SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 51 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission PA R T 3 : S P H I N C T E RO T OMY Sphincterotomy means ‘cutting the sphincter’. It is done by passing an electric current through a wire on the sphincterotome which passes into the body at the point that the wire touches the mucosa, and then dissipates through the body coming out at the pad that has been stuck on the patient. This is known as ‘monopolar diathermy’ - so a single (hence ‘mono’) point of contact with the body at the point of cutting. Purely out of interest, ’bipolar’ diathermy is where a specially designed device passes electricity through the area that needs to be cut from one part of the instrument to another (eg tweezers) and so no pad is required. Indications for sphincterotomy are: • to remove bile duct stones • to insert a stent (optional smaller sphincterotomy) • to take brushings (the brush won’t fit into a ‘virgin’ ampulla) • to gain access to the duct more easily The diathermy machine most used is the ERBE. I will not go through all the settings here but it’s important to familiarise yourself with this and ensure the correct setting is programmed. You will notice there are two coloured pedals: yellow for ‘cut’ and blue for ‘coagulation’ or coag. As you may expect, the coag function causes heat to be passed into tissue to cauterise it, and the cutting function slices through tissue. This can cause bleeding if done too quickly so in fact the yellow cutting pedal is a blend of both, and the ratio of cut to coag can be adjusted on the ERBE, although this is not usually necessary as the machine actually senses how much of each is needed. To carry out a sphincterotomy, the sphincterotome is slid along the guide wire which has been placed into the correct duct. It is manipulated into the right place (approximately the black stripe in the middle of the wire) and the direction of the cut is ascertained. The sphincterotome is bowed (see above - I prefer to do this myself, but if the operator asks you to do it, be aware that the more the sphincterotome is bowed, the more likely it is to distort, usually to the right on the screen, so bow it slowly a bit at a time until the operator is happy. 2 5