ERCP 3rd Edition Todd H Baron

Visit to download the full and correct content document:

https://textbookfull.com/product/ercp-3rd-edition-todd-h-baron/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

ERCP the fundamentals 3rd Edition Peter B. Cotton

https://textbookfull.com/product/ercp-the-fundamentals-3rd-
edition-peter-b-cotton/

Oncologic Emergency Medicine Principles and Practice

2nd Edition Knox H. Todd

https://textbookfull.com/product/oncologic-emergency-medicine-
principles-and-practice-2nd-edition-knox-h-todd/

Introduction to Econometrics 3rd Edition James H. Stock

https://textbookfull.com/product/introduction-to-
econometrics-3rd-edition-james-h-stock/

LANGE Pharmacology Flashcards Suzanne Baron

https://textbookfull.com/product/lange-pharmacology-flashcards-
suzanne-baron/
The new public health 3rd Edition Theodore H Tulchinsky

https://textbookfull.com/product/the-new-public-health-3rd-
edition-theodore-h-tulchinsky/

Non Conventional Energy Resources 3rd Edition B H Khan

https://textbookfull.com/product/non-conventional-energy-
resources-3rd-edition-b-h-khan/

Oncologic Emergency Medicine Principles and Practice

Knox H Todd Editor Charles R Thomas Jr Editor Kumar
Alagappan Editor

https://textbookfull.com/product/oncologic-emergency-medicine-
principles-and-practice-knox-h-todd-editor-charles-r-thomas-jr-
editor-kumar-alagappan-editor/

The Handbook of Groundwater Engineering 3rd Edition

John H. Cushman

https://textbookfull.com/product/the-handbook-of-groundwater-
engineering-3rd-edition-john-h-cushman/

Mass Spectrometry A Textbook 3rd Edition Jürgen H Gross

(Auth.)

https://textbookfull.com/product/mass-spectrometry-a-
textbook-3rd-edition-jurgen-h-gross-auth/
Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.

Expert Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.

Unlock your eBook today.

1 Visit expertconsult.inkling.com/redeem Scan this QR code to redeem your
eBook through your mobile device:
2 Scratch off your code
3 Type code into “Enter Code” box

4 Click “Redeem”
5 Log in or Sign up
6 Go to “My Library”
Place Peel Off
It’s that easy! Sticker Here

For technical assistance:

email expertconsult.help@elsevier.com
call 1-800-401-9962 (inside the US)
call +1-314-447-8200 (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on
expertconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book,
at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means.
2015v1.0
ERCP
This page intentionally left blank
ERCP
Third Edition

Todd H. Baron, MD, FASGE

Professor of Medicine
Division of Gastroenterology and Hepatology
University of North Carolina School of Medicine
Chapel Hill, North Carolina

Richard A. Kozarek, MD, FASGE

Executive Director
Digestive Disease Institute
Department of Gastroenterology
Virginia Mason Medical Center
Seattle, Washington

David L. Carr-Locke, MD, FRCP, FASGE, FACG

Clinical Director
Center for Advanced Digestive Care
Division of Gastroenterology and Hepatology
Weill Cornell Medicine
Cornell University
New York, New York
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

ERCP: THIRD EDITION ISBN: 978-0-323-48109-0

Copyright © 2019 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the Publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods, they should be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence, or otherwise or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2013 and 2008.

ISBN: 978-0-323-48109-0

Content Strategist: Nancy Anastasi Duffy

Senior Content Development Specialist: Ann Anderson
Publishing Services Manager: Catherine Albright Jackson
Senior Project Manager: Doug Turner
Designer: Brian Salisbury

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 The third edition of ERCP is dedicated to our patients… as well as to our
families, who have endured our long days at work only to watch in
exasperation as we spent our evenings and weekends finessing verbiage, adding
images and references, and cajoling tardy chapter authors: it’s finally your turn!
At least until we plan the fourth edition.
CONTRIBUTORS

Douglas G. Adler, MD, FACG, AGAF, João Guilherme Guerra de Andrade Brian C. Brauer, MD
FASGE Lima Cabral, MD Associate Professor of Medicine
Professor of Medicine Endoscopist University of Colorado School of Medicine
Director of Therapeutic Endoscopy Advanced Endoscopy Unit Aurora, Colorado
Director of GI Fellowship Program A.C. Camargo Cancer Center
Gastroenterology and Hepatology São Paulo, Brazil William R. Brugge, MD
University of Utah School of Medicine Professor of Medicine
Huntsman Cancer Center John Baillie, MD Harvard Medical School
Salt Lake City, Utah Professor of Medicine Director of Gastrointestinal Unit
Chief of Endoscopy Pancreas Biliary Center
Sushil K. Ahlawat, MD, FACP, FASGE, Virginia Commonwealth University School Massachusetts General Hospital
AGAF of Medicine Boston, Massachusetts
Associate Professor of Medicine Richmond, Virginia
Director of Endoscopy Jonathan M. Buscaglia, MD
Program Director, Gastroenterology and Rupa Banerjee, MD, DTM Associate Professor and Division Chief
Hepatology Fellowship Consultant Gastroenterologist Gastroenterology and Hepatology
Program Director, Advanced Endoscopy Asian Institute of Gastroenterology Stony Brook University School of Medicine
Fellowship Hyderabad, India Stony Brook, New York
Division of Gastroenterology and
Hepatology Todd H. Baron, MD, FASGE David L. Carr-Locke, MD, FRCP, FASGE,
Rutgers New Jersey Medical School Professor of Medicine FACG
Newark, New Jersey Division of Gastroenterology and Clinical Director
Hepatology Center for Advanced Digestive Care
Jawad Ahmad, MD, FRCP, FAASLD University of North Carolina School of Division of Gastroenterology and
Professor of Medicine Medicine Hepatology
Division of Liver Diseases Chapel Hill, North Carolina Weill Cornell Medicine
Icahn School of Medicine at Mount Sinai Cornell University
New York, New York Omer Basar, MD New York, New York
Gastrointestinal Unit
Firas H. Al-Kawas, MD Pancreas Biliary Center Prabhleen Chahal, MD
Professor of Medicine Massachusetts General Hospital Physician
Division of Gastroenterology and Boston, Massachusetts Department of Gastroenterology and
Hepatology Professor of Medicine Hepatology
Johns Hopkins University Department of Gastroenterology Cleveland Clinic
Baltimore, Maryland Hacettepe University Medical School Cleveland, Ohio
Director of Johns Hopkins Endoscopy Ankara, Turkey
Program Sujievvan Chandran, MBBS, FRACP
Sibley Memorial Hospital Petros C. Benias, MD Therapeutic Endoscopy Fellow
Washington, District of Columbia Director of Endoscopic Surgery Gastroenterology
Division of Gastroenterology St. Michaels’s Hospital
Michelle A. Anderson, MD Northwell Health System Toronto, Ontario, Canada
Associate Professor of Medicine Hofstra Zucker School of Medicine
Taubman Center Manhasset, New York Yen-I Chen, MD
University of Michigan Assistant Professor of Medicine
Ann Arbor, Michigan Ivo Boškoski, MD, PhD Division of Gastroenterology and
Digestive Endoscopy Unit Hepatology
Everson Luiz de Almeida Artifon, MD, Cattolic University of Rome McGill University Health Center
PhD, FASGE Rome, Italy Montreal, Quebec, Canada
Coordinator of Pancreatic Biliary
Endoscopy Unit Michael J. Bourke, MBBS, FRACP Anthony J. Choi, MD
GI Endoscopy Service Clinical Professor of Medicine Resident Physician
Hospital de Clinicas of the University of Sao Director of Endoscopy Department of Medicine
Paulo Gastroenterology and Hepatology Weill Cornell Medicine
Associate Professor of Surgery Westmead Hospital Cornell University
University of Sao Paulo Sydney, Australia New York, New York
Sao Paulo, Brazil

vi
 CONTRIBUTORS vii

Jonah Cohen, MD Douglas O. Faigel, MD, FACG, FASGE, Michael Gluck, MD

Clinical Fellow in Advanced Endoscopy
Division of Gastroenterology
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Guido Costamagna, MD, FACG
Digestive Endoscopy Unit
Catholic University
Gemelli University Hospital
Rome, Italy
Chair of Digestive Endoscopy
USIAS Strasbourg University
Strasbourg, France
Gregory A. Coté, MD
Associate Professor of Medicine
Division of Gastroenterology and
Hepatology
Department of Medicine
Medical University of South Carolina
Charleston, South Carolina
Peter Cotton, MD, FRCS, FRCP
Professor of Medicine
Digestive Disease Center
Medical University of South Carolina
Charleston, South Carolina
Koushik K. Das, MD
Assistant Professor of Medicine
Division of Gastroenterology
Washington University School of Medicine
St. Louis, Missouri
Jacques Devière, MD, PhD
Professor of Medicine
Head
Department of Gastroenterology,
Hepatology, and Digestive Oncology
CUB Erasme
Université Libre de Bruxelles
Brussels, Belgium
Steven A. Edmundowicz, MD
Professor of Medicine
University of Colorado School of Medicine
Aurora, Colorado
Ihab I. El Hajj, MD, MPH
Assistant Professor of Medicine
Division of Gastroenterology and
Hepatology
Indiana University
Indianapolis, Indiana
AGAF Past Chief of Medicine
Professor of Medicine Department of Gastroenterology
Department of Gastroenterology and Virginia Mason Medical Center
Hepatology Seattle, Washington
Mayo Clinic
Scottsdale, Arizona Khean-Lee Goh, MBBS, FRCP, MD
Professor
Pietro Familiari, MD, PhD Gastroenterology and Medicine
Fondazione Policlinico Gemelli University of Malaya
Digestive Endoscopy Unit Kuala Lumpur, Malaysia
Rome, Italy
Robert H. Hawes
Paul Fockens, MD, PhD, FASGE Professor of Medicine
Professor and Chair University of Central Florida College of
Gastroenterology and Hepatology Medicine
Academic Medical Center Medical Director
Amsterdam, Netherland Florida Hospital Institute for Minimally
Invasive Therapy
Evan L. Fogel, MD Center for Interventional Endoscopy
Professor of Medicine Florida Hospital Orlando
Division of Gastroenterology and Orlando, Florida
Hepatology
Indiana University School of Medicine Jennifer T. Higa, MD
Indianapolis, Indiana Advanced Endoscopy Fellow
Department of Gastroenterology
Victor L. Fox, MD Virginia Mason Medical Center
Associate Professor of Pediatrics Seattle, Washington
Harvard Medical School
Director of GI Procedure and Endoscopy Jordan D. Holmes, MD
Unit Gastroenterologist
Division of Gastroenterology, Hepatology, Iowa Digestive Disease Center
and Nutrition Clive, Iowa
Boston Children’s Hospital
Boston, Massachusetts Shayan Irani, MBBS, MD
Department of Gastroenterology
Martin L. Freeman, MD Virginia Mason Medical Center
Professor of Medicine Seattle, Washington
Division of Gastroenterology, Hepatology,
and Nutrition Takao Itoi, MD, PhD, FASGE, FACG
University of Minnesota Professor and Chair
Minneapolis, Minnesota Department of Gastroenterology and
Hepatology
S. Ian Gan, MD Tokyo Medical University
Department of Gastroenterology Tokyo, Japan
Virginia Mason Medical Center
Seattle, Washington Priya A. Jamidar, MD
Professor of Medicine
Andres Gelrud, MD, MMSc, FASGE Director of Endoscopy
Director Section of Digestive Diseases
Pancreatic Disease Center Yale University
Miami Cancer Institute New Haven, Connecticut
Miami, Florida
Michel Kahaleh, MD
Gregory G. Ginsberg, MD Professor of Medicine
Professor of Medicine Division of Gastroenterology and
Department of Medicine Hepatology
Division of Gastroenterology Department of Medicine
Hospital of the University of Pennsylvania Weill Cornell Medicine
Philadelphia, Pennsylvania Cornell University
New York, New York
viii CONTRIBUTORS

Anthony N. Kalloo, MD James Y.W. Lau, MD Michael X. Ma, MBBS, FRACP

The Moses and Helen Golden Paulson Chairman and Yao Ling Sun Professor of Advanced Endoscopy Fellow
Professor of Gastroenterology Surgery Gastroenterology and Hepatology
Director of Division of Gastroenterology The Chinese University of Hong Kong Westmead Hospital
and Hepatology Shatin, Hong Kong, China Sydney, Australia
The Johns Hopkins Hospital
Baltimore, Maryland Ryan Law, DO John T. Maple, DO
Clinical Lecturer Associate Professor of Medicine
Mouen A. Khashab, MD Division of Gastroenterology Division of Digestive Diseases and Nutrition
Director of Therapeutic Endoscopy University of Michigan University of Oklahoma
Associate Professor of Medicine Ann Arbor, Michigan Oklahoma City, Oklahoma
Department of Gastroenterology and
Hepatology Glen Lehman, MD Alberto Mariani, MD
The Johns Hopkins Hospital Professor of Medicine Pancreato-Biliary Endoscopy and
Baltimore, Maryland Division of Gastroenterology Endosonography Division
Department of Medicine Pancreas Translational and Clinical Research
Michael L. Kochman, MD Indiana University Center
Wilmott Family Professor of Medicine Indianapolis, Indiana San Raffaele Scientific Institute
Division of Gastroenterology Vita Salute San Raffaele University
Department of Medicine Joseph W. Leung, MD, FRCP, FACP, Via Olgettina
Perelman School of Medicine MACG, FASGE Milan, Italy
University of Pennsylvania Mr. and Mrs. C.W. Law Professor of
Philadelphia, Pennsylvania Medicine Gary May, MD, FRCPC, FASGE
Division of Gastroenterology and Division of Gastroenterology
Tadashi Kodama, MD, PhD Hepatology Department of Medicine
Advisor University of California Davis School of The Center of Advanced Therapeutic
Department of Gastroenterology Medicine Endoscopy and Endoscopic Oncology
Iwasaki Hospital Sacramento, California St. Michael’s Hospital
Mitoyo City, Kagawa, Japan Section Chief of Gastroenterology University of Toronto Faculty of Medicine
Veterans Affairs Northern California Health Toronto, Ontario, Canada
Andrew Korman, MD Care System
Division of Gastroenterology and Mather, California Lee McHenry, MD
Hepatology Professor of Medicine
Saint Peter’s University Hospital Dario Ligresti, MD Division of Gastroenterology
New Brunswick, New Jersey Endoscopy Service Department of Medicine
Department of Diagnostic and Therapeutic Indiana University
Paul Kortan, MD, FRCPC, FASGE, AGAF Services Indianapolis, Indiana
Department of Medicine IRCCS ISMETT (Instituto Mediterraneo per
St. Michael’s Hospital i Trapianti e Terapie ad Alta Meir Mizrahi, MD
University of Toronto Specializzazione) Director of Advanced Endoscopy
Toronto, Ontario, Canada Palermo, Italy Internal Medicine
Division of Gastroenterology
Tatsuya Koshitani, MD, PhD Eugene Lin, MD University of South Alabama College of
Director of Department of Gastroenterology Attending Radiologist Medicine
Japan Community Healthcare Organization Virginia Mason Medical Center Mobile, Alabama
Kobe Central Hospital Seattle, Washington
Kobe City, Hyogo, Japan Rawad Mounzer, MD
Simon K. Lo, MD, FACP Assistant Professor of Medicine
Richard A. Kozarek, MD, FASGE Director of Endoscopy Digestive Institute
Executive Director Head of Pancreatic Diseases Program Banner-University Medical Center
Digestive Disease Institute Division of Digestive Diseases and University of Arizona
Department of Gastroenterology Hepatology Phoenix, Arizona
Virginia Mason Medical Center Cedars-Sinai Medical Center
Seattle, Washington Clinical Professor of Medicine Thiruvengadam Muniraj, MD, PhD,
David Geffen School of Medicine at UCLA MRCP(UK)
Michael Larsen, MD Los Angeles, California Assistant Professor of Medicine
Gastroenterologist Director of Yale Center for Pancreatitis
Digestive Disease Institute Section of Digestive Diseases
Virginia Mason Medical Center Yale University School of Medicine
Seattle, Washington New Haven, Connecticut
 CONTRIBUTORS ix

