not mortality
in severe biliary pancreatitis and had no benet in mild pancreatitis. Two
other meta-analyses found no benet in morbidity or mortality from early
ERCP in biliary pancreatitis.
For all patients with suspected gallstone pancreatitis, those having a
high risk for common bile duct (CBD) stones should undergo CBD imaging
prior to discharge. High suspicion would include the presence of stones or
ductal dilation on cross-sectional imaging or persistent elevation in chole-
static labs (alkaline phosphatase, direct bilirubin). Patients at intermedi-
ate risk should undergo less invasive imaging of their extrahepatic biliary
tree in lieu of diagnostic ERCP, including EUS or MRCP. For stones less than
4mm, EUS is more sensitive, specic, and cost-eective than is MRCP. If
EUS or MRCP conrms the presence of choledocholithiasis, ERCP should
be performed soon thereafter.
e role of ERCP with sphincter of Oddi manometry in patients with
idiopathic, recurrent acute pancreatitis requires clarication. A recent
prospective randomized clinical trial suggested no incremental benet
of pancreatic sphincterotomy over biliary sphincterotomy alone in this
population. e benet of empiric biliary sphincterotomy is debatable and
also requires further investigation. Individually, or in combination, MRCP
and EUS have largely replaced ERCP in diagnosing less common causes of
recurrent acute pancreatitis, including pancreas divisum, intraductal papil-
lary mucinous neoplasm, and ampullary lesions, among others.
ENDOSCOPY IN THE SETTING OF PANCREATIC FLUID COLLECTIONS
Pancreatic duct disruption and uid collections may occur in the setting
of acute or CP. In properly selected cases, endoscopy can obviate the need
for percutaneous drains and surgery by promoting internal drainage. A
pseudocyst is an organized uid collection, consisting of pancreatic juice
Chapter 32 / Endoscopy in HPB Surgery Including ERCP and EUS 403
enclosed by a nonepithelialized tissue. Many pseudocysts can be managed
without intervention (even if over 6 cm) unless they enlarge or become
symptomatic. Traditional surgical drainage of pseudocyst carries a 10%
morbidity rate and 1% mortality; therefore, radiologic and endoscopic
drainage compete with surgery as rst-line treatment. Endoscopic drain-
age can involve either transpapillary or transmural (transgastric, transduo-
denal) placement of stents. A transpapillary approach is used for smaller
pseudocysts communicating with the main pancreatic duct, whereas larger
pseudocysts or those not clearly communicating with the pancreatic duct
are drained transmurally. Pseudocyst drainage is usually performed after
allowing the cyst wall to mature for at least 4 to 6 weeks after the onset of
acute pancreatitis.
Transpapillary Drainage
Ongoing pancreatic duct disruption may heal in 78% to 92% of cases with
stent placement across the disruption. Success rates plummet to 23%
to 44% with transpapillary stents that do not bridge the leak (Fig. 32.3).
Technical success may be lower for tail disruptions and denitely in the set-
ting of complete pancreatic duct disruption.
FIGURE 32.3 Severe CP with low-grade stula. A 45-year-old woman with severe alcohol-
induced CP presented with abdominal pain and pancreatic ascites. ERCP conrmed the
presence of a low-grade leak from the pancreatic head (arrow) with severe CP changes
in the main pancreatic duct and its side branches. The leak resolved following pancreatic
sphincterotomy and placement of a 7-Fr plastic pancreatic duct stent.
Section IV / Multidisciplinary HPB Care404
Transmural Drainage
e goal of transmural drainage is to create an internal communication
between the pseudocyst and the gastric or duodenal lumen. Traditionally,
endoscopic cystogastrostomy involved piercing an endoscopically visible
bulge using a needle knife catheter and electrocautery. e risk of bleeding
is reduced from 15.7% to 4.6% if a Seldinger technique (advancing a guide-
wire through a 19-gauge needle) is used. After obtaining access to the cyst
cavity, the opening is balloon dilated, and several pigtail stents are placed.
