SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 52 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission If the operator uses terminology such as ‘quarter-bow’ or ‘half-bow’ feel free to ensure that everyone understands what it meant . The cut is extended as far as is deemed safe by the operator to prevent cutting into the duodenal wall itself, and to avoid blood vessels which are present. The limit of the cut is usually dictated by a small fold of duodenum at the end of the longitudinal ridge of bile duct seen in the duodenum, (or ‘infundibulum’) and shown with a green arrow above. If there has been a sphincterotomy already carried out on a previous occasion, and the opening needs to be widened further then balloon sphincteroplasty can be performed. This is where a dilatation balloon is inserted into the lower bile duct so that half is inside the duct and half is visible in the duodenum (see on right) and inflated to stretch the opening to a specified diameter. The balloon itself is passed alongside the guide wire and is the same balloon as is used for oesophageal dilatation (CRE balloons). It is helpful to inflate the balloon with a mixture of water and contrast (approx 3:1) so the size of the balloon can be seen on Xray images, as the diameter of the balloon must not exceed the width of the bile duct to prevent damaging it . Similarly the operator must ensure that a stone is not caught between the balloon and the wall of the bile duct, as this too can cause a perforation. Maximum sphincteroplasty diameter is 18mm and usually 12-15mm is enough. The balloon is held inflated in position for 60 seconds . This is to ensure that any small bleeding points have been tamponaded. This may be uncomfortable for the patient so sometimes a little more analgesia is given at this point, as it is important not to deflate the balloon too early. When the tissue is oedematous, the opening will tend to swell up again quite rapidly after sphincteroplasty, so if multiple large stones need to be removed, there is a need for a bit of haste. Please ensure the extraction balloon (or basket) is ready - the 60 second window is a good time to do this. CRE balloons come in different sizes and some are wire guided, and some are not; it doesn’t really matter which you use. The inflation devices may also differ subtly, so as with all things it’s best to know what equipment will be necessary before the procedure starts , and the operator should be able to predict what will be needed. 2 6