Horst Neuhaus, MD Andrew S. Ross, MD Ajaypal Singh, MD

Professor of Medicine
Chief of the Department of Internal
Medicine
Evangelisches Krankenhaus Düsseldorf
Düsseldorf, Germany
Ian D. Norton, MBBS, PhD
Associate Professor
Department of Gastroenterology
Royal North Shore Hospital
Sydney, Australia
Section Head of Gastroenterology
Medical Director
Therapeutic Endoscopy Center of Excellence
Virginia Mason Medical Center
Seattle, Washington
Alexander M. Sarkisian, MD
Resident Physician
Internal Medicine
Tulane University School of Medicine
New Orleans, Louisiana
Director of Advanced Endoscopy
Rush University Medical Center
Chicago, Illinois
Adam Slivka, MD, PhD
Professor of Medicine
Associate Chief of Clinical Services
Division of Gastroenterology, Hepatology,
and Nutrition
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

Manuel Perez-Miranda, MD, PhD Beth Schueler, PhD Sanjeev Solomon, MD

Head of Gastroenterology and Hepatology Professor of Medical Physics Howard University Hospital
Hospital Universitario Rio Hortega Department of Radiology Washington, District of Columbia
Associate Professor of Medicine Mayo Clinic
Valladolid University Medical School Rochester, Minnesota Tae Jun Song, MD, PhD
Valladolid, Spain Associate Professor
Dong Wan Seo, MD, PhD Gastroenterology
Bret T. Petersen, MD Professor University of Ulsan College of Medicine
Professor of Medicine Gastroenterology Asan Medical Center
Department of Gastroenterology and University of Ulsan College of Medicine Seoul, South Korea
Hepatology Asan Medical Center
Mayo Clinic Seoul, South Korea Indu Srinivasan, MD
Rochester, Minnesota Advanced Endoscopy Fellow
Raj J. Shah, MD, FASGE, AGAF Maricopa Integrated Health System
Douglas Pleskow, MD Professor of Medicine Chandler, Arizona
Associate Clinical Professor Division of Gastroenterology
Department of Medicine University of Colorado School of Medicine Joseph J.Y. Sung, MD, PhD
Harvard Medical School Director of Pancreaticobiliary Endoscopy President and Vice Chancellor
Chief of Clinical Gastroenterology Division of Gastroenterology Mok Hing Yiu Professor of Medicine
Beth Israel Deaconess Medical Center University of Colorado Anschutz Medical The Chinese University of Hong Kong
Boston, Massachusetts Campus Shatin, Hong Kong, China
Aurora, Colorado
Tugrul Purnak, MD Ilaria Tarantino, MD
Associate Professor of Medicine Reem Z. Sharaiha, MD, MSc Endoscopy Service
Gastroenterology and Hepatology Assistant Professor of Medicine Department of Diagnostic and Therapeutic
Hacettepe University Medical School Division of Gastroenterology and Services
Ankara, Turkey Hepatology IRCCS ISMETT (Instituto Mediterraneo per
Weill Cornell Medicine i Trapianti e Terapie ad Alta
G. Venkat Rao, MS, MAMS, FRCS Cornell University Specializzazione)
Director and Chief of Gastrointestinal and New York City, New York Palermo, Italy
Minimally Invasive Surgery
Asian Institute of Gastroenterology Stuart Sherman, MD Paul R. Tarnasky, MD
Hyderabad, India Professor of Medicine and Radiology Physician
Glen Lehman Professor in Gastroenterology Methodist Dallas Medical Center
Anthony Razzak, MD Division of Gastroenterology and Dallas, Texas
Gastroenterologist Hepatology
Oregon Clinic Indiana University Pier Alberto Testoni, MD, FASGE
Portland, Oregon Indianapolis, Indiana Director of Division of Gastroenterology
and GI Endoscopy
D. Nageshwar Reddy, MBBS, MD, DM Chan Sup Shim, MD, PhD, FASGE, San Raffaele Scientific Institute
Director and Chief Gastroenterologist AGAF Vita Salute San Raffaele University
Asian Institute of Gastroenterology Professor Via Olgettina
Hyderabad, India Department of Gastroenterology Milan, Italy
Kunkuk University Medical Center
Seoul, South Korea
x CONTRIBUTORS
Catherine D. Tobin, MD
Associate Professor of Anesthesiology
Department of Anesthesia
Medical University of South Carolina
Charleston, South Carolina
Mark Topazian, MD
Professor of Medicine
Department of Gastroenterology and
Hepatology
Mayo Clinic
Rochester, Minnesota
Sachin Wani, MD
Associate Professor of Medicine
Division of Gastroenterology and
Hepatology
University of Colorado Anschutz Medical
Campus
Aurora, Colorado
John C.T. Wong, MD
Clinical Professional Consultant
Institute of Digestive Disease
The Chinese University of Hong Kong
Shatin, Hong Kong, China
Andrew W. Yen, MD, MAS, FACG, FASGE
Associate Chief of Gastroenterology
Veterans Affairs Northern California Health
Care System
Mather, California
Assistant Clinical Professor of Medicine
Division of Gastroenterology and
Hepatology
University of California Davis School of
Medicine
Sacramento, California

What a difference 10 years makes. Since the first edition of ERCP published
in 2008, it seems like there has been a cosmic shift in the practice of
gastrointestinal medicine and endoscopy. Diagnostic ERCP has given
way to continued improvements in computed tomography and magnetic
resonance imaging, as well as to endoscopic ultrasound (EUS), which
provides information not only about the diameter, contents, and contours
of the pancreaticobiliary ducts but also about the pancreatic and liver
parenchyma, contiguous organs, relevant vasculature, and lymph nodes.
Additionally, EUS has been shown to have improved sensitivity for the
diagnosis of pancreatic malignancy compared with brushing or biopsy
done at time of ERCP. Moreover, as technology and EUS experience
have expanded, therapeutic procedures previously relegated to ERCP
(or interventional radiology) are increasingly being done with an
echoendoscope: gallbladder and bile duct access for cholecystoduodenal,
hepatobiliary, and choledochoduodenal stenting; endoscopic anastomosis
of obstructed afferent limbs; gastroenterostomy for bypass of malignant
duodenal obstruction; PD imaging and duct decompression in difficult-
to-access anatomy; and imaging and treatment of pancreatic fluid
collections, many of which were previously imaged and variably treated
with ERCP. The barbarians are at the gate!
Or are they? ERCP with sphincterotomy and/or balloon dilation
remains the treatment of choice for choledocholithiasis and for many
cases of pancreatic stones. Moreover, it maintains primacy for the treat-
ment of benign pancreaticobiliary strictures and most malignancies
causing obstructive jaundice. In contrast, therapeutic EUS has evolved
to allow access in complex postoperative anatomy, duodenal obstruction,
or after failed ERCP. In fact, we are the barbarians who often employ
both echoendoscopes and duodenoscopes in the same patient under a
single anesthesia to stage a patient with malignant obstructive jaundice,
obtain a definitive tissue diagnosis, and render appropriate palliative
F O R E WO R D
therapy. Alternatively, we may use EUS to access the pancreaticobiliary
tree as part of a rendezvous procedure to improve the success rate of
ERCP. The third edition of this text acknowledges the expanded role
that EUS has come to play in patients previously undergoing diagnostic
or therapeutic ERCP alone. Utilizing one procedure without access to
the other is a disservice to our patients and encourages the overuse of
one of the (potentially) more dangerous therapeutic endoscopic proce-
dures we perform.
What a difference 10 years makes. Look for the new chapters, including
one on endoscope disinfection. This should not come as a surprise to
anyone as both the lay press and medical literature have been awash in
cases of antibiotic resistant bacterial infections, which can be traced
back to duodenoscopes contaminated with the same organism. What
else is new in the third edition of ERCP? Almost everything: new images,
updated videos, and multiple chapters that incorporate EUS and place
it into the perspective of modern ERCP practice. However, there is much
that has not changed in the current edition of this text. Most notably
we have retained the world’s premier clinicians and endoscopic researchers
to share their ERCP experience, their wisdom, and their cautions to
us all.
ACKNOWLEDGMENT
The Editors thank our medical colleagues and support staff for their
outstanding contributions to our patients’ care and the authors of this
textbook for their new or updated contributions.
Todd H. Baron, MD, FASGE
Richard A. Kozarek, MD, FASGE
David L. Carr-Locke, MD, FRCP, FASGE, FACG
xi
This page intentionally left blank

SECTION I General Topics
1. Approaching 50 Years: The History of ERCP, 1
Lee McHenry and Glen Lehman
2. The ERCP Room, 7
Brian C. Brauer and Steven A. Edmundowicz
3. Radiologic Issues and Radiation Safety During ERCP, 14
Eugene Lin and Beth Schueler
4. Endoscopes, Guidewires, and Accessories, 30
Sushil K. Ahlawat and Firas H. Al-Kawas
5. Duodenoscope Reprocessing, 44
Jennifer T. Higa, Michael Gluck, and Andrew S. Ross
6. Sedation in ERCP, 49
Catherine D. Tobin and Gregory A. Coté
7. Indications for and Contraindications to ERCP, 54
Sanjeev Solomon and John Baillie
8. Adverse Events of ERCP: Prediction, Prevention, and
Management, 59
Indu Srinivasan and Martin L. Freeman
9. ERCP Training, 68
Rawad Mounzer and Sachin Wani
10. Preparation of the Patient for ERCP, 80
John T. Maple
11. Principles of Electrosurgery, 86
Petros C. Benias and David L. Carr-Locke
12. Quality Issues and Measures in ERCP, 93
Jordan D. Holmes and Douglas O. Faigel
13. Medicolegal Issues in ERCP, 99
Peter Cotton
SECTION II Techniques
14. Cannulation of the Major Papilla, 108
Michael J. Bourke and Michael X. Ma
15. Access (Precut) Papillotomy, 123
Sujievvan Chandran, Gary May, and Paul Kortan
16. Sphincter of Oddi Manometry, 132
Tugrul Purnak and Evan L. Fogel
17. Biliary Sphincterotomy, 137
Horst Neuhaus
18. Balloon Dilation of the Native and Postsphincterotomy
Papilla, 148
Chan Sup Shim
19. Stone Extraction, 160
Andrew W. Yen and Joseph W. Leung
20. Pancreatic Sphincterotomy, 171
Jonathan M. Buscaglia and Anthony N. Kalloo
21. Minor Papilla Cannulation and Sphincterotomy, 182
Pier Alberto Testoni and Alberto Mariani
22. Plastic Pancreaticobiliary Stents and
Nasopancreaticobiliary Tubes: Concepts and Insertion
Techniques, 196
Ryan Law and Todd H. Baron
23. Biliary Metal Stent Insertion: Indications and Insertion
Techniques, 206
Koushik K. Das and Gregory G. Ginsberg
24. Pancreaticobiliary Stent Retrieval, 216
Anthony Razzak, Everson Luiz de Almeida Artifon, and
Richard A. Kozarek
CONTENTS
25. Papillectomy and Ampullectomy, 230
Shayan Irani and Richard A. Kozarek
26. Pancreatoscopy, 242
Tadashi Kodama and Tatsuya Koshitani
27. Cholangioscopy, 249
Raj J. Shah and Takao Itoi
28. Endomicroscopy in the Pancreaticobiliary Tree, 259
Anthony J. Choi and Michel Kahaleh
29. ERCP in Children, 263
Victor L. Fox
30. ERCP in Pregnancy, 282
Thiruvengadam Muniraj and Priya A. Jamidar
31. ERCP in Surgically Altered Anatomy, 288
Simon K. Lo
32. Endoscopic Ultrasonography–Guided Biliary Drainage, 308
Manuel Perez-Miranda
33. Endoscopic Ultrasound and EUS-Guided Endotherapy, 321
S. Ian Gan
SECTION III Approach to Clinical Problems
34. Pancreaticobiliary Disorders: What Are the Roles of CT,
MRCP, and EUS Relative to ERCP?, 328
Andres Gelrud and Ajaypal Singh
35. Pancreas Divisum, Biliary Cysts, and Other Congenital
Anomalies, 335
Mark Topazian
36. Dilated Bile Duct and Pneumobilia, 346
Koushik K. Das and Michael L. Kochman
37. The Dilated Pancreatic Duct, 354
Douglas G. Adler and Michelle A. Anderson
38. Ampullary Neoplasia, 361
Paul Fockens and Ian D. Norton
39. Malignant Biliary Obstruction: Distal, 372
Meir Mizrahi, Jonah Cohen, João Guilherme Guerra de Andrade
Lima Cabral, and Douglas Pleskow
40. Malignant Biliary Obstruction of the Hilum and Proximal
Bile Ducts, 385
Alexander M. Sarkisian and Reem Z. Sharaiha
41. Indeterminate Biliary Stricture, 394
Bret T. Petersen
42. Endoscopic Approaches to Concomitant Malignant Biliary
Obstruction and Gastric Outlet Obstruction, 405
Yen-I Chen, Todd H. Baron, and Mouen A. Khashab
43. Benign Biliary Strictures, 417
Guido Costamagna, Ivo Boškoski, and Pietro Familiari
44. Biliary Surgery Adverse Events, Including Liver
Transplantation, 422
Ilaria Tarantino, Todd H. Baron, and Dario Ligresti
45. ERCP and EUS for Acute and Chronic Adverse Events of
Pancreatic Surgery and Pancreatic Trauma, 432
Prabhleen Chahal and Todd H. Baron
46. Choledocholithiasis, 441
John C.T. Wong, James Y.W. Lau, and Joseph J.Y. Sung
47. Pancreaticobiliary Pain and Suspected Sphincter of Oddi
Dysfunction, 449
Paul R. Tarnasky and Robert H. Hawes
48. Sclerosing Cholangitis, 457
Jawad Ahmad and Adam Slivka
xiii
xiv CONTENTS
49. Tropical Parasitic Infestations, 464
D. Nageshwar Reddy, G. Venkat Rao, and Rupa Banerjee
50. Recurrent Pyogenic Cholangitis, 469
Tae Jun Song, Dong Wan Seo, and Khean-Lee Goh
51. Cystic Lesions of the Pancreas, 480
Omer Basar and William R. Brugge
52. Unexplained Acute Pancreatitis and Acute Recurrent
Pancreatitis, 486
Ihab I. El Hajj and Stuart Sherman
53. Biliary Intervention in Acute Gallstone Pancreatitis, 499
Andrew Korman and David L. Carr-Locke
54. Pancreatic Interventions in Acute Pancreatitis: Ascites,
Fistulae, Leaks, and Other Disruptions, 506
Michael Larsen and Richard A. Kozarek
55. Chronic Pancreatitis: Stones and Strictures, 516
Jacques Devière, Todd H. Baron, and Richard A. Kozarek
56. Endoscopic Drainage of Pancreatic Pseudocysts,
Abscesses, and Walled-Off (Organized) Necrosis, 525
Ryan Law and Todd H. Baron
 VIDEO CONTENTS