Cyst localization by EUS facilitates drainage, particularly in the setting of
a pseudocyst that is not causing an endoscopically visible bulge; EUS has
a higher technical success and lower morbidity versus a non-EUS–guided
approach. In addition, EUS can determine if the distance between cyst and
GI tract is ideal, identify intervening blood vessels, and quantify the volume
of necrotic debris within the cyst.
Necrotic debris within a pseudocyst often necessitates débridement:
Endoscopically, this entails entering the cavity with an endoscope and
removing necrotic debris using a variety of instruments. A retrospective study
suggested that, for patients with walled-o pancreatic necrosis (WOPN),
endoscopic necrosectomy was superior to endoscopic cystogastrostomy
alone for resolution of necrosis, decreased need for adjunctive surgical or per-
cutaneous drainage, and recurrence. A step-up approach was recently com-
pared to open necrosectomy as rst-line treatment for patients with proven
or suspected infected WOPN. Patients were randomized to primary open
necrosectomy and continuous postoperative lavage or to a step-up approach
(percutaneous/endoscopic drainage and if no clinical improvement repeat
drainage followed by video-assisted retroperitoneal debridement (VARD)
followed by open necrosectomy). Another recent trial compared endoscopic
necrosectomy to VARD and open surgery in the treatment of infected WOPN.
Pancreatic necrosis should ideally be addressed in the context of a multidis-
ciplinary team including pancreatic surgeons and endoscopists.
ERCP FOR THE MANAGEMENT OF POSTOPERATIVE COMPLICATIONS
e most common postoperative biliary strictures occur following liver
transplant and, less commonly, cholecystectomy. In general, the manage-
ment of benign bile duct strictures involves serial dilation using graduated
increasing size of balloons, followed by the placement of multiple plastic
stents in parallel to keep the stricture patent. For strictures involving the com-
mon hepatic duct, short-term success rates are generally greater than 90%
and have reasonable durability, with recurrence rates of approximately 10%.
Bile duct strictures occurring after liver transplant have an incidence of
4% to 16% and can be classied as anastomotic or nonanastomotic. Most anas-
tomotic strictures occur within 12 months of liver transplant. ose occurring
within 6 months of surgery respond well to endoscopic balloon dilation and
short-term (3 to 12 months) plastic stenting. Patients presenting greater than
6 months postoperatively require multiple endoscopic procedures to serially
dilate and upsize the number/maximum diameter of stents. Superior resolu-
tion rates are observed with higher total number of stents placed. In patients
with Roux-en-Y choledochojejunostomy, PTC is usually preferred to ERC since
patients require multiple procedures for serial dilation and endoscopic access
to the biliary anastomosis is challenging with Roux-en-Y anatomy.
ENDOSCOPIC ULTRASOUND
EUS for Tissue Sampling
EUS plays an important role in tissue diagnosis to conrm the presence
of pancreatic cancer and rule out metastatic lesions to the pancreas
Chapter 32 / Endoscopy in HPB Surgery Including ERCP and EUS 405
(11% in one study) or surrounding structures and to diagnose nonmalignant
processes such as autoimmune or CP. In general, EUS–FNA is the most
accurate diagnostic modality with sensitivity 80% to 95% and specicity of
100% compared to CT or transabdominal ultrasound–guided FNA (sensi-
tivity 62% to 81%). In the setting of CP, sensitivity of EUS decreases to 73%.
EUS–FNA is also more accurate than is CT or magnetic resonance imaging
at detecting pancreatic masses ≤1.5cm. e needle tract for EUS–FNA of
pancreatic head lesions lies within the surgical resection margin and thus
has a lower risk of tumor seeding. is is not the case with lesions of pan-
creatic body and tail, but to date, no data denitively show EUS–FNA nega-
tively impacts the likelihood of complete surgical resection or postoperative
recurrence. A decision to perform an EUS–FNA of a pancreatic mass should
be made in conjunction with a hepato-pancreatic-biliary (HPB) surgeon: If
the patient is a surgical candidate and the pretest probability of cancer is
greater than 90%, direct referral to surgery is also reasonable.
