SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 49 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission which will take time. A trainee can expect to cannulate successfully 80% of the time after they have completed around 200 procedures, so the learning curve is a long one. As mentioned already, the pancreatic duct (PD)and the common bile duct(CBD) converge at the ampulla and at times the instruments pass preferentially into the PD. It is important not to inject contrast up into the pancreatic duct if at all possible as this is thought to increase the chances of pancreatitis occurring. For this reason the wire is advanced and at the same time an Xray picture is taken before any contrast is injected in case the cannula is in the PD. Remember this image? If the wire is seen to cross the endoscope, then it must be in the CBD. If it crosses the vertebrae, it must be in the PD. Sometimes the wire enters the PD and cannot be manipulated into the CBD. In this case I like to employ a dual wire technique where I will leave the wire in the PD (ensuring it is in the main duct - it will appear fairly straight - rather than bunched up in a side branch) and lock it in place on the left side of the COOK locking device. This holds the PD opening in place and out of the way, so that cannulation can be attempted using the same sphincterotome, but loaded with a second wire. The first wire acts as a splint and also a guide on the Xray images. If successful, then the first wire (in the PD) can be removed immediately. If the procedure is taking time, and especially if contrast has been injected up the PD, then a stent is placed to allow the contrast and pancreatic juices to drain freely. 2 3 CBD PD