ERCP: a very personal history
2023; Lippincott Williams & Wilkins; Volume: 22; Issue: 6 Linguagem: Inglês
10.1097/cld.0000000000000028
ISSN2046-2484
Autores Tópico(s)Intestinal Malrotation and Obstruction Disorders
ResumoINTRODUCTION My career, so far, has spanned the birth, childhood, adolescence, and maturity of a group of procedures and techniques based on the simple idea of passing catheters and other devices across the major and minor duodenal papillae into the pancreatic and biliary ductal systems. But here, early on, I must digress and reflect on the 2 eponymous structures that have occupied so much of my professional life and were described, respectively, by Abraham Vater (1684–1751) and Ruggero Oddi (1864–1913). The university town of Wittenberg on the River Elbe, in Saxony-Anhalt, Germany, is inexorably associated with the memory of Martin Luther (1483–1546) and his arguments (95 Theses) against the Catholic Church, which tradition teaches he nailed to a church door thereby ushering in the Protestant Reformation. Wittenberg is thus known by the honorific Lutherstadt. But for gastroenterologists and especially endoscopists, it is memorialized as the town where Abraham Vater was born, flourished, and died. Having graduated in Medicine in Leipzig, some 37 miles away, Vater pursued his scientific studies peripatetically in Germany, North Holland in the Netherlands, and England, before gaining the prequisite habilitation as a Dozent, allowing him to achieve full professorship in his alma mater, where he became Professor Primus (Figure 1). Vater described the dilated confluence of the distal pancreatic and common bile ducts, which incidentally he called neither an ampulla nor a papilla, as is often mistaken, but a diverticulum.1—where bile and pancreatic juice mingle, and through the major papilla, they enter the duodenum. Vater was elected to both the Royal Society in London and the Prussian Academy of Sciences and, ironically, died of jaundice.FIGURE 1: Plaque commemorating Abraham Vater at Schloßstraße 14–16 in Wittenberg, Reproduced from Wikipedia.Compared with Vater's conventional staid career, Oddi's biography reads like a Victorian melodrama worthy of a streaming television series or a Hollywood movie. He discovered the sphincter that bears his name when he was a fourth-year medical student at Perugia in Umbria, Italy, after an extensive anatomical investigation in humans and many other species and physiological and neurophysiological studies of sphincter function. At age 29, he was promoted to the Chair of Physiology at the University of Genoa, but his life soon spiraled downward due to financial ruin, addiction, severe depression, the unexplained disappearance of his wife, his conversion to Indian mysticism, the practice of homeopathy including prescribing/purveying the concoction called Gatchkowski's Vitaline, [a mixture of glycerin, sodium borate, ammonium chloride, and alcohol] (which allegedly cured his own depression), and being accused of abuse of medications and involuntary manslaughter. His wanderings took him to Spain, Belgium, and the Congo and culminated in his mysterious death in Tunisia. Endoscopic cannulation of the major duodenal papilla under direct vision and the retrograde opacification of the bile ducts (cholangiography) and pancreatic ductal system (pancreatography) were first described by surgeons at the George Washington School of Medicine in Washington DC,2 using a specially modified duodenoscope to which a tract for the cannula was taped on the anterior side of the instrument, and just proximal to the viewing lens a cuff balloon was placed anteriorly, which when inflated brought the mucosa into focus. The term endoscopic retrograde cholangiopancreatography (and the acronym, ERCP) that was proposed by the British and future US Patriarch of Endoscopy and ERCP, Peter Benjamin Cotton [born 1939 in Herefordshire UK, now Emeritus Professor of Medicine at the Medical University of South Carolina, Charleston SC, USA. Dr Reuben, the Series Editor, recalls that "perhaps in jest, Peter Benjamin Cotton (PBC) inexplicably preferred the tautological term PancreatoBiliaryCholangiography (PBC), which somehow did not pass muster.] (Figure 2A), was adopted in 1974 at the World Congress of Gastroenterology in Mexico.3 However, it transpired that this was not the first recording of peroral access to the pancreatobiliary system. In 1965, Rabinov and Simon from the Department of Radiology, Harvard University Medical School, and the Department of Radiology Beth Israel Hospital, Boston, MA, published their success at cannulating the major duodenal papilla (in a patient with postcholecystectomy jaundice), using a Rube Goldberg-like [Byname of Reuben Lucius Goldberg, (1883–1970), American cartoonist who satirized the American preoccupation with technology. His name became synonymous with outlandishly complicated machinery designed to accomplish any simple process, akin to contemporaneous Heath Robinson (1872–1944) contraptions in Britain, where the eponymous term gained dictionary recognition around 1912] angled-tip