Procedure shortens hospital stays for patients with duct blockages

By BOB MASSEY

Feeling Fit Correspondent

At one time, having a gall stone get stuck in a bile duct was an ordeal.

"In the old days, they used to do the open laparotomy," said Port Charlotte internist and gastroenterologist Sovi Joseph, MD.

And that was serious, as he explained: "They had to make a big incision, take out the gall bladder. Then they had to open the bile duct and take out the stone. But you open the bile duct, and you had to leave it drain from there for a few weeks and then go back and pull it out. And then it would take another week of staying in the hospital."

In the late 1970s, a technique known as endoscopic retrograde cholangiopancreatography (ERCP) changed all that.

Yes, the name is a mouthful. And speaking of mouth -- that also happens to be how the procedure it performed. But that's for later. For now, let's look at what ERCP is and why it's used.

Inside job

ERCP is used to treat problems of bile or pancreatic ducts, which are used to transport fluids that break down food. The procedure works by combining upper gastrointestinal endoscopy -- using a thin, flexible, lighted fiber-optic scope -- with traditional x-ray techniques.

According to James Amontree, MD, a Port Charlotte gastroenterologist specializing in digestive and liver disorders, ERCP can be used for several reasons:

•Evaluating people who have obstruction of bile or pancreas ducts.

•Tumors or cysts in pancreas.

•Suspected infection coming from the bile duct.

•Suspected billiary leak -- leakage of bile -- following gall bladder surgery, as a surgical complication.

•Evaluation of unexplained recurrent pancreatitis.

•Treatment of chronic pancreatitis, in some cases.

ERCP requires a physician trained in endoscopy to insert the endoscope through your mouth, esophagus and stomach until it reaches its destination in the small intestine. If the thought of this makes you gag, the procedure itself may, too. That's why an anesthetic is first sprayed into the throat to prevent discomfort -- and to desensitize the gag reflex. However, gagging, nausea and a bloated feeling may occur. (For some patients, the most uncomfortable feeling is the prick of the IV through which a sedative is sometimes administered.)

Once the endoscope reaches the trouble area, the physician releases a dye through the scope, to provide contrast for the x-rays.

Using an x-ray video camera, called a fluoroscope, the physician can treat any narrowed areas or blockages. He or she can open blocked ducts, remove or break up gallstones, remove tumors or insert stents (bridges that allow liquids to flow between one place and another).

However unpleasant the procedure might seem, it's a far cry from the "old days," as Joseph suggested in the case with a blocked bile duct.

A complicated choice

"If we do it with ERCP and go in and pull out the stone, then we can do the gall bladder procedure laparoscopically," he explained. "It's a one-day thing. Something which needed hospitalization for a week or longer -- and having a long, big incision with a risk of getting an infection or a hernia later -- is brought down to one day of hospital for the laparoscopic procedure, and no drains, no tubes. That's the best situation."

But there is a caveat. While technology hasn't changed ERCP since its inception, it has changed the way it's used.

ERCP is used today as a therapeutic tool -- to treat a condition -- rather than a diagnostic one, which is just to find out what's wrong.

"Nowadays with good CT scans and MRIs, we don't need to do much ERCP to make a diagnosis," Joseph said, "because you pretty much know the problem from the other tests. Years ago when I started out, most of the ERCPs were diagnostic. Now there are good, easier, less invasive techniques to diagnose problems."

And that's a good thing -- because ERCP should usually be a "last resort" option.

"It's a relatively common procedure -- but it's one of the most complicated endoscopic procedures around," Amontree said, "and it has got a lot of risks involved. It's probably the riskiest thing gastroenterologists do, as far as procedures go. It's something that shouldn't be done without great thought. If you're going to have one done, you've got to make sure it's the best way to proceed with your problem."

For more information, contact Joseph at 941-258-9500 or Amontree at 941-764-6664.