Chapter 8 Adverse Events of ERCP: Prediction, Prevention, and Chapter 23 Biliary Metal Stent Insertion
Management Video 23.1 Biliary Self-Expandable Stent Placement
Video 8.1 Postsphincterotomy Oozing Video 23.2 Biliary Self-Expandable Stent Placement
Video 8.2 Postampullectomy Bleeding: Hemoclip
Video 8.3 Guidewire Perforation of the Bile Duct Chapter 24 Pancreatobiliary Stent Retrieval
Video 8.4 Retroperitoneal Perforation Video 24.1 Endoscopic Technique for the Extraction of Pancreatic
Video 8.5 Retroperitoneal Perforation Stents: Snare and Forceps
Video 8.6 Retroperitoneal Sphincterotomy Perforation Video 24.2 Endoscopic Technique for the Extraction of
Pancreatic Stents: Direct Grasping With a Polypectomy
Chapter 14 Cannulation of the Major Papilla Snare
Video 14.1 Wire Lead Technique of Cannulation Video 24.3 Endoscopic Technique for the Extraction of Pancreatic
Video 14.2 Wire Lead Technique of Cannulation Stents: Lasso Technique
Video 14.3 Needle-Knife Sphincterotomy Video 24.4 Endoscopic Technique for the Extraction of Pancreatic
Video 14.4 Needle-Knife Sphincterotomy Stents: Dormia Basket Technique
Video 14.5 Needle-Knife Sphincterotomy Video 24.5 Endoscopic Technique for the Extraction of Pancreatic
Video 14.6 Pancreatic Cannulation Stents: Fragmentation and Direct Grasping

Chapter 15 Access (Precut) Papillotomy Chapter 25 Papillectomy and Ampullectomy

Video 15.1 Fistulotomy in a Diverticulum Video 25.1 Ampullary Adenoma
Video 15.2 Impacted Stone Fistulotomy
Chapter 26 Pancreatoscopy
Chapter 16 Sphincter of Oddi Manometry Video 26.1 Video Pancreatoscopy of Intraductal Papillary Mucinous
Video 16.1 Sphincter of Oddi Manometry Neoplasm
Video 26.2 Intraductal Papillary Mucinous Neoplasm Biopsy Under
Chapter 17 Biliary Sphincterotomy Direct Vision
Video 17.1 Biliary Sphincterotomy: Biliary Cannulation
Video 17.2 Biliary Sphincterotomy: EST Double-Wire Biliary Chapter 27 Cholangioscopy
Cannulation Video 27.1 Videocholangioscopy
Video 17.3 Biliary Sphincterotomy and Prophylactic Pancreatic Duct Video 27.2 Image-Enhanced Videocholangioscopy Using Narrow-
Stenting in Sphincter of Oddi Dysfunction Band Imaging
Video 17.4 Biliary Sphincterotomy Video 27.3 1.9- to 3-Fr Electrohydraulic Lithotripsy or Laser
Video 17.5 Biliary Sphincterotomy Lithotripsy Using Holmium:YAG and FREDDY

Chapter 18 Balloon Dilation of the Native and Postsphincterotomy
Papilla
Video 18.1 Balloon Dilation of the Major Papilla in Billroth II
Gastrojejunostomy and Extraction of the Bile Duct Stone
Video 18.2 Sphincterotomy and Balloon Dilation of the Major
Papilla
Video 18.3 Postsphincterotomy Large Balloon Dilation of the Major
Papilla and Extraction of a Huge (4.5- × 2.0-cm) Stone
Video 18.4 Balloon Dilation of the Major Papilla and Extraction of
Multiple Bile Duct Stones
Chapter 19 Stone Extraction
Video 19.1 Papillotomy and Basket Stone Extraction
Video 19.2 Papillotomy- and Papillotome-Assisted Stone Extraction
Followed by Basket Stone Extraction
Video 19.3 Papillotomy, Balloon Sphincteroplasty, and Stone
Extraction With Balloon
Video 19.4 Impacted Ampullary Stone
Chapter 20 Pancreatic Sphincterotomy
Video 20.1 Pancreatic Sphincterotomy
Chapter 21 Minor Papilla Cannulation and Sphincterotomy
Video 21.1 Minor Papilla Cannulation and Sphincterotomy
Chapter 28 Endomicroscopy in the Pancreaticobiliary Tree
Video 28.1 Probe-Based Confocal Laser Endomicroscopy of the Bile
Duct Showing Dark Clumps, Epithelium, and Fluorescein
Leak, All Suggestive of Cancer
Chapter 31 ERCP in Surgically Altered Anatomy
Video 31.1 Cholangiography in Patient With Roux-en-Y
Hepaticojejunostomy
Chapter 39 Malignant Biliary Obstruction: Distal
Video 39.1 Stenting in Pancreatic Cancer
Chapter 44 Biliary Surgery Adverse Events, Including Liver
Transplantation
Video 44.1 Multistenting of a Postorthotopic Liver Transplantation
Anastomotic Biliary Stricture
Chapter 46 Choledocholithiasis
Video 46.1 Second-Generation Peroral Cholangioscopy and
Holmium:YAG Laser Lithotripsy for Rescue of Impacted
Biliary Stone Extraction Basket
Video 46.2 Efficacy and Safety of a Single-Operator Digital Peroral
Cholangioscopy–Guided Laser Lithotripsy of
Complicated Biliary Stones

xv
xvi VIDEO CONTENTS
Video 46.3 Novel Use of Spyglass Optical Fiber in Triple-Lumen
Catheter for Percutaneous Choledochoscopy and
Holmium:YAG Laser Lithotripsy of Intrahepatic Bile
Duct Stones
Chapter 47 Pancreaticobiliary Pain and Suspected Sphincter of
Oddi Dysfunction
Video 47.1 Biliary Cannulation Using a Manometry Catheter
Without Contrast Injection Freehand Without Biliary
Cannulation
Video 47.2 Biliary Injection of Contrast and Pancreatic Cannulation
Using a Manometry Catheter Without Contrast
Video 47.3 Biliary Manometry and Sphincterotomy
Video 47.4 Placement of a 3-Fr Pigtail Pancreatic Duct Stent
Video 47.5 Placement of a 5-Fr Straight Pancreatic Duct Stent
Video 47.6 Pancreatic and Biliary Sphincterotomy With Pancreatic
Duct Stent Placement for Sphincter of Oddi
Dysfunction
Video 47.7 Pancreatic and Biliary Sphincterotomy With Pancreatic
Duct Stent Placement for Sphincter of Oddi Dysfunction
Video 47.8 Biliary Sphincterotomy for Sphincter of Oddi
Dysfunction
Video 47.9 Use of Dilute Methylene Blue to Identify the Pancreatic
Orifice After Biliary Sphincterotomy for Sphincter of
Oddi Dysfunction
Chapter 48 Sclerosing Cholangitis
Video 48.1 Endoscopic Treatment of Dominant Primary Sclerosing
Cholangitis Stricture
Chapter 49 Tropical Parasitic Infestations
Video 49.1 Endoscopic Biliary Sphincterotomy to Facilitate
Extraction of Hydatid Cysts and Worms
Video 49.2 Use of Balloon Catheter Following Biliary
Sphincterotomy
Chapter 50 Recurrent Pyogenic Cholangitis
Video 50.1 The Hallmark of Recurrent Pyogenic Cholangitis: The
Presence of Stones and Strictures, Which Can Be Both
Intrahepatic and Extrahepatic in Location
Video 50.2 Direct Peroral Cholangioscopy Using an Ultraslim
Upper Endoscope Introduced Directly Into the Biliary
Tree
Video 50.3 Direct Peroral Cholangioscopic Biopsy Using an
Ultraslim Upper Endoscope
Video 50.4 Electrohydraulic Lithotripsy
Video 50.5 Ductal Changes Post–Stone Removal
Video 50.6 Alterations in Ductal Mucosa Post–Stone Removal
Chapter 51 Cystic Lesions of the Pancreas
Video 51.1 Endoscopic Ultrasound-Guided Ethanol Ablation of
Pancreatic Cyst
Chapter 54 Pancreatic Interventions in Acute Pancreatitis: Ascites,
Fistulae, Leaks, and Other Disruptions
Video 54.1 Transduodenal Pancreatic Duct Decompression
Video 54.2 Transpapillary Pseudocyst Drainage and Disconnected
Pancreatic Duct Decompression in Pancreatic Pleural
Effusion
Video 54.3 Internal Fistula/Duodenal Abscess Treated With
Pancreatic Duct Stone Retrieval/Stent Placement/
Effusion
Chapter 55 Chronic Pancreatitis: Stones and Strictures
Video 55.1 Postextracorporeal Shock Wave Lithotripsy Pancreatic
Stone Extraction
Chapter 56 Endoscopic Drainage of Pancreatic Pseudocysts,
Abscesses, and Walled-Off (Organized) Necrosis
Video 56.1 Endoscopic Gastric Drainage of Pancreatic Pseudocyst
Video 56.2 Endoscopic Transduodenal Drainage of Pancreatic
Necrosis
Video 56.3 Endoscopic Transduodenal Debridement of Pancreatic
Necrosis
Video 56.4 Endoscopic Transduodenal Debridement of Pancreatic
Necrosis
Video 56.5 Use of Partially Covered and Fully Covered Self-
Expandable Stents to Establish Percutaneous Access for
Endoscopic Necrosectomy
Video 56.6 Transgastric Drainage of Pancreatic Necrosis
SECTION I General Topics
Approaching 50 Years: The History of ERCP
Endoscopic retrograde cholangiopancreatography (ERCP) has been a
remarkable technological advance that has evolved over its nearly 50
years in the field of gastrointestinal endoscopy and has redefined the
medical and surgical approach to patients with pancreatic and biliary
tract diseases. Since its inception in 1968, the medical community has
witnessed significant achievements by the pioneers in endoscopy who
incrementally advanced ERCP techniques from their infancy to maturity.
The infancy focused on diagnoses, the adolescence on therapies of
common biliary tract diseases such as bile duct stones and malignant
strictures, the early adulthood on therapy for diseases of the pancreas
and prevention of pancreatitis, and now the mature adulthood focuses
on continued refinement of techniques to make ERCP safer and more
effective. The pioneers in the ERCP field are numerous and have played
significant roles in developing new techniques and novel instrumentation,
spearheaded innovative techniques to reduce adverse events, and
effectively trained future generations of endoscopists to safely perform
ERCP. We are now approaching a 50-year milestone, and as we look
back, we can recall a journey in ERCP that has been enjoyable, exciting,
and replete with enthusiastic innovation, and in the end has benefitted
many patients (Box 1.1). It would encompass an entire book to incor-
porate all of the important contributions made by the many ERCP
endoscopists over the past 50 years. We apologize in advance to individuals
who have advanced the field and are not mentioned in this brief summary
of the history of ERCP.
ERCP IN ITS INFANCY: 1968 TO 1980
In the 1920s, bile duct imaging was performed by surgeons Evarts
Graham and Warren Cole with the use of intravenously administered
iodinated phenolphthalein that was selectively excreted into the bile
and recorded radiographically. Oral cholecystography and percutaneous
skinny “Chiba” needle cholangiography were additionally developed to
improve the visualization of the bile duct.1,2 What defied the clinician
was a nonoperative technique to image the pancreatic duct. In 1965
two innovative radiologists, Rabinov and Simon,3 fashioned a bendable
catheter that was inserted through a per oral basket catheter. The medial
duodenal wall was “blindly scratched” with the tip of the catheter and the
first pancreatogram was successfully obtained nonoperatively. In eight
attempts, an interpretable pancreatogram was obtained in two patients.
The gastrointestinal endoscopist now entered the arena. In 1968 William
McCune and his surgical colleagues at George Washington University
were credited with the first report of endoscopic cannulation of the
ampulla of Vater in living patients.4 McCune used an Eder fiberoptic
1
Lee McHenry and Glen Lehman
duodenoscope (Eder Instrument Company, Chicago, IL), which had
both a forward and side lens and an endotracheal-type cuff placed on
the scope just beyond the lens. The balloon was inflated and deflated to
enable adequate focal length for mucosal visualization. McCune taped
a small-diameter plastic tube that served as a tract to the endoscope
that could house a bendable cannula. The cannula was advanced to
the major duodenal papilla under endoscopic guidance. In his report
of 50 patients, McCune’s duodenal intubation success rate was only
50%, with only 25% pancreatic duct opacification. As stated in his
discussion: “Anyone who looks through one of these instruments has
to have 2 personality characteristics. First, he has to be honest, and
second, must have an undying, blind, day and night, uncompromising
persistence.” ERCP was now born, and it slowly grew to an established
technique as a result of the honesty and persistence of the pioneers of
endoscopy.
In March 1969 in Japan, Oi (Fig. 1.1) and colleagues—in close
collaboration with Machida (Machida Endoscope, Ltd., Tokyo, Japan)
and Olympus corporations (Olympus Optical Co., Ltd., Tokyo, Japan)—
developed a side-viewing fiberoptic duodenoscope with a channel and
an elevator lever to enable manipulation of the cannula. Initially, Oi
visualized the ampulla in about half of 105 cases.4 In a subsequent report,
Oi cannulated the papilla in 41 of 53 patients (77%) without significant
morbidity.5 By 1972, Jack Vennes and Steven Silvis of the University of
Minnesota published the experience in their first 80 attempts at cannula-
tion of the bile and pancreatic ducts, paving the way for acceptability
in the American endoscopic wilderness6 (Table 1.1).7,8 Over the next
5 years, pioneers such as Safrany, Cotton, Geenen, Siegel, Classen, and
Demling and the Japanese groups embraced this new technique and
reported on the successes (cannulation rates of >90%) (Fig. 1.2), the
shortcomings (e.g., post-ERPC pancreatitis [PEP]), the nuances (variety
of cannula types, cannulation angles), and the practical application of
ERCP in our understanding of biliary and pancreatic disorders.9–15 But
what could we as endoscopists do with this new-found knowledge?
Simultaneously in 1973, in separate regions on the globe, ERCP
investigators conceived the concept of a therapeutic application of ERCP.
The sphincter of the intact papilla served as a barrier to reflux of duodenal
contents into the bile and pancreatic duct and was an impediment to
removal of stones from the bile duct. Independently, Demling and
Classen in Erlangen, Germany, and Kawai in Kyoto, Japan, developed
similar techniques to split the sphincter. Demling and Classen developed
a high-frequency diathermy snare, the Demling-Classen probe consisting
of a Teflon catheter with a thin steel wire that could be protruded to
create a “bowstring” that would sever the papillary muscle (Fig. 1.3).15–17
1
2 SECTION I General Topics

