ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) 447

be administered as the papilla comes into view. Increments of these drugs are given intermittently as required. Electrocardiographic monitoring may be utilized if deemed necessary. With the patient lying in the left lateral position, the flexible endoscope (side-viewing duodenoscope) is passed with external controls while the patient is asked to swallow, and the scope is passed gently and smoothly to the upper body of the stomach. Here the stomach is insufflated with air until the incisura angularis and pyloric antrum are identified. When the pyloric canal is appropriately identified, the controls are managed so that the scope will flip into the duodenal bulb, and moderate insufflation is once again utilized. Gastroscopy and duodenos- copy should not be attempted at this time but perhaps reserved for after the primary procedure. With appropriate insufflation, and now with the patient prone, the scope is maneuvered into the second part of the duodenum and once again minimal insufflation is used. Hypotonicity is necessary, and more glucagon may be administered at this time, since the papilla is much more easily identified in the atonic duodenum. The papilla of Vater is usually situated about 1 to 3 cm below the minor papilla and the endoscopist must learn to recognize these structures, particularly in view of the considerable variation in papillary location and the course of the duodenum (Vennes). The actual maneuvers necessary for cannulation are outside the scope of this text, and the student is referred to Vennes for this purpose. When cannulation of the duct occurs, the cannula should be inserted just far enough so that it does not fall out during respiration or minor movement. A small quantity of contrast medium is injected under fluoroscopic control. One or both ducts may be filled with variable reflux at this time. Usually the procedure requires that an excellent visualization of the biliary tract be obtained on one occasion and a visualization of the pancreatic ductal system on another. Contrast medium is injected slowly under fluoroscopic control so that the cholangiogram is complete in the one instance and the pancreatic duct in the other. The patient is turned appropriately so that there is no obscuration by overlapping anatomic detail. Usually the pancreatic duct will be filled more readily than the common bile duct, and it should be largely emptied before cholangiography is begun. It should be recalled, however, that in about 80 per cent of patients the common bile duct and main pancreatic ducts have a common channel that is 1 to 15 mm in length. Moreover, the common bile duct is directed cephalad, whereas the pancreatic duct has a sinusoidal curvature directed toward the hilum of the spleen. Usually the common bile duct is above the main pancreatic duct, with a thin septum lying between them. As with all radiographic procedures a completely equipped emergency cart must be available so that cardiorespiratory emergencies can be immediately treated.

a focal spot that is 0.3 to 0.6 mm in size. Exposure time is kept as short as possible (0.10 second or less) to minimize motion. Kilovoltage is kept as low as possible (90 to 95 kilovolts) to enhance contrast. A radiographic table capable of being tilted for the upright to at least a 15-degree Trendelenburg position and padded for patient comfort is utilized. A television monitor is essential, so that both the radiologist and endoscopist observe each of the features of the procedure. As is customary with all contrast agent studies, preliminary films of the abdominal part are obtained to exclude the possibility of opaque materials or other obscuration in the area of interest. Since the fiberoptic bundles of the endoscope may be damaged by the radiation, the fluoroscopic image should be utilized very quickly, highly collimated, and only sufficiently to assist in positioning the endoscope and visualizing the injection. When the pancreatic duct is injected, the contrast agent first moves in a cephalad direction and usually then turns obliquely across the spine until the entire ductal system is visualized in the tail of the pancreas. The presence or absence of obstruction, filling defects, evidences of overinjection, or cystic ectasia of the branching ducts of the pancreatic duct must be quickly identified. Injection must be stopped immediately if overfilling occurs. Appropriate positioning of the patient is necessary to insure complete ductal filling, primarily by gravity if at all possible. First the patient is in the prone or the prone oblique position, and the pancreatic duct may be filled entirely in this position. In the presence of pancreatic calculi or other abnormalities the patient may be placed with the left side dependent or in the supine position so that gravity favors filling the tail of the pancreas. With regard to the cholangiogram, the anterior and posterior relationships of the bile ducts are best appreciated when seen laterally; since the water- soluble contrast medium is heavier than bile, the most dependent portions of the biliary tree are filled preferentially; and when the patient is in the prone position, the most dependent portions of the biliary tree are the left intrahepatic ductal system and proximal common hepatic duct. With the patient supine, the right intrahepatic ducts and distal common bile duct are most dependent.

RADIOGRAPHIC TECHNIQUE (Mossetai)

The radiographic unit should have high milliamperage and kilovoltage capacity and a radiographic tube with