EUS for Staging
e accuracy of EUS for locoregional staging of pancreatic malignancy is
operator dependent. A prospective clinical trial demonstrated EUS had
no incremental value over contrast-enhanced CT scan in determining the
resectability of a pancreatic mass. A recent review of studies comparing EUS
and CT for preoperative staging of pancreatic cancer determined that it is
unclear which modality is superior for both tumor and nodal staging, though
this is less likely to impact on surgical management. A recent meta-analysis
evaluating the accuracy of individual EUS criteria for vascular invasion had
73% sensitivity and 90% specicity.
EUS for Pancreatobiliary Drainage
e technical success of deep biliary cannulation by skilled endoscopists
during ERCP is greater than 90%. e development of EUS-guided ante-
grade cholangiopancreatography refers to two dierent approaches to
pancreatic drainage: EUS rendezvous or direct EUS intervention. ese
techniques have recently emerged as salvage methods for failed biliary
cannulation, although their utilization is only available in selected centers.
During rendezvous, EUS is used to access the bile duct transgastrically using
a 19-gauge or 22-gauge FNA needle. A guidewire is then advanced through
the needle and into the duodenum, followed by exchange of the echoen-
doscope for a duodenoscope to complete the ERCP procedure. Successful
drainage occurred in 56% of patients in a recent cohort. Direct intervention
via EUS involves creating an enterobiliary or enteropancreatic stula. Here,
EUS is again used to direct an FNA needle into the bile or pancreatic duct
and advancing a guidewire across the obstructing lesion. Instead of switch-
ing to a duodenoscope and completing the procedure via ERCP, passage or
balloon dilation of the EUS needle track is performed followed by deploying
a stent directly. In one report, this technique had a 71% success rate but a
16% complication rate, including self-limited pneumoperitoneum and mild
to severe pancreatitis. ese techniques remain experimental and should
not be performed in routine practice. However, advances in EUS-based
devices are expected to expand the role of EUS-based therapy in the future.
EUS for Palliation of Pain
e celiac plexus is one of several purported locations mediating pain
from the pancreas. Celiac plexus neurolysis (CPN) utilizes ethanol injec-
tion to ablate the celiac plexus in cases of refractory abdominal pain due to
pancreatic cancer, whereas a celiac plexus block (CPB) involves the injec-
tion of a local anesthetic with or without steroid to achieve a temporary
Section IV / Multidisciplinary HPB Care406
(3 to 6 month) block in patients with CP. CPN or CPB can be achieved via
surgical and transcutaneous approaches with small but potentially sig-
nicant morbidity. EUS-guided CPN/CPB is technically feasible given the
plexus location adjacent to the celiac artery takeo from the descending
aorta. While the celiac artery origin is easily identied during EUS, celiac
ganglia are only visualized in a minority of cases (Fig. 32.4). For patients
undergoing celiac block, a recent trial suggested the addition of triamcino-
lone did not increase the proportion of patients who reported signicant
pain relief or reduce self-reported pain scores compared to injection of a
local anesthetic alone.
A recent meta-analysis suggests that EUS–CPN is safe and eective for
patients with pancreatic cancer and CP. In pancreatic cancer, nearly 80% of
patients experience pain relief after EUS–CPN; pain reduction lasts approx-
imately 20 weeks. Early consideration (i.e., during the initial diagnostic pro-
cedure in select patients) for EUS–CPN should be made in patients with
unresectable PDAC with abdominal pain requiring opioids, as it is associ-
ated with less pain and opioid requirements. In CP, the response rate and
durability are lower with EUS–CPB, with 55% of individuals having a sig-
nicant response rate initially but only 10% reporting a sustained response
after 24 weeks.
ERCP IN THE SETTING OF POSTOPERATIVE ANATOMY
ERCP for patients with postoperative anatomy (i.e., status post pancreato-
duodenectomy, Roux-en-Y gastrojejunostomy, antrectomy with Billroth I/II
reconstruction) is challenging. e optimal therapeutic approach (endo-
scopic, percutaneous, surgical, or some combination) remains unclear
but probably relates to a combination of the indication for ERCP (biliary
FIGURE 32.4 EUS-guided CPB. An EUS–FNA needle can be inserted into a celiac ganglion,
typically located anterior to the celiac artery takeoff from the aorta. Factors associated
with a better response to CPB include direct injection of celiac ganglia (when visualized)
and absence of tumor invasion of the celiac plexus. (Reproduced from Coté GA, Sherman S.