BOX 1.1 History of ERCP: Five Decades, Decade by Decade

1970s: Diagnosis and Therapy • Safer sphincterotomy: monofilament wires and computer-regulated blended
• Locating the ampulla current
• Biliary and pancreatic duct cannulation • Self-expandable metallic stents
• Interpretation of cholangiography and pancreatography, identifying • Complementary pancreaticobiliary techniques developed
pathology • Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopan-
• First reports of biliary sphincterotomy creatography (MRCP)
• Developing the instruments: balloon extraction of bile duct stones and stent
placement 2000s: Prevention, Pulverizing, and Peculiar Pancreas
Diseases
1980s: Slowly Shifting from Surgery to Endoscopic • Pancreatic stents and post-ERCP pancreatitis prevention
Management of Pancreaticobiliary Disorders • Improved techniques for extraction of “large” bile duct stones are implemented
• Refinement of accessories, improvements in radiographic imaging • Papillary balloon dilation
• Reporting adverse events of sphincterotomy • Single-operator system for intraductal lithotripsy
• Biliary stent placement for obstructive jaundice and shift from palliative surgery • Intraductal papillary mucinous neoplasm (IPMN) and autoimmune pancreatitis
• Introduction of the teaching head: “seeing is believing” (AIP) recognized
• Acceptance of ERCP by the medical community • “Hands-on” courses
• Management of CBD stones shifts from surgery to endoscopy • EUS and ERCP therapeutic interface
• ERCP training gets its start for physicians and ERCP nurses
• Basic threshold numbers for competence 2010s: Refinements of ERCP Techniques and New
Treatments
1990s: Training and Expanding Our Therapies • Pharmacologic agents (rectal NSAIDs) for post-ERCP prevention
• More emphasis on advanced training • Revised recommendations for sphincter of Oddi dysfunction diagnosis and
• Endoscopic photography and videography: sharing images with others therapy
• Referring MDs, patients, and industry • ERCP scope infections are revisited and rigorous cleaning processes of ERCP
• Comparison of one procedure to another scopes are revised
• Teaching and training • Novel ERCP treatments for cholangiocarcinoma, including photodynamic therapy
• “Theater presentations” of ERCP and radiofrequency ablation, are introduced
• Therapies for pancreatic disorders: chronic pancreatitis, pseudocysts, and • Charge-coupled device (CCD) imaging improves intraductal cholangioscopy
necrosis and pancreatoscopy
• Era of laparoscopic cholecystectomy and bile duct injuries

TABLE 1.1 ERCP in Its Infancy: Cannulation Rates Around 1972

Group Total Overall Success (%)* Selective Success Pancreatic (%) Selective Success Biliary (%)
Ogoshi 283 88
Oi 310 81
Kasugai 270 74
Cremer 144 76 68 63
Cotton 132 83 78 73
Classen 541 86
Safrany 145 94
Vennes 80 75

*Generally defined as entry into either duct.

From Cotton PB. Progress report: cannulation of the papilla of Vater by endoscopy and retrograde pancreatography (ERCP). Gut
1972;13:1014–1025.

Canine experiments ensued and demonstrated that a papillotomy could
be performed safely without bleeding or perforation. An added benefit
of the Demling-Classen probe was that contrast dye could be instilled
while the catheter was in place. In Japan, Kawai developed a papillotomy
device consisting of two separate 2-mm-long diathermy knives that
protruded from the catheter tip and could be used to incise the papillary
sphincter, similar to the present-day needle knife technique.15 This device
was particularly useful in patients with impacted stones at the papilla.
The Erlangen probe, because of a perceived reduction in the risk of
perforation, was more accepted in the West, and sphincterotomy as a
technique was born. The initial concern of postsphincterotomy scarring
was postulated, but the incidence was found to be infrequent. The first
therapeutic application during ERCP, with incumbent well-chronicled
risks, was gradually adopted by endoscopists around the world. Bile
duct stones were accurately diagnosed at the time of cholangiography,
biliary sphincterotomy was performed, and the stones were left in the
bile duct to pass on their own. This clinical problem needed a solution,
and as is true with the many endoscopic techniques, the fundamental
elements for major endoscopic technological advances were borrowed
heavily from other fields (i.e., urology: basket, stent, and balloon technol-
ogy; radiology: catheter and guidewire technology; cardiology: catheters
and metallic stents). To solve the clinical problem of removing stones
from the bile duct, in 1975 Zimmon and colleagues18 in New York
reported removal of bile duct stones with balloon-tipped catheters, a
 CHAPTER 1 Approaching 50 Years: The History of ERCP
technique that further expanded the endoscopist’s therapeutic arma-
mentarium. Long, flexible balloon-tipped catheters, basket catheters,
stone-grasping forceps, and endoscopic laser or ultrasound stone dis-
integrators were miniaturized to fit through the endoscope working
channel, and removal of bile duct stones no longer required surgical
laparotomy and open choledochotomy.
FIG 1.1 One year after Dr. William McCune successfully performed
the first ERCP at George Washington University, in Japan Dr. Itaru Oi,
with his chief, Dr. Takemoto, performed endoscopic cholangiopancrea-
togram (ECPG), as it was called, with a Machida scope in 1969.5 The
method used was almost the same as Dr. McCune’s method of using
a prolonged gastrofiberscope. In close collaboration with the Machida
and Olympus corporations, Oi developed a side-viewing fiberoptic
duodenoscope with a channel and an elevator lever to enable manipulation
of the cannula. (Photo courtesy Dr. Peter Cotton, Medical University of
South Carolina.)
FIG 1.2 In the early days: First ERCP by Dr. Ogoshi at the Niigata Cancer Center Hospital, Japan, in 1970.
Radiographs showing complete pancreatography (left) and the distal bile duct (right). Note the long scope
position to obtain pancreatography. (Photo courtesy Dr. Peter Cotton, Medical University of South Carolina.)
3
The 1970s were an exciting time for ERCP, but many physicians
(gastroenterologists and surgeons) were appropriately concerned about
the dangers of the procedure, particularly PEP, bleeding, and biliary
sepsis. In 1976, Bilbao and colleagues19 surveyed 402 U.S. owners of
side-viewing duodenoscopes who had collectively performed 10,435
ERCPs. The procedure failed in 30%, adverse events occurred in 3%,
and death occurred in 0.2%. Pancreatitis was associated with injection
into the pancreatic duct and sepsis with injection into an obstructed
bile duct. Inexperience led to a fourfold increase in failures (62%) and
twice the rate of adverse events (7%). ERCP was the riskiest procedure
for the endoscopist, yet was gradually embraced, and the physicians
who had the willingness and ability to perform ERCP forged ahead. In
looking back in ERCP history over the past 5 decades, the gastroenterology
community was aware of the high incidence and potentially severe
adverse events associated with ERCP; however, the absolute requirement
of advanced training and expertise before subjecting patients to this
potentially lethal procedure was understated, minimized, and inadequately
addressed. These should serve as reminders and lessons for the future
as new endoscopic procedures are introduced.
Malignant bile duct obstruction posed a problem to the ERCP
physician in the 1970s. Endoscopic cannulation of the bile duct intro-
duced bacteria-laden contrast dye into an obstructed biliary tree, and
endoscopic sphincterotomy alone would not provide adequate biliary
drainage except in the most distal bile duct or ampullary cancers.
Percutaneous transhepatic methods for biliary drainage were commonly
employed preoperatively in patients with deep jaundice or for palliation,
and the first report of a percutaneous transhepatic cholangiography
(PTC)-guided internal bile duct prosthesis was reported by Burcharth
et al. in 1979.20 In 1980, the ERCP groups in England (Laurence and
Cotton21) and Germany (Soehendra and Reynders-Frederix22) reported
the early cases of internal decompression of malignant biliary obstruction
by ERCP-directed biliary endoprosthesis placement (Fig. 1.4). The initial
methods relied on “borrowed” technology and reported the uses of a
7-Fr nasobiliary drain fashioned from an angiographic catheter and a
“pigtail” stent cut from a 7-Fr Teflon catheter. Over the next 30 years,
with the aid of industry and ingenuity, biliary endoprosthesis design
continued to advance from the back table of the craftsman/endoscopist
to the precision engineering of multisized polyethylene stents and
4 SECTION I General Topics

FIG 1.3 The endoscopic and fluoroscopic images from the first sphincterotomy performed by Drs. Nakajima
and Kawai in Kyoto, Japan, in 1974. Clockwise from left: The fluoroscopic images on the left show the distal
bile duct calculus (arrow) with upstream filling of the bile duct. The catheter was used for cannulation and
sphincterotomy. On the right, the cholangiogram and pancreatogram revealing bile duct clear of filling defect.
In the bottom middle is the limited field of view of the duodenal papilla on the left and the papilla after
sphincterotomy on the right. (Photo courtesy Dr. Peter Cotton, Medical University of South Carolina.)

