There are many websites one can visit which will explain what ERCP is, at a basic level. The patient Information leaflet hospitals provide should also provide similar information. Some hospitals may also have information on their web-sites.

However, there is a very important aspect of ERCP that is rarely explained adequately. It is the use of a pre-cut. This is this procedure which led to the death of my partner. Its use came as a complete shock to me as we had not been advised of this aspect of the procedure and there was no mention in the Patient Information leaflet we had. 

Patients are told that ERCP is an endoscopic procedure with two stages. The first (diagnostic) stage involves the insertion of a small tube up the ampulla of vater (the location in the duodenum where bile - from the liver and gall-bladder - and pancreatic secretions enter the gut). The tube is directed into the lower end of the common bile duct (biliary tract) and a dye injected to delineate (on an X-Ray) the pathology of the bile duct. This will locate where any bile duct stones and/or other restrictions / diseased areas are located. When this has been done, the second (therapeutic) stage is started whereby a larger instrument is inserted which has the ability to break up / extricate gall-stones and/or insert stents, etc.

One might imagine from this explanation that the first stage is relatively safe and the second stage riskier. However, one would be wrong to believe this! I believe many patients are proceeding to have ERCP in the mistaken belief that they will be ‘safe’ up until the point when it has been categorically confirmed that the procedure needs to become ‘riskier’. This is the great ERCP deception!

What patients are most unlikely to be told is this:

The process of inserting the tube into the biliary tract can be difficult. Success depends on the skill of the surgeon, on the anatomy of the patient and luck. Anatomy can vary a lot between patients, so can ERCPist skill levels. As a result, many attempts may be necessary to get the tube inserted correctly. The problem then is that every attempt pushes more bacteria from the gut into the pancreatic duct (from which the biliary tract leads off). These bacteria can cause pancreatitis and post ERCP pancreatitis is very common (about a 1 in 20 risk). Sometimes this can be serious and lead to sepsis: which can in turn be fatal. As a result, many ERCP surgeons will not want to make too many such 'cannulation' attempts: they will elect to do a 'precut' instead. A pre-cut involves the use of a needle-knife: a small 2mm diameter heated needle which is positioned at a very precise point (on the periphery of the ampulla of vater) and inserted so as to burn a hole through to the biliary tract. Done successfully, this will then enable the tube to be inserted into the biliary tract so that the die can be injected. The therapeutic stage can then also occur through this access point.

However, performing a 'pre-cut' also carries another serious risk: that of a perforation of the duodenum. It can also cause bleeding. The skill of the ERCP surgeon is of paramount importance and success rates can vary a lot between surgeons. Patients also need to be lucky with their anatomy! If one has a large diameter bile duct (some can be up to 10 mm diameter) it is a relatively easy target to hit. However, if one has a more typical bile duct of no more than 4mm diameter (some can be as little as 3 mm) it is a more difficult target to hit. Also some people have thick duodenal walls and may even have the pancreas head surrounding it. Others may have thin walls and no pancreatic cover. It is the latter patients, with small bile ducts who are most at risk of perforation: the needle-knife can burn through the abdominal wall into the abdominal cavity. Not only will such an event cause the ERCP procedure to be abandoned before it has done any good (because the common bile duct has not been accessed), but the patient has now received a most serious life threatening injury. Such perforations have a high chance of leading to sepsis and death through the leakage of bile, pancreatic juices and bacteria into the abdominal cavity: which all cause a highly inflammatory response. Unless such patients receive truly world-class expert care at this point they stand a high chance of death. Sadly, such expert care appears to be rare in the UK and so (I believe) such patients are likely to have a 1 in 3 chance of death.

I have learnt that some surgeons resort to precuts quite early because they believe the risks from pancreatitis is greater than the risks from perforation. However, the paper that provides the evidence for this view (I'll add the link later) is one that draws on experiences from many international sources. My own research to date has however indicated that the countries / establishments providing the supporting data all appear to use best 'world-class' procedures for treating patients with perforations. In particular, the majority use endoscopic naso-biliary drainage (ENBD) to try and ensure there is no leakage through the perforation. This, I am reliably informed, is not common in UK hospitals.

I strongly suspect there is NO UK derived evidence that will support the use of early pre-cuts in Hospitals where ENBD is not routinely used after perforations. If there is I would very much like to be provided with this (as I would any other useful information) and I will incorporate this into this web-site.

I have reluctantly concluded our NHS does not generally practice world class medicine with its ERCP procedures and that patients undergoing ERCP should be aware of this. They need to truly assess for themselves that their risks from not having ERCP are greater than the risks of having it. All patients should realize that if a perforation happens, and sepsis sets in, they are most likely to:

- have a major laparotomy operation (with a high risk of death) after 2 to 3 days after which they will probably be put into an induced coma in an intensive care ward.

- if they are lucky, they will come round after a few weeks and spend another 3 months in hospital. There may be some life changing ramifications stemming from the surgery and / or the antibiotics. 

- if they are unlucky (like my partner) they may die within an average of 9 days after ERCP without regaining consciousness.

I would wager that few elective patients would have died that quickly if they had not had ERCP, no matter how ill they were. Patients should be told to consider this. I would urge all patients to fully inform their family of the risks as it is incredibly traumatic to lose a loved one so quickly. There is no time to prepare for death as with most other illnesses.