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SurgSpace

03 / Hepatobiliary Surgery · endoscopic

ERCP with sphincterotomy

Endoscopic drainage of the obstructed bile duct: cannulate the papilla, cut the sphincter, clear the stones, and in cholangitis, drainage beats everything else on the list.

Indication: Choledocholithiasis, ascending cholangitis, malignant obstruction for stenting; therapeutic, not diagnostic.

Part of Hepatobiliary Surgery →4 stages2 complications to knowendoscopic
Gallstones on ultrasound: the disease ERCP most often serves
Nevit Dilmen · CC BY-SA 3.0

Read the imaging first

Practice before you scrub

Read the gallbladder

Fatty-food pain for months, now constant for 18 hours with fever. RUQ ultrasound. (Fictional educational case.)

  • Stones plus an inflamed wall plus a tender probe is cholecystitis: the operation is laparoscopic cholecystectomy on this admission, not a deferred clinic date.
  • The duct's calibre on the same scan sequences the pathway: dilated means the duct is interrogated before the gallbladder leaves.
Practice this image View the anatomy

Stage

1 / 4

Reaching the papilla

A side-viewing duodenoscope is passed to the second part of the duodenum and the major papilla brought face-on.

Explore anatomy: The biliary tree & its variants

Watch for: Perforation from scope trauma, highest in altered anatomy

Why are we operating?

ERCP treats the biliary tree from inside: a side-viewing endoscope reaches the papilla, a wire cannulates the duct, and stones are extracted or strictures stented without an incision. It earned its place as therapy, not diagnosis, MRCP looks, ERCP acts, and its defining emergency role is decompressing the obstructed, infected duct of cholangitis.

Pulls toward surgery

Choledocholithiasis needing clearanceCholangitis needing urgent decompressionMalignant obstruction needing a stentBile leak needing sphincter depressurisation

Gives the team pause

Purely diagnostic intent (MRCP's job now)Post-ERCP pancreatitis as the signature riskAltered anatomy defeating the scopeCoagulopathy against sphincterotomy

Shared foundations

The obstructed, infected system

One rule underlies the specialty's emergencies and echoes across all of surgery: an obstructed system that becomes infected must be drained. Cholangitis is the reference example; the blocked kidney and the abscess follow the same law.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Reaching the papilla

    Why a side-viewing scope?

    The papilla sits on the duodenum's medial wall, facing sideways: a forward-viewing scope stares past it. The duodenoscope's side optics and elevator exist for exactly this one address, which is also why ERCP is its own craft rather than gastroscopy's extension.

  • Selective biliary cannulation

    Why is cannulation the step everyone talks about?

    Because selectivity is everything: the bile duct and pancreatic duct share the papilla, and every wire pass or contrast injection into the pancreatic duct raises the pancreatitis risk. Skilled cannulation is minimal, biliary and quick, and the discipline includes counting attempts and knowing when to stop.

  • Sphincterotomy and clearance

    What does cutting the sphincter actually buy?

    A permanently widened biliary exit: stones can be swept out with balloons and baskets, and future drainage improves. Its price is bleeding (a cut in a vessel-bearing mound) and perforation, which is why the cut is measured, oriented along the duct's axis, and respected.

  • Ensuring drainage

    The stones will not all come. Why is a stent still a success?

    Because drainage, not clearance, is what treats the pressurised infected system: a stent past the obstruction converts an emergency into a scheduled procedure. In cholangitis this is the entire point of the night, decompress now, perfect later.

Decision points

  • Cannulation is difficult: multiple attempts, one pancreatic wire pass. Continue, change technique, or stop?

    • Advanced techniques (double-wire, precut) by an expert

      Legitimate escalations with their own risk curves: the operator's experience is part of the indication.

    • Stop and return another way

      Pancreatitis risk climbs with attempts: a pancreatic stent, a planned re-attempt, or percutaneous drainage is a strategy, not a defeat.

    Post-ERCP pancreatitis is largely a complication of persistence: attempt counts, pancreatic-duct events and rectal NSAID prophylaxis are all part of modern practice, and the best endoscopists are defined as much by their stopping rules as their success rates.

  • Cholangitis at 02:00, the duct decompressed with a stent, stones remaining. When does definitive management happen?

    • Interval clearance and same-admission cholecystectomy

      The standard arc: cool the sepsis, clear the duct, and take the stone factory before discharge where fitness allows.

    • Stent as destination

      For the frail with limited reserve: permanent stenting is honest palliation of stone disease, with its exchange schedule owned.

    The emergency and the definitive plan are separate transactions: the night's job was pressure, the admission's job is the gallbladder and the duct, and conflating them, heroic clearance in a septic patient, is how simple cases become complicated ones.

Leaving the OR

The handoff

Procedure
ERCP, sphincterotomy, balloon trawl; 10 Fr stent for residual stones
Indication
Ascending cholangitis, decompressed; bile drained under pressure
Prophylaxis
Rectal NSAID given; cultures sent from bile
Watch for
Post-ERCP pancreatitis (new pain + amylase), sphincterotomy bleed, fever failing to settle

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. First hoursDefervescence in cholangitis is the procedure's report card: a settling fever says the pressure problem is solved.
  2. Evening / overnightNew epigastric pain earns amylase and attention: pancreatitis is the complication with the short window for honest recognition.
  3. POD 1-2Sphincterotomy bleeding can be delayed: melaena or a haemoglobin drop points back at the papilla.
  4. This admission / intervalThe definitive steps get diarised, duct clearance and cholecystectomy, so the stent is a bridge with a far bank, not a destination by default.

Watch it done

Find ERCP with sphincterotomy videos on YouTube

What can go wrong

Postoperative bleedingBile leak
Live this operation as a case →Live this operation as a case →OR Prep this operationReview the instruments