{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 28, Ep 4 of 7: When Standard ERCP Fails","html":"<iframe width=\"100%\" height=\"180\" frameborder=\"no\" scrolling=\"no\" seamless src=\"https://share.transistor.fm/e/9c70a9f6\"></iframe>","width":"100%","height":180,"duration":976,"description":"Episode four picks up the moment standard ERCP fails, and it runs on a single habit: name the anatomic barrier and let it choose the technique. When you cannot cannulate the papilla, a dilated duct becomes an EUS target, and the finishing options rank by how much natural drainage they keep, rendezvous over choledochoduodenostomy over hepaticogastrostomy. When surgery has hidden the papilla, the question is how to restore the duodenoscope's en face view through the particular barrier, so EDGE tunnels into the bypassed stomach, balloon enteroscopy reaches a hepaticojejunostomy, and a reversed cautious approach handles Billroth two. Device design and technique are consequences of the anatomy, not lists to memorize.\n \nTopics covered\n\nEUS-guided biliary drainage and the dilated-duct target\nEUS-guided rendezvous\nCholedochoduodenostomy with a LAMS\nHepaticogastrostomy and anti-migration stents\nRoux-en-Y gastric bypass and the EDGE procedure\nBalloon enteroscopy for hepaticojejunostomy\nBillroth two and the reversed sphincterotomy\nEn face access as the organizing principle\n \n \nKey decisions\n\nReserve EUS-guided biliary drainage for obstruction with upstream dilation, because a dilated duct is the only target you can puncture; a normal-caliber duct offers nothing to aim at.\nChoose EUS-guided rendezvous first whenever the papilla is reachable, since advancing a wire across the papilla for a duodenoscope preserves natural drainage and leaves no permanent fistula.\nUse choledochoduodenostomy with a lumen-apposing metal stent when the papilla is unreachable but the extrahepatic duct sits within a centimeter of the duodenal bulb with no intervening vessels on Doppler.\nFall back to hepaticogastrostomy with a partially covered stent (covered tract segment, uncovered intraductal segment) only when neither the papilla nor the extrahepatic duct is available and a dilated left intrahepatic duct remains.\nPrefer the EDGE procedure over balloon enteroscopy in Roux-en-Y gastric bypass, then...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}