Endoscopic palliation of pancreatic cancer. Cancer J 2012;18(6):584–590.)
Chapter 32 / Endoscopy in HPB Surgery Including ERCP and EUS 407
or pancreatic and the overall urgency for the procedure), specic anatomy
(length of Roux limb), and patient preference. For patients who have under-
gone Roux-en-Y gastric bypass for weight loss, endoscopy obviates the
need for percutaneous catheters but has a lower technical success rate. If
an endoscopic approach is recommended, patients with bariatric-length
Roux limbs who require pancreatic duct therapies (e.g., sphincter of Oddi
dysfunction, pancreatic duct stones, or strictures) should undergo surgical
placement of a large-bore (≥30 Fr) gastrostomy tube into the gastric rem-
nant to facilitate ERCP access. On the other hand, based on limited data,
patients requiring short-term bile duct therapy (e.g., CBD stones) may be
approached endoscopically (i.e., double balloon enteroscopy) if the antici-
pated success rate is greater than 80%.
For patients with a native papilla and short (≤30cm) Roux limb, a
transoral approach using a duodenoscope can be attempted but is often
unsuccessful. Alternatively, a colonoscope or small bowel enteroscope may
be used to perform ERCP, but the number of ERCP accessories is limited
by the longer length of these scopes. For patients with a native papilla and
long Roux limb, surgical gastrostomy–assisted ERCP has higher success
rates than has deep enteroscopy (balloon-assisted, spiral enteroscopy) but
with higher morbidity (primarily related to complications from the surgical
gastrostomy tube). For patients without a native papilla (i.e., bilioenteric/
pancreatoenteric anastomosis) and a short Roux limb, a forward-viewing
colonoscope or enteroscope can be used successfully in most cases.
CONCLUSION
Pancreatobiliary endoscopy represents an important component of the
diagnostic and therapeutic management of patients with pancreatobi-
liary disease. Ideally, the majority of patients will be served by a multi-
disciplinary approach early in their disease course, combining the expert
opinions of abdominal radiology, medical oncology, and gastroenterology
with hepatobiliary–pancreatic surgery. A collegial working relationship
between pancreatobiliary endoscopists and their surgical colleagues is
critical since patients often require interventions from both disciplines. To
that end, surgeons should recognize the potential benets and limitations
of pancreatobiliary endoscopy.
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409
Injuries to the liver, extrahepatic biliary tree, and pancreas are often deadly
and always challenging. is area is also commonly referred to as the “sur-
gical soul.” ey will engage all of your senses, test your skills, and demand
great teamwork from you and your colleagues.
HEPATIC INJURIES
Although textbooks are often lled with a complex hierarchy of operative
interventions and maneuvers for treating hepatic trauma, the vast majority
of liver injuries are treated nonoperatively. is process involves diagnosis
with cross-sectional imaging (CT), serial clinical observation, and labora-
tory (hemoglobin, white blood cell count [WBC], and liver function tests/
enzymes) monitoring. is algorithm allows the clinician to successfully
treat and predict both the initial injury and potential complications such as
delayed/ongoing hemorrhage and interval formation of a biloma. Clearly,
any patient who presents with hypotension and/or peritonitis (i.e., concur-
rent injuries) requires emergent operative therapy.
Management
Preoperative Considerations
e dominant challenge with hepatic trauma is management of the hemo-
dynamically unstable patient with ongoing hemorrhage from a high-grade
liver injury. ese patients often present in physiologic extremis and therefore
require damage control resuscitation techniques. Early recognition of their crit-
ical condition, as well as imme diate hemorrhage control, is essential to survival.
Patients with major injury caused by blunt trauma or right upper
quadrant penetrating mechanisms must undergo an immediate F.A.S.T.
