Indications: Abdominal pain, Abnormal liver function test, For therapy of chronic pancreatitis, Pancreatic duct stricture
Procedure:After obtaining informed consent, the scope was passed under direct vision. Throughout the procedure,the patient's blood pressure, pulse, and oxygen saturations were monitored continuously. The Duodenoscope was introduced through the mouth, and advanced to the duodenum and used to inject contrast into the bile duct and ventral pancreatic duct. The ERCP was accomplished without difficulty.
The patient tolerated the procedure well.
FINDINGS:A scout film of the abdomen was obtained. The esophagus was successfully intubated under direct vision without detailed
examination of the pharynx, larynx, and associated structures, and upper GI tract. The upper GI tract was grossly normal.
A pancreatic sphincterotomy had been performed previously. The sphincterotomy appeared open. The ventral pancreatic
duct was deeply cannulated with the short-nosed traction sphincterotome. Contrast was injected. Chronic pancreatitis
changes were seen diffusely throughout the main pancreatic duct. These changes include beading of the main pancreatic
duct, dilation of the main pancreatic duct, irregularity of the main pancreatic duct, and abnormal side branches with dilation
of side branches, irregularity of side branches and tortuosity of side branches. The pancreatic duct in the genu of the
pancreas contained a severe stenosis four mm in length. Despite multiple attempts using a 0.035 inch Dreamwire, 0.025
inch Visiglide wire, 0.021 inch Tracer Metro Direct wire, and 0.018 inch Roadrunner wire, the stricture could not be
traversed. A 0.025 inch angled Visiglide wire was passed into the biliary tree. The short-nosed traction sphincterotome
was passed over the guidewire and the bile duct was then deeply cannulated. Contrast was injected. The lower third of
the main bile duct contained a single localized stenosis 20 mm in length. The middle third of the main bile duct, upper third
of the main bile duct and left and right hepatic ducts and all intrahepatic branches were diffusely dilated. The largest
diameter was 12 mm. A 6 mm biliary sphincterotomy was made with a monofilament short-tip traction sphincterotome
using ERBE Endocut electrocautery. There was no post-sphincterotomy bleeding. The biliary tree was swept with an 11.5
mm balloon starting at the bifurcation. Nothing was found. Dilation of the stricture and biliary orifice with a 10-11-12 mm x
180 cm CRE balloon (to a maximum balloon size of 12 mm) dilator was successful. Two 10 Fr by 7 cm biliary stents with a
single external flap and a single internal flap were placed into the bile duct. Bile flowed through the stents. The stents
were in good position. The echoendoscope was then inserted into the body of the stomach. The body and tail of the
pancreas was atrophic and contained numerous parenchymal calcifications. The main pancreatic duct in the body and tail
of the pancreas was dilated. A 19 gauge EchoTip Access needle was then inserted through the stomach and into the main
pancreatic duct in the body of the pancreas. Contrast was injected and a pancreatogram was obtained confirmed position
within the pancreatic duct. A long 0.035 inch Jagwire was then advanced in an antegrade fashion through the FNA needle
and into the main pancreatic duct in the body of the pancreas. The guidewire was then successfully advanced through the
stricture and through the major papilla and into the duodenum. The echoendoscope was then removed and the duodenoscope was advanced into the duodenum over the guidewire. A 4mm dilating balloon was then successfully advanced in a retrograde fashion over the guidewire and into the main pancreatic duct and through the stricture. The
stricture was dilated with a 4mm balloon and then a 6mm balloon. Both dilations were extended to the pancreatic orifice. The guidewire was then repositioned into the tail of the pancreas. One 10Fr by 8cm pancreatic duct stent (Johlin) was then placed across the stricture and across the site of trans-gastric pancreatic duct puncture.
IMPRESSION:- Fluoroscopic and endosonographic changes of the pancreas consistent with severe pancreatitis with
severe stricture of the main pancreatic duct in the genu. EUS guided pancreatic duct rendezvous
performed to access the entire pancreatic duct. Stricture treated with balloon dilation to 6mm and placement of a 10Fr by 8cm pancreatic duct stent. - Stricture of the intrapancreatic portion of the CBD with dilation of the biliary tree proximally. After biliary
sphincterotomy, the stricture was dilated to 12mm and two 10Fr by 7cm plastic biliary stents placed
Our physician is calling the EUS guided a non standard procedure.
This is how I would could it. 43264,43268-59,43271-59,43262-59,43273 for the ERCP 43249,43248 Am I correct? I have never coded and ERCP & EUS like this ever.