self-expandable metallic stents. Effective palliation of malignant biliary
obstruction was wrestled from the surgeon and radiologist, and planted
for good into the endoscopist’s hands.
THE SECOND DECADE: 1980 TO 1990
Over the next 10 years from 1980 to 1990, medicine witnessed an explosion
in the number of ERCPs performed throughout the world. However,
this explosion did not occur in a vacuum and was fueled by burgeoning
technology in other medical disciplines such as radiology, anesthesia,
pathology, and surgery. In 1979, the Nobel Prize in Medicine was awarded
jointly to Godfrey N. Hounsfield (U.K.) and Allan McLeod Cormack
(Tufts University, Medford/Somerville, MA) for independently inventing
the computerized axial tomography (CAT) scanner. Assessment of the
patient with pancreatobiliary disease was transformed from physical
examination, ultrasound, and plain radiographs, and their inherent
limitations to precise computed tomography (CT) characterization and
localization of the problem at hand. Improved perioperative manage-
ment and anesthesia care made the ERCP procedure more acceptable to
patients. Pathologic interpretation of endoscopic biopsies and cytologic
assessment of brushings continued to improve, with increased number
of specimens and physician experience allowing tissue diagnosis to
be made nonoperatively. The surgeon’s role evolved from exploration
for diagnosis with its inherent morbidity and mortality to a more
focused therapeutic operation that would lead to improved patient
outcomes.
Industry played a major role in the close collaboration with endos-
copists in designing improved versions of ERCP accessories, including
cannulas, sphincterotomes, and endoscopic stents, which led to improved
therapeutics and improved patient outcomes. Companies such as
Wilson-Cook (now Cook Endoscopy, Winston-Salem, NC), Olympus
(Center Valley, PA, and Tokyo, Japan), Bard (now ConMed, Utica, NY),
and Microvasive (now Boston-Scientific, Marlborough, MA) and many
others forged tight, long-lasting relationships with the pioneers in ERCP,
which accelerated innovation in the field (Fig. 1.5). Both ERCP endos-
copists and patients benefited from increased cannulation rates, improved
sphincterotomies, and reliable prostheses. The domain of bile duct stones
and palliation of malignancies shifted from surgeons to endoscopists.
One of the recurring themes in endoscopic advances is the importance
of close collaboration of engineers and clinicians to attempt to solve
clinical problems.
Fiberoptic endoscopy was the platform for the ERCP gastroenterolo-
gist in the 1970s and posed a challenge for performance of and training
and reporting in ERCP. Documenting endoscopic findings was limited
in quality, as the camera head attachment was bulky and, when affixed,
precluded real-time visualization of the endoscopy image. To share the
endoscopy experience, a teaching head apparatus would connect to the
endoscope to allow a second observer (an ERCP trainee or procedural
nurse) to visualize the endoscopic image. The major drawbacks were
halving of the light transmitted through the fibers to the eyepiece,
allowing only one observer on the teaching head, and limiting the nurse
to the use of only one hand to perform important functions such as
wire advancement while holding the teaching head with the other hand.
The first videoendoscope had a small television camera in the tip of
the endoscope (charge-coupled device [CCD]) and was connected to
a computer capable of transforming electronic signals into a recognizable
image. Sivak and Fleischer23 in the United States and Classen and Phillip24
in Germany reported on their first experiences in 1984. Videoendoscopy
had transformed the ERCP experience for the performing physician,
the trainees, and the ERCP nurses to a more dynamic, less solitary
experience and launched ERCP training to a new level.
THE THIRD DECADE: 1990 TO 2000
In the decade of 1990 to 2000, several breakthrough technologies in
radiology, endoscopy, and surgery were introduced that would impact
 CHAPTER 1 Approaching 50 Years: The History of ERCP
FIG 1.4 ERCP-directed bile duct drainage using biliary stents was
introduced by Soehendra and Reynders-Frederix from Hamburg, Germany,
in 1979, adding to the armamentarium of therapeutic ERCP. The team
used a 20-cm-long, 7-Fr radioopaque angiographic catheter with 12 side
holes inserted over a guidewire with a single pigtail that allowed it to
be fixed inside the bile duct. (Photo courtesy Dr. Peter Cotton, Medical
University of South Carolina.)
FIG 1.5 Industry played a pivotal role in the field of ERCP. The Olympus
duodenoscope model JF (pictured here with camera attached) was
introduced in 1971. The JF duodenoscope was fiberoptic, had a 65-degree
view angle, and was fitted with an elevator. The channel size was
<2 mm diameter, limiting the size of catheters that could be used and
making suctioning around the catheter problematic. (Photo courtesy Dr.
David Barlow, Olympus Corporation.)
the field of pancreaticobiliary disease and the ERCP endoscopist. These
technologies blossomed and ultimately transformed the indications
for ERCP from a diagnostic/therapeutic procedure to a predomi-
nately therapeutic one.25 This transformation was driven in part by
the introduction of magnetic resonance imaging (MRI)/magnetic
5
resonance cholangiopancreatography (MRCP) to image noninvasively
the bile and pancreatic ducts.26,27 Endoscopic ultrasonography (EUS),
originally described in 1980 by DiMagno et al.,28 was introduced
with the radial scanning echoendoscope, which became a staple for
clinical care in the late 1980s. Linear endosonography followed in 1994
and had the added advantage of diagnostic fine-needle aspiration.
Laparoscopic cholecystectomy was first performed in 1987 by Mouret
(unpublished) and reported in 1989 in Europe by Dubois et al.29 and
Perissat et al.30 and in the United States by Reddick and Olsen.31 Lapa-
roscopic cholecystectomy transformed the practice of ERCP, with more
reliance on endoscopists to remove bile duct stones preoperatively or
postoperatively.32
ERCP IN THE NEW MILLENNIUM
In the fourth and fifth decades, ERCP as an endoscopic procedure was
widely available and practiced by many gastroenterologists in nearly
every hospital with more than a 50-bed capacity. In the earlier decades
of ERCP, the technique was adopted initially based on logic and began
to grow based on cannulation success and eventually therapeutic success.
There were few prospective, controlled, randomized, outcome-based
studies in the early years, in part because of the excitement and enthu-
siasm of innovation and the lack of funding (and applications for
funding) for endoscopic studies. The growth of ERCP decade by decade
was in part attributable to the continued refinement of techniques and
introduction of new innovations. In the new millennium, the “science
of ERCP” has now become the focus. Prospective scientific studies have
flourished since the year 2000, including studies evaluating the role of
ERCP in gallstone pancreatitis,33 malignant biliary obstruction (preopera-
tive endoscopic drainage followed by pancreaticoduodenectomy
compared with primary pancreaticoduodenectomy alone),34 and sphincter
of Oddi dysfunction (National Institutes Health–sponsored EPISOD
trial) comparing sham therapy to manometrically directed sphincter-
otomy),35 and studies using pancreatic stents and pharmacologic agents
to prevent PEP.36 Comparative trials evaluating novel therapies for
cholangiocarcinoma, including photodynamic therapy (PDT) and
radiofrequency ablation (RFA), emerged.
With the benefit of hindsight, in the 5-decade history of ERCP we
could pose the following: What were the shortcomings of the incorpora-
tion of this technology into standard clinical practice? The risks of
ERCP were underrecognized and underreported, particularly with respect
to pancreatitis and perforation.37 An attempt to stratify patients at the
greatest risk for PEP was not addressed until the fourth decade by
Freeman and colleagues in 2001.38 Informed consent for ERCP was
cursory, and in many instances, full disclosure of the potential risks
and severity of adverse events was not provided to patients. Self-training
was the norm in the first decade of ERCP, but advanced training became
more readily available in the 1980s and 1990s. The endoscopy societies
were lax in guiding ERCP training programs and community hospitals
in the number of ERCPs necessary to attain a base level of competence.
The Gastroenterology Core Curriculum of the Gastroenterology Leader-
ship Council (joint effort of the American Association for the Study of
Liver Diseases [AASLD], American College of Gastroenterology [ACG],
American Gastroenterological Association [AGA], and American Society
for Gastrointestinal Endoscopy [ASGE]) in 1996 did not recommend
a specific number of ERCPs necessary to assess competence. An early
ASGE guideline recommended 100 ERCP procedures (75 diagnostic
and 25 therapeutic) as the minimum number of ERCPs before one
could assess competency. The threshold still remains unclear, with the
suggestion that at least 180 procedures are necessary.39 Yearly ERCP
volume by the endoscopist practicing ERCP has not been established
to guide credentialing agencies.
6 SECTION I General Topics

ERCP CASES OVER 25 YEARS

INDIANA UNIVERSITY GI DIVISION
THE FUTURE OF ERCP
As we look back at the history of ERCP, we can take time to speculate
3500
3069 about ERCP in the future. Capsule cameras and remote-guided cameras
3000 2840 may complement or replace handheld gastroscopy, enteroscopy, and
2495 colonoscopy, but we foresee that endoscopic cannulation of the pan-
2500 creaticobiliary system will remain the standard. Improvements with
CCDs, even smaller-diameter choledochoscopes, and pancreatoscopes
2000
# ERCPs

1658 are eagerly awaited and should soon become a practical reality. However,
1500 optimal view, steerability, and durability remain as challenges. Hands-free
1153 manipulation of endoscopes, similar to robotic-assisted surgery, is
1000 anticipated with the advantages of reduced endoscopist fatigue, improved
550 ability to train endoscopists, and more refined movement of accessories.
500 Pancreaticobiliary tumor diagnosis and tissue sampling will undoubtedly
150
0
improve with advances in intraductal endoscopy. Endoscopic pancreatic
cancer screening of high-risk groups may become a reality. Pancreatitis
1983 1988 1993 1998 2003 2008 2010
management may benefit from a more defined endoscopic role. Dis-
FIG 1.6 ERCP case volume over 25 years at the Indiana University
solution of intraductal pancreatic stones may be possible with the aid
Division of Gastroenterology.
of endoscopically placed catheters. Studies of pancreatic juice may
provide predictors of recurrent pancreatitis, pancreatic cancer risk, and
response to chemotherapy. Continued effort is needed to make ERCP
safer and more effective. Advanced training programs must continue
A “shift” of high-risk, complicated ERCP procedures to referral to ensure that ERCP endoscopists are adequately trained and skilled in
centers is reflected in the growing number of ERCPs performed at our the performance of this procedure.
institution over the past 15 years (Fig. 1.6). Hands-on training opportuni-
ties for practicing gastroenterologists to improve ERCP skills are scarce, The complete reference list for this chapter can be found online at
and real-life simulators for ERCP are still not available. www.expertconsult.com.

KEY POINTS
• In the early years of ERCP in the 1970s, pioneers such as McCune,
Oi, Classen, Kawai, Cotton, Vennes, Silvis, Geenen and others
established a new technology.
• Close collaboration was vital between the endoscopist and industry
to design new instrumentation, leading to higher cannulation rates,
improved sphincterotomy, more effective drainage techniques, and
improved outcomes.
• The early adopters of ERCP were self-taught, and subsequent trainees
were schooled using the apprentice model. Training accelerated with
introduction of videoendoscopy. Minimum qualifications for ERCP
competency were poorly defined.
• In the new millennium, ERCP endoscopists have emphasized scientific
rigor with several prospective, outcome-based studies. Newer
techniques such as prophylactic pancreatic stent placement were
adopted to make ERCP safer in high-risk patients.
 CHAPTER 1 Approaching 50 Years: The History of ERCP
REFERENCES
1. Tsuchiya Y. A further study of percutaneous transhepatic cholangiography.
Jpn J Gastroenterol. 1972;69:1163.
2. Redeker AG, Karvountzis GG, Richman RH, et al. Percutaneous
transhepatic cholangiography: an improved technique. JAMA.
1975;231:386–388.
3. Rabinov KR, Simon M. Peroral cannulation of the ampulla of Vater for
direct cholangiography and pancreatography: preliminary report of a new
method. Radiology. 1965;85:693–697.
4. McCune WS, Shorb PE, Moscowitz H. Endoscopic cannulation of the
ampulla of Vater: a preliminary report. Ann Surg. 1968;167:752–756.
5. Oi I, Takemoto T, Kondo T. Fiberduodenoscope: direct observation of the
papilla of Vater. Endoscopy. 1969;3:101–103.
6. Oi I. Fiberduodenoscopy and endoscopic pancreatocholangiography.
Gastrointest Endosc. 1970;17:59–62.
7. Vennes JA, Silvis SE. Endoscopic visualisation of bile and pancreatic ducts.
Gastrointest Endosc. 1972;18:149–152.
8. Cotton PB. Progress report: cannulation of the papilla by endoscopy and
retrograde cholangiography (ERCP). Gut. 1972;13:1014–1024.
9. Ogoshi K, Tobita Y, Hara T. Endoscopic observation of the duodenum
and pancreatocholedochography using duodenofiberscope under direct
vision. Gastrointest Endosc. 1970;12:83–96.
10. Kasugai T, Kuno N, Aoki I, et al. Fiberduodenoscopy: analysis of 353
examinations. Gastrointest Endosc. 1971;18:9–16.
11. Classen M, Koch H, Fruhmorgen P, et al. Results of retrograde
pancreaticography. Acta Gastroenterol Jpn. 1972;7:131–136.
12. Blackwood WD, Vennes JA, Silvis SE. Post-endoscopy pancreatitis and
hyperamylasuria. Gastrointest Endosc. 1973;20:56–58.
13. Safrany L, Tari J, Barna L, et al. Endoscopic retrograde cholangiography:
experience of 168 examinations. Gastrointest Endosc. 1973;19:163–168.
14. Demling L. Operative endoskopie. Med Welt. 1973;24:1253.
15. Kawai K, Nakajiama M. Preliminary report on endoscopic papillotomy.
J Koyoto Pref Univ Med. 1973;82:353.
16. Classen M, Demling L. Endoskopische sphinkterotomie der papilla vateri
und steinextracktion aus dem ductus choledochus. Dtsch Med
Wochenscher. 1974;99:496–497.
17. Demling L, Koch H, Classen M, et al. Endoscopic papillotomy and
removal of gall-stones: animal experiments and first clinical results. Dtsch
Med Wochenscher. 1974;99(45):2233–2237.
18. Zimmon DS, Falkenstein DB, Kessler RE. Endoscopic papillotomy for
choledocholithiasis. N Engl J Med. 1975;293(23):1181–1182.
19. Bilbao MK, Dotter CT, Lee TG, et al. Complications of endoscopic
retrograde cholangiopancreatography (ERCP): a study of 10,000 cases.
Gastroenterology. 1976;70:314–320.
20. Burcharth F, Jensen LI, Olesen K. Endoprosthesis for internal drainage of
the biliary tract. Gastroenterology. 1979;77:133–137.
21. Laurence BH, Cotton PB. Decompresson of malignant biliary obstruction
by duodenoscope intubation of the bile duct. Br Med J. 1980;I:522–523.
6.e1
22. Soehendra N, Reynders-Frederix V. Palliative bile duct drainage: a new
endoscopic method of introducing a transpapillary drain. Endoscopy.
1980;12:8–11.
23. Sivak MJ, Fleischer DE. Colonoscopy with a video-endoscope: a
preliminary experience. Gastrointest Endosc. 1971;18:66.
24. Classen M, Phillip J. Electronic endoscopy of the upper GI tract: initial
experience with a new type of endoscope that has no fiberoptic bundle
for imaging. Endoscopy. 1984;16:16.
25. Sherman S, Lightdale CJ, editors. Endoscopic therapy of pancreatic
disease. Gastrointest Endosc Clin North Am. 1998;8:1–272.
26. Wallner BK, Schumacher KA, Weidenmaier W, et al. Dilated biliary tract:
evaluation with MR cholangiography with a T2-weighted contrast-
enhanced fast sequence. Radiology. 1991;181:805–808.
27. Fulcher AS, Turner MA, Capps GW, et al. Half-Fourier RARE MR
cholangiopancreatography: experience in 300 subjects. Radiology.
1998;207:21–32.
28. DiMagno EP, Buxton JL, Regan PT, et al. Ultrasonic endoscope. Lancet.
1980;1:629–631.
29. Dubois F, Berthelot G, Levard H. Cholecystectomies par coelioscopie.
Presse Med. 1989;18:980–982.
30. Perissat J, Collet DR, Belliard R. Gallstones: laparoscopic treatment,
intracorporeal lithotripsy followed by cholecystostomy or
cholecystectomy—a personal technique. Endoscopy.
1989;21(suppl):373–374.
31. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: a comparison
with mini-lap cholecystectomy. Surg Endosc. 1989;3:131–133.
32. NIH Consensus Conference. Gallstones and laparoscopic cholecystectomy
[review]. JAMA. 1993;269:1018–1024.
33. Attasanaranya S, Fogel EL, Lehman GA. Choleledocholithiasis, ascending
cholangitis, and gallstone pancreatitis. Med Clin North Am.
2008;92:925–960.
34. van der Gaag NA, Rauws EA, van Eijck MD, et al. Preoperative biliary
drainage for cancer of the head of the pancreas. N Engl J Med.
2010;362:129–137.
35. Cotton PB, Durkalski V, Orrell KB, et al. Challenges in planning and
initiating a randomized clinic study of sphincter of Oddi dysfunction.
Gastrointest Endosc. 2010;72:986–991.
36. Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of
rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med.
2012;366:1–9.
37. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy
complications and their management: an attempt at consensus.
Gastrointest Endosc. 1991;37:383–391.
38. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP
pancreatitis: a prospective, multicenter study. Gastrointest Endosc.
2001;54:425–434.
39. Jowell PS. Quantitative assessment of procedural competence: a
prospective study of training in ERCP. Ann Intern Med. 1996;125:
937–939.

