ERCP with Insertion of a Metallic Stent: Tips and Tricks

ERCP with insertion of a metallic stent: tips and tricks. In this illustrative video, we outline the key steps for inserting a biliary metallic stent during ERCP in a lower CBD neoplasic stricture.

Cannulation and Initial Assessment

- After successful cannulation, determine the required stent length.  

- Inject contrast starting at the upper common bile duct while withdrawing the sphincterotome to identify the upper boundary of the stricture.

 Measuring Stent Length

- Option 1: Use the diameter of the scope (11 mm) to approximate the length, ensuring the stent extends about 2 cm above the stricture and 1 cm beyond the papilla.  

- Option 2: Use the marker on the sphincterotome. Place the marker 2 cm above the stricture, then withdraw the sphincterotome while maintaining your finger position. Measure the length of the sphincterotome outside the scope to determine the required stent length.

 Sphincterotomy

- Perform a short, limited sphincterotomy. While there is no strict consensus, many experts recommend a minimal sphincterotomy when placing SEMS across the sphincter to reduce the risk of pancreatitis.  

- After the sphincterotomy, withdraw the sphincterotome, leaving the guidewire in place.

Stent Insertion

- Slowly insert the stent while securing the guidewire with the elevator.  

- Push the stent out of the scope and carefully approach the papilla using the large wheel of the endoscope.  

- As the stent advances into the lower CBD, you may encounter resistance due to the stricture. Ensure the guidewire is not looping in the intrahepatic duct. If looping occurs, retract the guidewire by 2 cm to facilitate stent progression.  

- Confirm the proximal part of the stent is visible outside the scope.

Stent Deployment

- Once the stent is in position, focus on the endoscopic view and instruct the nurse to begin releasing the stent.  

- As the stent starts moving within the sheath, switch to fluoroscopy to monitor the release of the distal portion and ensure it is fully opened.  

- Return to the endoscopic view to confirm the distal portion is correctly positioned. Maintain visualization of the proximal part during release, ensuring it is 1.5 cm outside the papilla. Remember, the stent will shorten after full expansion within 1–2 days.

Final Steps

- Apply suction near the stent to evacuate the injected contrast, confirming complete drainage.  

- Verify the entire stent placement and ensure proper drainage before concluding the procedure.