(i.e., Focused Assessment with Sonography for Trauma) examination in the
trauma bay to conrm the presence of large-volume intraperitoneal uid.
is exam is repeatable and can be used to reevaluate patients in urban cen-
ters who present immediately following their injuries. Massive transfusion
protocols as part of a damage control resuscitation must be initiated early
during the patient assessment process. If the patients rapidly stabilize their
hemodynamics, they should undergo an emergency CT scan of the torso
(blunt and gunshot). If they remain clinically unstable, however, patients
must be transferred to the operating theater without delay. Hemorrhage con-
trol is the dominant driver in these patients. Collateral issues such as optimal
intravenous access, imaging of other areas (brain, spine, bones), and fracture
xation are important but, nevertheless, secondary priorities. In summary :
1. In hemodynamically stable patients without CT evidence of a hepatic
arterial blush or other reasons to proceed to the operating theater,
admission and close observation are warranted.
HPB Trauma
Chad G. Ball
33
Section IV / Multidisciplinary HPB Care410
2. In hemodynamically stable patients with a hepatic arterial extravasa-
tion/blush, immediate transfer to the interventional angiography suite
(or hybrid O.R.) is mandated for hepatic angiography and/or portography
with selective embolization. Autologous clot or absorbable embolization
medium is optimal.
3. In patients with persistent hemodynamic instability, immediate transfer
to the operating theater for laparotomy is essential. Delays will lead to
loss of life.
Operative Care and Technical Tips
e patient should be rapidly prepared and draped with available access
from the neck to the knees. Vascular instruments and balloons must be
open and ready within the theater. A midline laparotomy from xiphoid
process to pubic bone should be performed with three passes of a sharp
scalpel. e peritoneal cavity should be packed in its entirety with laparot-
omy sponges for patients with blunt liver injuries. e falciform ligament
should be left intact to provide a medial wall against which to improve
medial packing pressure. e right upper quadrant (and midline vascular
structures) should be evaluated prior to any intraperitoneal packing for
penetrating injuries. If hemorrhage continues, an early Pringle maneuver
(clamping of the porta hepatis with a vascular clamp) is mandated. is is
both diagnostic and potentially therapeutic. If bleeding continues despite
application of a Pringle clamp, a retrohepatic inferior vena cava (IVC) or
hepatic venous injury is likely. Critically injured patients in physiologic
extremis do not tolerate extended Pringle maneuvers to the same extent
as patients with hepatic tumors undergoing elective hepatic resection.
Forty minutes represents the upper limit of viability. If the liver hemor-
rhage responds to packing (which describes the vast majority of cases
85% to 99% depending on the series) but continues to hemorrhage when
unpacking is completed, the patient should be repacked and transferred
to the ICU with an open abdomen once damage control of concurrent
injuries is complete. Cover the liver with a plastic layer of sterile x-ray cas-
sette material to avoid capsular trauma upon eventual unpacking. Topical
hemostatic agents are also helpful. If control of the liver hemorrhage is
dependent on maintenance of a Pringle maneuver despite packing (i.e.,
the retrohepatic IVC hematoma has ruptured), call for senior assistance,
mobilize the right lobe, and suture the IVC or hepatic veins with 4-0
Prolene on SH needles or 5-0 Prolene on RB1 needles (assuming that a
replaced left hepatic artery is not the source of inow occlusion failure).
ese patients may also require total vascular exclusion (TVE) of the liver
(complete occlusion of the infrahepatic IVC, suprahepatic IVC, porta
hepatis (Pringle maneuver), as well as an aortic cross-clamp within the
abdomen). If TVE is pursued without concurrent clamping of the aorta,
the patient will arrest due to a lack of coronary perfusion. I prefer to obtain
suprahepatic IVC control within the abdomen in patients with a normal
length of IVC inferior to the diaphragm. An alternate option includes
access of the IVC within the pericardium itself (i.e., as it enters the heart).
is 2-cm length of IVC is easily accessible by opening the pericardial sac
after dividing the diaphragm. Alternatively, the suprahepatic IVC can also
be accessed from the thorax if a thoracotomy has already been performed.
Veno–veno bypass is also a theoretical option but rarely used due to a lack
of transplant training for most trauma/general surgeons.
In the case of central hepatic gunshot wounds or deep central lac-
erations where access and exposure are dicult, ongoing hemorrhage
should be stopped with balloon occlusion. Either a Blakemore esophageal
balloon or variant (red rubber catheter with overlying Penrose drain and