The ERCP room can range from very basic to state-of-the-art. Whereas
smaller institutions with low ERCP volumes often perform ERCP in
the radiology department or operating room, most centers with a larger
ERCP volumes perform ERCP in dedicated rooms within the endoscopy
unit. The basic ERCP room requires a quality fluoroscopy unit with
still-image capability in addition to standard endoscopic equipment.
Major innovations in the field of interventional endoscopy have led to
the development of multipurpose interventional rooms with the ability
to combine endoscopic ultrasonography (EUS), cholangioscopy, pan-
creatoscopy, confocal endomicroscopy, and other interventions in
combination with ERCP. A well-designed ERCP room is needed to
accommodate this expansion in the procedural intensity of ERCP. In
addition, changes in the patient population have led to the necessity
to be able to perform ERCP on morbidly obese patients and those with
altered anatomy using deep enteroscopy instruments. Many centers
have moved to have anesthesia support for all ERCPs. The cumulative
effect of these changes in the practice of ERCP has led to significant
changes in the design of the typical ERCP room with the incorporation
of new technology to benefit the patient, physician, and staff.
EVOLUTION OF THE ERCP ROOM
The basic intent of ERCP has not changed. Endoscopic visualization
of the ampulla and cannulation of the desired ductal system with
high-quality radiographic imaging guiding the appropriate therapy is
still the goal. In the great majority of cases the basic equipment is all
that is needed to remove a stone or place a stent across uncomplicated
strictures. What has changed is the potential complexity of ERCP,
especially at tertiary referral centers. The need for high-quality radio-
graphic imaging of focal pathology in larger patients has led to modified
digital fluoroscopy equipment with improved resolution, reduced
radiation exposure, and the ability to function continuously for long
procedures without overheating. In addition, wider tables (>30 inches)
capable of accommodating larger, heavier patients (≥450 lbs.) and space
for anesthesia to assist in these procedures have become essential.
Additional room space is also needed to accommodate larger beds and
stretchers to allow for bariatric patients (Fig. 2.1). The use of a mobile
or fixed C-arm system is often employed to improve visualization of
the biliary tree by allowing the plane of examination to be altered to
profile the bifurcation and selected ductal systems. Additional space
for supplemental equipment for cholangioscopy, EUS, laser lithotripsy,
electrohydraulic lithotripsy, deep enteroscopy, and other adjuvant
techniques has increased the size of the typical advanced ERCP room.
Space for anesthesia equipment has further increased the need for
additional space at the patient’s head. All this, in combination with the
need to accommodate morbidly obese patients and store a large variety
of devices in close proximity to the patient, has increased the size of
well-designed, advanced interventional endoscopy rooms to greater than
500 square feet.
2
The ERCP Room
Brian C. Brauer and Steven A. Edmundowicz
STAFFING FOR THE ERCP PROCEDURE
Staffing for ERCP procedures varies across the world. Typically, a
physician and a minimum of two additional assistants are necessary.
The first assistant (nurse or technician) stands immediately adjacent
to the physician and operates devices such as guidewires and accessories.
A sedation nurse or member of the anesthesia staff is positioned at the
patient’s head and administers sedation or anesthesia while monitoring
the patient throughout the procedure. Often, a second assistant (nurse
or technician) assists in preparing devices for use and documents specifics
of the procedure. In some settings a radiology technician is also needed
to operate the radiographic equipment. In many centers, a trainee is
often present. This creates a close working environment for the procedure
with at least three individuals clustered around the patient’s head. A
well-designed workspace makes this proximity tolerable and efficient.
ROOM LAYOUT
The key to successful room design is early collaboration with all the
disciplines that will be involved in performance and delivery of ERCP
so that the room is functional and beneficial to all parties. Collaborative
input from ERCP physicians, the endoscopy nursing team and technicians,
anesthesia team, patient advocates, radiologists and technicians, radiation
safety technicians, the ergonomics consultant, and the construction or
design team can result in major design evolution to allow the final
design to be optimized for the work group. The layout of a typical
tertiary-level ERCP room is depicted in Fig. 2.2. The ERCP room can
be divided into multiple work areas. The epicenter of the ERCP room
is the fluoroscopy table. The physician stands adjacent to the patient’s
head while performing ERCP. In this room design the physician also
has direct access to the radiographic equipment controls that allow
movement of the fixed C-arm or table to obtain the optimum radio-
graphic imaging. The first assistant’s workspace is immediately to the
right of the physician. Space for a trainee is preferably located immediately
to the physician’s left side. Adjacent to the first assistant’s work space
is a preparation area for a second assistant with a countertop or movable
table to prepare devices. This space should be immediately adjacent to
the in-room storage of the most often used devices. Directly above the
patient’s head is space for the sedation nurse or anesthesia team member.
This space also includes room for all necessary medications, monitoring
equipment, and resuscitative equipment. When using anesthesia, often
there are two carts: the anesthesia machine at the patient’s head, and
a secondary cart for medication and equipment storage, which must
be within easy reach of the anesthesia provider. An optimal room design
will allow ample space for these pieces of equipment, and easy access
to all spaces during the procedure. Ideally, adequate additional space
for radiograph review and report generation should be available. This
space may be behind a protective lead glass screen or in another space
altogether. In some configurations, a separate control room space for
7
8 SECTION I General Topics

FIG 2.1 Large-capacity room door and extra space around the radiography FIG 2.3 The endoscopic equipment boom allows easy access to the
table allow for transfer of large patients. There is easy access to the endoscope processor, the light source, and other key equipment, including
back of the table to facilitate movement of sedated patient after the the electrosurgical generator, CO2 insufflator, and water irrigator. The
procedure. boom keeps wires and electrical cords organized and off the floor.

Monitor panel

Anesthesia
machine
C-arm
Pre/post physician workspace
Anesthesia

Patient Anesthesia/sedation
cart

nurse workspace

First
Physician assistant
workspace workspace

Endoscope Preparation table

processor
boom Second assistant workspace

FIG 2.4 Adjustable monitor boom that can be adjusted to a height

Storage cabinets Storage cabinets Countertop
FIG 2.2 Drawing of a modern interventional endoscopy room with
workspace for the endoscopist, first assistant, anesthesia or sedation
nurse, and second assistant. The drawing also depicts the endoscopist
preprocedure and postprocedure work area, suspended bank of monitors,
and endoscopic equipment boom.
the radiographic equipment may be necessary; alternatively, if required,
a radiation technologist may be in the room.
The physician should have immediate access to all the endoscopic
and radiographic controls that are necessary to complete ERCP. The
use of ceiling booms greatly facilitates the placement of processors and
devices in close proximity to the physician and assistant with minimal
cords or tubing on the floor of the procedure room (Fig. 2.3). The
boom can be used to house the endoscope processor and light source,
electrocautery unit, and other ancillary equipment such as a CO2
insufflator, water irrigation system, EUS equipment (if compact), and
other devices. The typical room design has the endoscopic and radio-
graphic monitors directly across from the physician to allow a direct
line of sight (Fig. 2.4). The monitors should be adjustable in height to
accommodate physicians of various heights and be freely mobile during
patient positioning and procedure preparation. An ancillary monitor
to display additional images or information such as choledochoscopy,
manometry, EUS, or even patient vital signs greatly facilitates the
completion of procedures without awkward head angulation. Rooms
with video integration systems allow multiple video sources to be
displayed on the monitor array in the patient room. This can be
suitable for the endoscopist and assistants. The upper monitors can
display inputs from a variety of sources.
particularly helpful if viewing an imaging study (computed tomography
and magnetic resonance imaging) is necessary during the procedure.
The monitors should be in the line of sight of the first assistant as well
to allow coordinated device manipulation with endoscopic and/or
fluoroscopic guidance. There should be ample space for ancillary devices
(EUS processors, choledochoscopy devices, etc.) to be placed in the
room in close proximity to the physician. In larger centers with multiple
ERCP rooms, infrequently used equipment may be placed on carts that
can be moved from room to room. In the overall layout of the room,
there should be sufficient space for patients to be moved on large
stretchers or beds. Mobile ceiling-mounted booms greatly facilitate
patient movement. For improved efficiency, a portal for endoscope
cleaning should be considered to allow rapid movement of used
endoscopes to the cleaning room to facilitate room turnover. If this is
not available, appropriate containers for rapid and safe transport of
used endoscopes should be kept in the ERCP suite adjacent to the
endoscope reprocessor (Fig. 2.5).
RADIOLOGIC IMAGING EQUIPMENT
The selection of a radiologic system is one of the most important and
expensive decisions to be made during ERCP room design or upgrade.
Most hospital systems have purchasing agreements and alignments with
specific vendors, and all major manufacturers of radiology and fluoroscopy
rooms have a unit that can be well adapted to ERCP. There are

A B
FIG 2.5 (A) Portal to cleaning and cold sterilization area. (B) Trays are then covered, and following scope
use, these trays are used to immediately transfer contaminated equipment back to the reprocessing area.
TABLE 2.1 Available Fluoroscopy Units
Company C-arm Fixed Unit
Philips Y Y
Seimens Y Y
Omega N Y
GE Y Y
Toshiba N Y
also dedicated ERCP systems and portable digital C-arm systems. A
review of the principles of radiographic imaging and different imaging
systems is found in Chapter 3. The transition to digital imaging systems
in the last decade has greatly simplified image processing and storage
while essentially eliminating the need for in-room radiologic support.
The selection of a radiologic system is dependent on many factors,
including case volume, type, and patient mix. For low-volume, relatively
simple ERCP cases, many available systems are adequate. For high-volume,
complex case work (American Society for Gastrointestinal Endoscopy
[ASGE] grade of difficulty type 2 or 3 cases),1 a high-end dedicated fixed
C-arm is often best. High-end fixed rooms have sufficient power and
imaging systems to optimally image obese patients and complex strictures
and allow visualization of devices and guidewires in situations where
mobile units are inadequate. In addition, pulse rates may be adjusted
for more rapid image acquisition during difficult maneuvers while still
avoiding continuous fluoroscopy. Digital flat panel detectors provide
improved image quality, have durability over traditional analog image
intensifiers, and allow magnification of the image without increasing
radiation dose. They are available on most fixed fluoroscopy systems
and many portable C-arm platforms, but at a substantially increased
cost. A list of available fluoroscopy units is provided in Table 2.1. In
CHAPTER 2 The ERCP Room 9
Flat Detector Website
Y usa.philips.com
Y usa.healthcare.seimens.com
Y omegamedicalimaging.com
Fixed unit only www3.gehealthcare.com
Y medical.toshiba.com
addition, the radiation generation and cooling properties of fixed units
allow for prolonged procedure times without overheating or image
degradation. Investment in a fixed fluoroscopy room also allows the
room design to include dedicated shielding and radiation protection for
the staff. The addition of a radiation-attenuating drape around the image
detector has been shown to significantly decrease the radiation dose to
staff during ERCP.2 The use of ceiling-mounted and table-mounted
shielding can greatly reduce radiation scatter and staff exposure (Fig.
2.6a). Portable shields on wheels may also be integrated to provide
additional shielding (Fig. 2.6b). Building codes and hospital safety mandates
may also require shielding of the walls and doors of the suite.
ROOM INTEGRATION SYSTEMS
Video integration systems have evolved to give the operator control
over the numerous video inputs used in a state-of-the-art interventional
room. Several manufacturers sell integrated units that can be customized
for a specific room or unit layout. In a well-designed integration system,
video inputs from multiple sources can be placed on the main imaging
display in the room (Fig. 2.7). The typical integration system has multiple
inputs for EUS, choledochoscopy, or any other video signal to be placed
10 SECTION I General Topics

A B

FIG 2.6 (A) Ceiling-mounted lead shielding that can be positioned to shield those close to the radiation
source. (B) Rolling shield on wheels that can be used in units without ceiling-mounted shielding.

video integration system, it is important to have the flexibility to add

new inputs to the system as new technology becomes available.

