What is a therapeutic ERCP?
Endoscopic retrograde cholangiopancreatography, or ERCP, is a study of the ducts that drain the liver and pancreas. Ducts are drainage routes into the bowel. The ones that drain the liver and gallbladder are called bile or biliary ducts. The one that drains the pancreas is called the pancreatic duct. The bile and pancreatic ducts join together just before they drain into the upper bowel, about 3 inches from the stomach. The drainage opening is called the papilla. The papilla is surrounded by a circular muscle, called the sphincter of Oddi.
Diagnostic ERCP is when X-ray contrast dye is injected into the bile duct, the pancreatic duct, or both. This contrast dye is squirted through a small tube called a catheter that fits through the ERCP endoscope. X-rays are taken during ERCP to get pictures of these ducts. That is called diagnostic ERCP. However, most ERCPs are actually done for treatment and not just picture taking. When an ERCP is done to allow treatment, it is called therapeutic ERCP.
What treatments can be done through an ERCP scope?
Sphincterotomy is cutting the muscle that surrounds the opening of the ducts, or the papilla. This cut is made to enlarge the opening. The cut is made while your doctor looks through the ERCP scope at the papilla, or duct opening. A small wire on a specialized catheter uses electric current to cut the tissue. A sphincterotomy does not cause discomfort, you do not have nerve endings there. The actual cut is quite small, usually less than a 1/2 inch. This small cut, or sphincterotomy, allows various treatments in the ducts. Most commonly the cut is directed towards the bile duct, called a biliary sphincterotomy. Occasionally, the cutting is directed towards the pancreatic duct, depending on the type of treatment you need.
The most common treatment through an ERCP scope is removal of bile duct stones. These stones may have formed in the gallbladder and traveled into the bile duct or may form in the duct itself years after your gallbladder has been removed. After a sphincterotomy is performed to enlarge the opening of the bile duct, stones can be pulled from the duct into the bowel. A variety of balloons and baskets attached to specialized catheters can be passed through the ERCP scope into the ducts allowing stone removal. Very large stones may require crushing in the duct with a specialized basket so the fragments can be pulled out through the sphincterotomy.
Stents are placed into the bile or pancreatic ducts to bypass strictures, or narrowed parts of the duct. These narrowed areas of the bile or pancreatic duct are due to scar tissue or tumors that cause blockage of normal duct drainage. There are two types of stents that are commonly used. The first is made of plastic and looks like a small straw. A plastic stent can be pushed through the ERCP scope into a blocked duct to allow normal drainage. The second type of stent is made of metal wires that looks like the cross wires of a fence. The metal stent is flexible and springs open to a larger diameter than plastic stents. Both plastic and metal stents tend to clog up after several months and you may require another ERCP to place a new stent. Metal stents are permanent while plastic stents are easily removed at a repeat procedure. Your doctor will choose the best type of stent for your problem.
There are ERCP catheters fitted with dilating balloons that can be placed across a narrowed area or stricture. The balloon is then inflated to stretch out the narrowing. Dilation with balloons is often performed when the cause of the narrowing is benign (not a cancer). After balloon dilation, a temporary stent may be placed for a few months to help maintain the dilation.
One procedure that is commonly performed through the ERCP scope is to take samples of tissue from the papilla or from the bile or pancreatic ducts. There are several different sampling techniques although the most common is to brush the area with subsequent examination of the cells obtained. Tissue samples can help decide if a stricture, or narrowing, is due to a cancer. If the sample is positive for cancer it is very accurate. Unfortunately, a tissue sampling that does not show cancer may not be accurate.
Probiotics are living, microscopic (very small) organisms that can help your gut health.
Most often, probiotics are bacteria, but they may also be other organisms, such as yeasts.
Experts are still studying and sorting out exactly how probiotics work. They may:
Boost your immune system.
Help prevent infection.
Stop harmful bacteria from attaching to the gut lining and growing there.
Send signals to your cells to build up the mucus in your gut and help it act as a barrier against infection.
Stop or kill toxins released by certain bacteria that can make you sick.
Promote the growth of other bacteria that can improve your health.
Maintain healthy skin and a healthy nervous system.
Many types of bacteria may be probiotics. Research is being done to learn more. The most common probiotic bacteria come from two groups, Lactobacillus and Bifidobacterium.
Probiotics can now be found as a pill or powder, or in some foods, such as yogurt.
Probiotics have been around for many years, but lately have become more popular. There are many kinds you can buy. Talk to your doctor about which kinds of probiotics are best for you.
Experts and doctors say more studies are needed to help find out which probiotics are helpful and which might be a waste of money.
Any time an internal body part pushes into an area where it doesn’t belong, it’s called a hernia.
The hiatus is an opening in the diaphragm — the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus (food pipe) goes through the hiatus and attaches to the stomach. In a hiatal hernia (also called hiatus hernia) the stomach bulges up into the chest through that opening.
There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).
In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia.
The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become “strangled,” or have its blood supply shut off.
Many people with hiatal hernia have no symptoms, but others may have heartburn related to gastroesophageal reflux disease, or GERD. Although there appears to be a link, one condition does not seem to cause the other, because many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia.