ENDOSCOPIST WORK AREA

FIG 2.7 Video integration system touch screen monitor that allows any
video input to be placed on one of four video monitors in direct view
of the endoscopist and assistant.
into the system for recording and display on the in-room monitors,
and can be controlled by the physician or assistant directly from the
room. More sophisticated systems may allow for inputs from the hospital
radiology imaging system and electronic medical record (EMR) so that
radiology images from diagnostic studies, as well as text, images, and
other information from the EMR, can be displayed in the procedure
room. Some integration systems allow for recording and editing of
inputs to create compilation recordings or for broadcasting of multiple
inputs to a local or even distant conference room. When planning a
Intraprocedure
The endoscopist workspace during the procedure should be ergonomically
designed to be comfortable, shielded from radiation, and efficient.3,4 A
soft floor surface or cushioned mat will help prevent operator fatigue
that results from prolonged standing.5 The main room video monitors
should be directly in front of the endoscopist at eye level to reduce the
need for head rotation and to minimize neck strain.6 The monitors
should be adjustable in height and positioned to simultaneously visualize
endoscopy and fluoroscopy without the need for significant head
movement (eye shifting only) (Fig. 2.8).
The floor of the endoscopist workspace can become crowded with
pedals needed to operate the radiology equipment, electrocautery units,
irrigators, electrohydraulic lithotripsy units, and lasers. Having a set
orientation for the different activation pedals can be helpful and easily
integrated into the staff room setup procedure.
PREPROCEDURE AND POSTPROCEDURE
WORK AREA
An extensive amount of preparation is necessary before and after
performance of interventional endoscopic procedures (see Chapter 10);
a well-designed ERCP suite provides a comfortable and convenient
Another random document with
no related content on Scribd:
pretty girls and music. Well a showman’s business is to give the
public what they want.”
“I think that this city is full of people wanting inconceivable
things.... Look at it.”
“It’s all right at night when you cant see it. There’s no artistic
sense, no beautiful buildins, no old-time air, that’s what’s the matter
with it.”
They stood a while without speaking. The orchestra began
playing the waltz from The Lilac Domino. Suddenly Ellen turned to
Goldweiser and said in a curt tone. “Can you understand a woman
who wants to be a harlot, a common tart, sometimes?”
“My dear young lady what a strange thing for a sweet lovely girl to
suddenly come out and say.”
“I suppose you’re shocked.” She didnt hear his answer. She felt
she was going to cry. She pressed her sharp nails into the palms of
her hands, she held her breath until she had counted twenty. Then
she said in a choking little girl’s voice, “Harry let’s go and dance a
little.”
The sky above the cardboard buildings is a vault of beaten lead. It
would be less raw if it would snow. Ellen finds a taxi on the corner of
Seventh Avenue and lets herself sink back in the seat rubbing the
numb gloved fingers of one hand against the palm of the other.
“West Fiftyseventh, please.” Out of a sick mask of fatigue she
watches fruitstores, signs, buildings being built, trucks, girls,
messengerboys policemen through the jolting window. If I have my
child, Stan’s child, it will grow up to jolt up Seventh Avenue under a
sky of beaten lead that never snows watching fruitstores, signs,
buildings being built, trucks, girls, messengerboys, policemen.... She
presses her knees together sits up straight on the edge of the seat
with her hands clasped over her slender belly. O God the rotten joke
they’ve played on me, taking Stan away, burning him up, leaving me
nothing but this growing in me that’s going to kill me. She’s
whimpering into her numb hands. O God why wont it snow?
 As she stands on the gray pavement fumbling in her purse for a
bill, a dusteddy swirling scraps of paper along the gutter fills her
mouth with grit. The elevatorman’s face is round ebony with ivory
inlay. “Mrs. Staunton Wells?” “Yas ma’am eighth floor.”
The elevator hums as it soars. She stands looking at herself in the
narrow mirror. Suddenly something recklessly gay goes through her.
She rubs the dust off her face with a screwedup handkerchief, smiles
at the elevatorman’s smile that’s wide as the full keyboard of a piano,
and briskly rustles to the door of the apartment that a frilled maid
opens. Inside it smells of tea and furs and flowers, women’s voices
chirp to the clinking of cups like birds in an aviary. Glances flicker
about her head as she goes into the room.

There was wine spilled on the tablecloth and bits of tomatosauce

from the spaghetti. The restaurant was a steamy place with views of
the Bay of Naples painted in soupy blues and greens on the walls.
Ellen sat back in her chair from the round tableful of young men,
watching the smoke from her cigarette crinkle spirally round the fat
Chiantibottle in front of her. In her plate a slab of tricolor icecream
melted forlornly. “But good God hasnt a man some rights? No, this
industrial civilization forces us to seek a complete readjustment of
government and social life ...”
“Doesnt he use long words?” Ellen whispered to Herf who sat
beside her.
“He’s right all the same,” he growled back at her.... “The result has
been to put more power in the hands of a few men than there has
been in the history of the world since the horrible slave civilizations
of Egypt and Mesopotamia....”
“Hear hear.”
“No but I’m serious.... The only way of bucking the interests is for
working people, the proletariat, producers and consumers, anything
you want to call them, to form unions and finally get so well
organized that they can take over the whole government.”
“I think you’re entirely wrong, Martin, it’s the interests as you call
em, these horrible capitalists, that have built up this country as we
have it today.”
“Well look at it for God’s sake.... That’s what I’m saying. I wouldnt
kennel a dog in it.”
“I dont think so. I admire this country.... It’s the only fatherland I’ve
got.... And I think that all these downtrodden masses really want to
be downtrodden, they’re not fit for anything else.... If they werent
they’d be flourishing businessmen ... Those that are any good are
getting to be.”
“But I don’t think a flourishing businessman is the highest ideal of
human endeavor.”
“A whole lot higher than a rotten fiddleheaded anarchist agitator....
Those that arent crooks are crazy.”
“Look here Mead, you’ve just insulted something that you dont
understand, that you know nothing about.... I cant allow you to do
that.... You should try to understand things before you go round
insulting them.”
“An insult to the intelligence that’s what it is all this socialistic
drivel.”
Ellen tapped Herf on the sleeve. “Jimmy I’ve got to go home. Do
you want to walk a little way with me?”
“Martin, will you settle for us? We’ve got to go.... Ellie you look
terribly pale.”
“It’s just a little hot in here.... Whee, what a relief.... I hate
arguments anyway. I never can think of anything to say.”
“That bunch does nothing but chew the rag night after night.”
Eighth Avenue was full of fog that caught at their throats. Lights
bloomed dimly through it, faces loomed, glinted in silhouette and
faded like a fish in a muddy aquarium.
 “Feel better Ellie?”
“Lots.”
“I’m awfully glad.”
“Do you know you’re the only person around here who calls me
Ellie. I like it.... Everybody tries to make me seem so grown up since
I’ve been on the stage.”
“Stan used to.”
“Maybe that’s why I like it,” she said in a little trailing voice like a
cry heard at night from far away along a beach.
Jimmy felt something clamping his throat. “Oh gosh things are
rotten,” he said. “God I wish I could blame it all on capitalism the way
Martin does.”
“It’s pleasant walking like this ... I love a fog.”
They walked on without speaking. Wheels rumbled through the
muffling fog underlaid with the groping distant lowing of sirens and
steamboat whistles on the river.
“But at least you have a career.... You like your work, you’re
enormously successful,” said Herf at the corner of Fourteenth Street,
and caught her arm as they crossed.
“Dont say that.... You really dont believe it. I dont kid myself as
much as you think I do.”
“No but it’s so.”
“It used to be before I met Stan, before I loved him.... You see I
was a crazy little stagestruck kid who got launched out in a lot of
things I didnt understand before I had time to learn anything about
life.... Married at eighteen and divorced at twentytwo’s a pretty good
record.... But Stan was so wonderful....”
“I know.”
“Without ever saying anything he made me feel there were other
things ... unbelievable things....”
 “God I resent his craziness though.... It’s such a waste.”
“I cant talk about it.”
“Let’s not.”
“Jimmy you’re the only person left I can really talk to.”
“Dont want to trust me. I might go berserk on you too some day.”
They laughed.
“God I’m glad I’m not dead, arent you Ellie?”
“I dont know. Look here’s my place. I dont want you to come up....
I’m going right to bed. I feel miserably....” Jimmy stood with his hat off
looking at her. She was fumbling in her purse for her key. “Look
Jimmy I might as well tell you....” She went up to him and spoke fast
with her face turned away pointing at him with the latchkey that
caught the light of the streetlamp. The fog was like a tent round
about them. “I’m going to have a baby.... Stan’s baby. I’m going to
give up all this silly life and raise it. I dont care what happens.”
“O God that’s the bravest thing I ever heard of a woman doing....
Oh Ellie you’re so wonderful. God if I could only tell you what I....”
“Oh no.” Her voice broke and her eyes filled with tears. “I’m a silly
fool, that’s all.” She screwed up her face like a little child and ran up
the steps with the tears streaming down her face.
“Oh Ellie I want to say something to you ...”
The door closed behind her.
Jimmy Herf stood stockstill at the foot of the brownstone steps.
His temples throbbed. He wanted to break the door down after her.
He dropped on his knees and kissed the step where she had stood.
The fog swirled and flickered with colors in confetti about him. Then
the trumpet feeling ebbed and he was falling through a black
manhole. He stood stockstill. A policeman’s ballbearing eyes
searched his face as he passed, a stout blue column waving a
nightstick. Then suddenly he clenched his fists and walked off. “O
God everything is hellish,” he said aloud. He wiped the grit off his lips
with his coatsleeve.
 She puts her hand in his to jump out of the roadster as the ferry
starts, “Thanks Larry,” and follows his tall ambling body out on the
bow. A faint riverwind blows the dust and gasoline out of their
nostrils. Through the pearly night the square frames of houses along
the Drive opposite flicker like burnedout fireworks. The waves slap
tinily against the shoving bow of the ferry. A hunchback with a violin
is scratching Marianela.
“Nothing succeeds like success,” Larry is saying in a deep
droning voice.
“Oh if you knew how little I cared about anything just now you
wouldnt go on teasing me with all these words.... You know,
marriage, success, love, they’re just words.”
“But they mean everything in the world to me.... I think you’d like it
in Lima Elaine.... I waited until you were free, didnt I? And now here I
am.”
“We’re none of us that ever.... But I’m just numb.” The riverwind is
brackish. Along the viaduct above 125th Street cars crawl like
beetles. As the ferry enters the slip they hear the squudge and
rumble of wheels on asphalt.
“Well we’d better get back into the car, you wonderful creature
Elaine.”
“After all day it’s exciting isnt it Larry, getting back into the center
of things.”

Beside the smudged white door are two pushbuttons marked

Night Bell and Day Bell. She rings with a shaky finger. A short
broad man with a face like a rat and sleek black hair brushed straight
back opens. Short dollhands the color of the flesh of a mushroom
hang at his sides. He hunches his shoulders in a bow.
 “Are you the lady? Come in.”
“Is this Dr. Abrahms?”
“Yes.... You are the lady my friend phoned me about. Sit down my
dear lady.” The office smells of something like arnica. Her heart
joggles desperately between her ribs.
“You understand ...” She hates the quaver in her voice; she’s
going to faint. “You understand, Dr. Abrahms that it is absolutely
necessary. I am getting a divorce from my husband and have to
make my own living.”
“Very young, unhappily married ... I am sorry.” The doctor purrs
softly as if to himself. He heaves a hissing sigh and suddenly looks
in her eyes with black steel eyes like gimlets. “Do not be afraid, dear
lady, it is a very simple operation.... Are you ready now?”
“Yes. It wont take very long will it? If I can pull myself together I
have an engagement for tea at five.”
“You are a brave young lady. In an hour it will be forgotten.... I am
sorry.... It is very sad such a thing is necessary.... Dear lady you
should have a home and many children and a loving husband ... Will
you go in the operating room and prepare yourself.... I work without
an assistant.”
The bright searing bud of light swells in the center of the ceiling,
sprays razorsharp nickel, enamel, a dazzling sharp glass case of
sharp instruments. She takes off her hat and lets herself sink
shuddering sick on a little enamel chair. Then she gets stiffly to her
feet and undoes the band of her skirt.
The roar of the streets breaks like surf about a shell of throbbing
agony. She watches the tilt of her leather hat, the powder, the rosed
cheeks, the crimson lips that are a mask on her face. All the buttons
of her gloves are buttoned. She raises her hand. “Taxi!” A fire engine
roars past, a hosewagon with sweatyfaced men pulling on rubber
coats, a clanging hookandladder. All the feeling in her fades with the
dizzy fade of the siren. A wooden Indian, painted, with a hand raised
at the streetcorner.
“Taxi!”
“Yes ma’am.”
“Drive to the Ritz.”
Third Section
I. Rejoicing City That Dwelt Carelessly

T
here are flags on all the flagpoles up
Fifth Avenue. In the shrill wind of history
the great flags flap and tug at their
lashings on the creaking goldknobbed poles
up Fifth Avenue. The stars jiggle sedately
against the slate sky, the red and white
stripes writhe against the clouds.
In the gale of brassbands and trampling
horses and rumbling clatter of cannon,
shadows like the shadows of claws grasp at
the taut flags, the flags are hungry tongues
licking twisting curling.
Oh it’s a long way to Tipperary ... Over there! Over there!
The harbor is packed with zebrastriped
skunkstriped piebald steamboats, the
Narrows are choked with bullion, they’re
piling gold sovereigns up to the ceilings in
the Subtreasury. Dollars whine on the radio,
all the cables tap out dollars.
There’s a long long trail awinding ... Over there! Over there!
In the subway their eyes pop as they spell
out Apocalypse, typhus, cholera, shrapnel,
insurrection, death in fire, death in water,
death in hunger, death in mud.
Oh it’s a long way to Madymosell from
Armenteers, over there! The Yanks are
coming, the Yanks are coming. Down Fifth
Avenue the bands blare for the Liberty Loan
 drive, for the Red Cross drive. Hospital ships
sneak up the harbor and unload furtively at
night in old docks in Jersey. Up Fifth Avenue
the flags of the seventeen nations are flaring
curling in the shrill hungry wind.
O the oak and the ash and the weeping willow tree
And green grows the grass in God’s country.
The great flags flap and tug at their
lashings on the creaking goldknobbed poles
up Fifth Avenue.

C
aptain James Merivale D.S.C. lay with his eyes closed while
the barber’s padded fingers gently stroked his chin. The lather
tickled his nostrils; he could smell bay rum, hear the drone of an
electric vibrator, the snipping of scissors.
“A little face massage sir, get rid of a few of those blackheads sir,”
burred the barber in his ear. The barber was bald and had a round
blue chin.
“All right,” drawled Merivale, “go as far as you like. This is the first
decent shave I’ve had since war was declared.”
“Just in from overseas, Captain?”
“Yare ... been making the world safe for democracy.”
The barber smothered his words under a hot towel. “A little lilac
water Captain?”
“No dont put any of your damn lotions on me, just a little
witchhazel or something antiseptic.”
The blond manicure girl had faintly beaded lashes; she looked up
at him bewitchingly, her rosebud lips parted. “I guess you’ve just
landed Captain.... My you’ve got a good tan.” He gave up his hand to
her on the little white table. “It’s a long time Captain since anybody
took care of these hands.”
“How can you tell?”
 “Look how the cuticle’s grown.”
“We were too busy for anything like that. I’m a free man since
eight o’clock that’s all.”
“Oh it must have been terr ... ible.”
“Oh it was a great little war while it lasted.”
“I’ll say it was ... And now you’re all through Captain?”
“Of course I keep my commission in the reserve corps.”
She gave his hand a last playful tap and he got to his feet.
He put tips into the soft palm of the barber and the hard palm of
the colored boy who handed him his hat, and walked slowly up the
white marble steps. On the landing was a mirror. Captain James
Merivale stopped to look at Captain James Merivale. He was a tall
straightfeatured young man with a slight heaviness under the chin.
He wore a neat-fitting whipcord uniform picked out by the insignia of
the Rainbow Division, well furnished with ribbons and service-
stripes. The light of the mirror was reflected silvery on either calf of
his puttees. He cleared his throat as he looked himself up and down.
A young man in civilian clothes came up behind him.
“Hello James, all cleaned up?”
“You betcher.... Say isnt it a damn fool rule not letting us wear
Sam Browne belts? Spoils the whole uniform....”
“They can take all their Sam Browne’s belts and hang them on the
Commanding General’s fanny for all I care.... I’m a civilian.”
“You’re still an officer in the reserve corps, dont forget that.”
“They can take their reserve corps and shove it ten thousand
miles up the creek. Let’s go have a drink.”
“I’ve got to go up and see the folks.” They had come out on
Fortysecond Street. “Well so long James, I’m going to get so drunk
... Just imagine being free.” “So long Jerry, dont do anything I
wouldnt do.”
 Merivale walked west along Fortysecond. There were still flags
out, drooping from windows, waggling lazily from poles in the
September breeze. He looked in the shops as he walked along;
flowers, women’s stockings, candy, shirts and neckties, dresses,
colored draperies through glinting plateglass, beyond a stream of
faces, men’s razorscraped faces, girls’ faces with rouged lips and
powdered noses. It made him feel flushed and excited. He fidgeted
when he got in the subway. “Look at the stripes that one has.... He’s
a D.S.C.,” he heard a girl say to another. He got out at
Seventysecond and walked with his chest stuck out down the too
familiar brownstone street towards the river.
“How do you do, Captain Merivale,” said the elevator man.
“Well, are you out James?” cried his mother running into his arms.
He nodded and kissed her. She looked pale and wilted in her
black dress. Maisie, also in black, came rustling tall and rosycheeked
behind her. “It’s wonderful to find you both looking so well.”
“Of course we are ... as well as could be expected. My dear we’ve
had a terrible time.... You’re the head of the family now, James.”
“Poor daddy ... to go off like that.”
“That was something you missed.... Thousands of people died of
it in New York alone.”
He hugged Maisie with one arm and his mother with the other.
Nobody spoke.
“Well,” said Merivale walking into the living room, “it was a great
war while it lasted.” His mother and sister followed on his heels. He
sat down in the leather chair and stretched out his polished legs.
“You dont know how wonderful it is to get home.”
Mrs. Merivale drew up her chair close to his. “Now dear you just
tell us all about it.”
 In the dark of the stoop in front of the tenement door, he reaches
for her and drags her to him. “Dont Bouy, dont; dont be rough.” His
arms tighten like knotted cords round her back; her knees are
trembling. His mouth is groping for her mouth along one cheekbone,
down the side of her nose. She cant breathe with his lips probing her
lips. “Oh I cant stand it.” He holds her away from him. She is
staggering panting against the wall held up by his big hands.
“Nutten to worry about,” he whispers gently.
“I’ve got to go, it’s late.... I have to get up at six.”
“Well what time do you think I get up?”
“It’s mommer who might catch me....”
“Tell her to go to hell.”
“I will some day ... worse’n that ... if she dont quit pickin on me.”
She takes hold of his stubbly cheeks and kisses him quickly on the
mouth and has broken away from him and run up the four flights of
grimy stairs.
The door is still on the latch. She strips off her dancing pumps and
walks carefully through the kitchenette on aching feet. From the next
room comes the wheezy doublebarreled snoring of her uncle and
aunt. Somebody loves me, I wonder who.... The tune is all through
her body, in the throb of her feet, in the tingling place on her back
where he held her tight dancing with her. Anna you’ve got to forget it
or you wont sleep. Anna you got to forget. Dishes on the tables set
for breakfast jingle tingle hideously when she bumps against it.
“That you Anna?” comes a sleepy querulous voice from her
mother’s bed.
“Went to get a drink o water mommer.” The old woman lets the
breath out in a groan through her teeth, the bedsprings creak as she
turns over. Asleep all the time.
Somebody loves me, I wonder who. She slips off her party dress
and gets into her nightgown. Then she tiptoes to the closet to hang
up the dress and at last slides between the covers little by little so
the slats wont creak. I wonder who. Shuffle shuffle, bright lights, pink
blobbing faces, grabbing arms, tense thighs, bouncing feet. I wonder
who. Shuffle, droning saxophone tease, shuffle in time to the drum,
trombone, clarinet. Feet, thighs, cheek to cheek, Somebody loves
me.... Shuffle shuffle. I wonder who.

The baby with tiny shut purplishpink face and fists lay asleep on
the berth. Ellen was leaning over a black leather suitcase. Jimmy
Herf in his shirtsleeves was looking out the porthole.
“Well there’s the statue of Liberty.... Ellie we ought to be out on
deck.”
“It’ll be ages before we dock.... Go ahead up. I’ll come up with
Martin in a minute.”
“Oh come ahead; we’ll put the baby’s stuff in the bag while we’re
warping into the slip.”
They came out on deck into a dazzling September afternoon. The
water was greenindigo. A steady wind kept sweeping coils of brown
smoke and blobs of whitecotton steam off the high enormous
blueindigo arch of sky. Against a sootsmudged horizon, tangled with
barges, steamers, chimneys of powerplants, covered wharves,
bridges, lower New York was a pink and white tapering pyramid cut
slenderly out of cardboard.
“Ellie we ought to have Martin out so he can see.”
“And start yelling like a tugboat.... He’s better off where he is.”
They ducked under some ropes, slipped past the rattling
steamwinch and out to the bow.
“God Ellie it’s the greatest sight in the world.... I never thought I’d
ever come back, did you?”
“I had every intention of coming back.”
“Not like this.”
“No I dont suppose I did.”
 “S’il vous plait madame ...”
A sailor was motioning them back. Ellen turned her face into the
wind to get the coppery whisps of hair out of her eyes. “C’est beau,
n’est-ce pas?” She smiled into the wind into the sailor’s red face.
“J’aime mieux Le Havre ... S’il vous plait madame.”
“Well I’ll go down and pack Martin up.”
The hard chug, chug of the tugboat coming alongside beat
Jimmy’s answer out of her ears. She slipped away from him and
went down to the cabin again.
They were wedged in the jam of people at the end of the
gangplank.
“Look we could wait for a porter,” said Ellen.
“No dear I’ve got them.” Jimmy was sweating and staggering with
a suitcase in each hand and packages under his arms. In Ellen’s
arms the baby was cooing stretching tiny spread hands towards the
faces all round.
“D’you know it?” said Jimmy as they crossed the gangplank, “I
kinder wish we were just going on board.... I hate getting home.”
“I dont hate it.... There’s H ... I’ll follow right along.... I wanted to
look for Frances and Bob. Hello....” “Well I’ll be ...” “Helena you’ve
gained, you’re looking wonderfully. Where’s Jimps?” Jimmy was
rubbing his hands together, stiff and chafed from handles of the
heavy suitcases.
“Hello Herf. Hello Frances. Isn’t this swell?”
“Gosh I’m glad to see you....”
“Jimps the thing for me to do is go right on to the Brevoort with the
baby ...”
“Isn’t he sweet.”
“... Have you got five dollars?”
 “I’ve only got a dollar in change. That hundred is in express
checks.”
“I’ve got plenty of money. Helena and I’ll go to the hotel and you
boys can come along with the baggage.”
“Inspector is it all right if I go through with the baby? My husband
will look after the trunks.”
“Why surely madam, go right ahead.”
“Isnt he nice? Oh Frances this is lots of fun.”
“Go ahead Bob I can finish this up alone quicker.... You convoy
the ladies to the Brevoort.”
“Well we hate to leave you.”
“Oh go ahead.... I’ll be right along.”
“Mr. James Herf and wife and infant ... is that it?”
“Yes that’s right.”
“I’ll be right with you, Mr. Herf.... Is all the baggage there?”
“Yes everything’s there.”
“Isnt he good?” clucked Frances as she and Hildebrand followed
Ellen into the cab.
“Who?”
“The baby of course....”
“Oh you ought to see him sometimes.... He seems to like
traveling.”
A plainclothesman opened the door of the cab and looked in as
they went out the gate. “Want to smell our breaths?” asked
Hildebrand. The man had a face like a block of wood. He closed the
door. “Helena doesn’t know prohibition yet, does she?”
“He gave me a scare ... Look.”
“Good gracious!” From under the blanket that was wrapped round
the baby she produced a brownpaper package.... “Two quarts of our
special cognac ... gout famille ’Erf ... and I’ve got another quart in a
hotwaterbottle under my waistband.... That’s why I look as if I was
going to have another baby.”
The Hildebrands began hooting with laughter.
“Jimp’s got a hotwaterbottle round his middle too and chartreuse
in a flask on his hip.... We’ll probably have to go and bail him out of
jail.”
They were still laughing so that tears were streaming down their
faces when they drew up at the hotel. In the elevator the baby began
to wail.
As soon as she had closed the door of the big sunny room she
fished the hotwaterbottle from under her dress. “Look Bob phone
down for some cracked ice and seltzer.... We’ll all have a cognac a
l’eau de selz....”
“Hadn’t we better wait for Jimps?”
“Oh he’ll be right here.... We haven’t anything dutiable.... Much
too broke to have anything.... Frances what do you do about milk in
New York?”
“How should I know, Helena?” Frances Hildebrand flushed and
walked to the window.
“Oh well we’ll give him his food again.... He’s done fairly well on it
on the trip.” Ellen had laid the baby on the bed. He lay kicking,
looking about with dark round goldstone eyes.
“Isnt he fat?”
“He’s so healthy I’m sure he must be halfwitted.... Oh Heavens
and I’ve got to call up my father.... Isnt family life just too desperately
complicated?”
Ellen was setting up her little alcohol stove on the washstand. The
bellboy came with glasses and a bowl of clinking ice and White Rock
on a tray.
“You fix us a drink out of the hotwaterbottle. We’ve got to use that
up or it’ll eat the rubber.... And we’ll drink to the Café d’Harcourt.”
 “Of course what you kids dont realize,” said Hildebrand, “is that
the difficulty under prohibition is keeping sober.”
Ellen laughed; she stood over the little lamp that gave out a quiet
domestic smell of hot nickel and burned alcohol.

George Baldwin was walking up Madison Avenue with his light

overcoat on his arm. His fagged spirits were reviving in the sparkling
autumn twilight of the streets. From block to block through the
taxiwhirring gasoline gloaming two lawyers in black frock coats and
stiff wing collars argued in his head. If you go home it will be cozy in
the library. The apartment will be gloomy and quiet and you can sit in
your slippers under the bust of Scipio Africanus in the leather chair
and read and have dinner sent in to you.... Nevada would be jolly
and coarse and tell you funny stories.... She would have all the City
Hall gossip ... good to know.... But you’re not going to see Nevada
any more ... too dangerous; she gets you all wrought up.... And
Cecily sitting faded and elegant and slender biting her lips and hating
me, hating life.... Good God how am I going to get my existence
straightened out? He stopped in front of a flowerstore. A moist warm
honied expensive smell came from the door, densely out into the
keen steelblue street. If I could at least make my financial position
impregnable.... In the window was a minature Japanese garden with
brokenback bridges and ponds where the goldfish looked big as
whales. Proportion, that’s it. To lay out your life like a prudent
gardener, plowing and sowing. No I wont go to see Nevada tonight. I
might send her some flowers though. Yellow roses, those coppery
roses ... it’s Elaine who ought to wear those. Imagine her married
again and with a baby. He went into the store. “What’s that rose?”
“It’s Gold of Ophir sir.”
“All right I want two dozen sent down to the Brevoort
immediately.... Miss Elaine ... No Mr. and Mrs. James Herf.... I’ll write
a card.”
 He sat down at the desk with a pen in his hand. Incense of roses,
incense out of the dark fire of her hair.... No nonsense for Heaven’s
sake ...
Dear Elaine,
I hope you will allow an old friend to call on you and your
husband one of these days. And please remember that I am
always sincerely anxious—you know me too well to take this
for an empty offer of politeness—to serve you and him in any
way that could possibly contribute to your happiness. Forgive
me if I subscribe myself your lifelong slave and admirer
George Baldwin
The letter covered three of the florists’ white cards. He read it over
with pursed lips, carefully crossing the t’s and dotting the i’s. Then he
paid the florist from the roll of bills he took from his back pocket and
went out into the street again. It was already night, going on to seven
o’clock. Still hesitating he stood at the corner watching the taxis
pass, yellow, red, green, tangerinecolored.

The snubnosed transport sludges slowly through the Narrows in

the rain. Sergeant-Major O’Keefe and Private 1st Class Dutch
Robertson stand in the lee of the deckhouse looking at the liners at
anchor in quarantine and the low wharfcluttered shores.
“Look some of em still got their warpaint—Shippin Board boats....
Not worth the powder to blow em up.”
“The hell they aint,” said Joey O’Keefe vaguely.
“Gosh little old New York’s goin to look good to me....”
“Me too Sarge, rain or shine I dont care.”
They are passing close to a mass of steamers anchored in a
block, some of them listing to one side or the other, lanky ships with
short funnels, stumpy ships with tall funnels red with rust, some of