Emergency medicine, also known as accident and emergency medicine, is the medical specialtyconcerned with caring for undifferentiated, unscheduled patients with illnesses or injuries requiring immediate medical attention. In their role as first-line providers, emergency physicians are responsible for initiating resuscitation and stabilization, starting investigations and interventions to diagnose and treat illnesses in the acute phase, coordinating care with specialists, and determining disposition regarding patients’ need for hospital admission, observation, or discharge. Emergency physicians generally practice in hospital emergency departments
Critical care: The specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring.
Matthew Johnson is a Fellowship Trained Trauma, Emergency & Critical Care physician.
What Is General Surgery?
General surgeons care for a wide range of conditions, from cancer to obesity. General surgery is a surgical specialty that focuses on the complex and interrelated organs in the abdomen. These include:
- Small bowel
- Bile ducts
General Surgery Procedures
You may have many questions about your surgical procedure. How will my doctor decide whether I need surgery? Will I need to stay overnight in the hospital? What type of anesthesia will the surgeon use?
Dr Matthew Johnson and the entire staff at Desert Surgical Associates are available to answer your questions.
MATTHEW JOHNSON, MD Trauma Surgeon, General Surgeon &
Critical Care Surgeon
Dr. Matthew Johnson is a very compassionate surgeon that always takes extra time when communicating with his patients as well as their families regarding their care. He is driven, kind, and extremely innovative in the field of surgery. He is also one of the few surgical endoscopists in the country. In 2011, as a chief resident, he received the Professionalism Award at the University of Nevada School of Medicine and continues to emphasize this professionalism throughout his surgical practice. He is very well respected by his colleagues in the field and always strives for perfection.
Dr. Johnson did his undergraduate training at the University of Texas at Austin and is a faithful Texas Longhorn to this day. He subsequently attained his Medical Doctorate at the American University of the Caribbean, in St. Maarten, N.A. where he also attained a Masters in Medical Science (M.M.S.). Dr. Johnson’s residency training was completed at the University of Nevada School of Medicine, Las Vegas, NV in General Surgery (2005-11).
He then went on to become one of the early fellows in the country to complete an Acute Care Surgery fellowship at the University of Nevada School of Medicine, Las Vegas, NV (2011-13). During his residency and fellowship, Dr. Johnson also trained in Surgical Endoscopy with a specific emphasis on both diagnostic & therapeutic ERCP. In fact, along with other colleagues, he developed a new method for treating obstructing complicated biliary disease using combined cholecystectomy and ERCP in a one stage procedure, so-called the “One-Step/ELBS”. Throughout residency and fellowship, Dr. Johnson presented at many national conferences regarding ERCP use by surgeons for trauma and general surgery in addition to authoring several publications.
Following post-graduate training, Dr. Johnson joined Desert Surgical Associates and hit the ground running. He cares for patients in the field of general surgery, minimally invasive surgery, trauma, and critical care. Dr. Johnson’s specific interests involve minimally invasive robotic surgery, advancement of minimally invasive surgery in trauma patients, foregut surgery, hepatobiliary surgery and the use of ERCP for both diagnostic and therapeutic measures.
Medical historians disagree on which was the first robot for medical use and when the first robot-assisted surgery took place. Some say the first was the “Arthrobot”, which was developed and used for the first time in Vancouver, BC, Canada in 1983. Others say the first documented use of a robot to assist with a surgical procedure occurred in 1985 when the PUMA 560 was used with CT scan to place a needle for a neurosurgical biopsy. They can agree on one thing about its history, though; the robotic system offered greater precision and successful outcomes. This led to the first robot-assisted laparoscopic procedure in 1987.
Experts continued to improve on these surgery-enhancing robotic machines over the next 20 years, and in 2000, the da Vinci robot became the first complete robotic surgical system to be approved by the FDA for general laparoscopic surgery. Since then, the list of procedures performed laparoscopically with robot assistance has grown at a pace consistent with improvements in technology and the technical skill of surgeons. Now daVinci is used frequently around the world for performing bariatric and gastrointestinal surgery, cardiothoracic surgery, ear, nose and throat surgery, gynecological surgery, and even pediatric surgery, among others.
Surgeons, patients, and insurance companies agree that minimally invasive, robot-assisted surgery offers great benefits over traditional open surgery. Incisions are smaller, so procedures leave little to no scars. The risk of infection is less, hospital stays are shorter, if necessary at all, and convalescence is significantly reduced. Many studies have shown that laparoscopic procedures result in decreased hospital stays, a quicker return to the workforce, decreased pain, and better postoperative immune function.
If you think you might be a candidate for robotic surgery, schedule a consultation with Dr. Johnson, a Las Vegas board-certified robotic surgeon.
Nighttime heartburn may be particularly dangerous. Waking up with a sour taste in the mouth, coughing, or sore throat may indicate nighttime acid reflux. Not only does it disturb sleep, but the esophagus may sustain more damage. That’s because when you are lying down for several hours, acid has a lot of time to linger in the esophagus and damage the tissue. When we are awake, we swallow saliva throughout the day. Saliva helps neutralize stomach acid. We naturally swallow less saliva when we sleep, so stomach acid is not neutralized.