catheter that was positioned skillfully/fortuitously using external fluoroscopy.4 Instillation of contrast medium showed dilatation of the common bile duct containing calculi.FIGURE 2: A. Professor Peter Cotton (retired), "Leading Light" Endoscopist, Medical University of South Carolina, USA. (B) Mr Derek Sibson* In the UK, male surgeons traditionally rejoice in the title "Mister (Mr.) " and not "Doctor (Dr)",—female surgeons being addressed as "Miss" or equivalent—since before 1800, because physicians were by definition doctors who possessed a university degree (eg, an MD), whereas surgeons seldom had any formal qualifications. After the founding of the Royal College of Surgeons of London in 1800, surgeons qualified as Members of the Royal College of Surgeons (MRCS) became so proud to be distinguished from physicians that the title "Mr." became a badge of honor. Retired Consultant Surgeon, Kettering General Hospital, UK. Reproduced from the author's image collection.In my own experience, having seen absolutely no gastrointestinal endoscopy as a medical student between 1966 and 1972, I was immediately attracted to the whole concept of endoscopic procedures during my internship (house officer jobs) at Kettering General Hospital, UK, which is located in an industrial town some 83 miles north of London, in the county of Northamptonshire. Gratefully, I owe my initiation into the nascent world of endoscopy, as it was then, to the influential consultants (attendings) Gene Crockett (internist) and Derek Sibson (surgeon) (Figure 2B). It is now hard for me to believe that my first ERCPs and incisions of Oddi's sphincter in 1975 (Figure 3A and B) in the City of Leicester, the County Town of Leicestershire [pronounced Lester and Lestershuh, respectively], were accomplished almost half a century ago. In the mid-70s, we had so little equipment with which to do anything, and at the beginning at least, we had to beg for time and space from our Radiology Department, granted by our far-sighted Medical Director, Derek James. At that time, the population being referred for ERCP largely comprised endoscopically-virgin cases of biliary obstruction since this had been the domain of surgeons. Noninvasive imaging was confined to ultrasound and emerging computerized tomography (CT)—Yes, there was a time before CT and MRI.FIGURE 3: (A) Dr David Carr-Locke performing an ERCP in 1975 at Leicester Royal Infirmary, UK. (B) ERCP cholangiogram from 1975 showing a long endoscope position (because we did not know any better then) and numerous bile duct stones. Reproduced from the author's image collection. Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography.The ability to interrogate the pancreatic and biliary ductal systems directly by ERCP, without surgery, was so revolutionary and exciting that, initially at least, we paid little attention to the risks of the procedure. Probably because the first group of patients were elderly with choledocholithiasis, the adverse event rate of sphincterotomy and spontaneous stone passage or stone extraction was predictably low. Small caliber plastic stent placement soon followed, such that by 1978 when I left to spend a research fellowship year in Boston, our unit had already performed many hundreds of ERCPs. I recall the understandable antagonism from some surgeons in the UK East Midlands [comprising the English countries of Derbyshire, Leicestershire, Lincolnshire, Northamptonshire, and Nottinghamshire (pronounced "shuh", respectively) and Rutland] when I presented the experience of our first cases, which started to show the relative safety of the endoscopic approach to biliary disease compared with open surgery—yes, this was long before laparoscopy. Concurrently, Roy Cockel in the West Midlands [an English metropolitan county created in 1974 from parts of Staffordshire, Worcestershire, and Warwickshire—pronounced Staffordshuh, Woostershuh, (phon: Wu-stuh-shuh or Wu-stuh-shur) and Warrickshuh, respectively] was achieving the same results. It did not take long for surgeons in the East Midlands to start referring patients for ERCP, and our volume grew rapidly. By the time laparoscopic cholecystectomy came along in the early 1990s, ERCP was already established as the standard for treating choledocholithiasis. I was encouraged by a few senior physicians, notably Conel Alexander, John Hearnshaw, John Swales, and Robert Kilpatrick (Figure 4A-D), but in contradistinction to the outside world, my greatest institutional support came from surgical colleagues. The most enthusiastic were also the most senior surgeons, John Bolton-Carter, Ken Wood (Figure 4E), and Peter Bell (Figure 4F), who saw the advantages of avoiding open surgical access to the bile duct, especially in sick patients with cholangitis. With the support of subsequent generations of surgeons in Leicester like David Fossard, Nick London, Trevor Leese, David Lloyd (Figure 4G), and others, John Neoptolemos (Figure 4H) and I were able to publish our nonrandomized and, later, randomized comparisons of ERCP to open surgery,5–10 culminating in our 1988 Lancet publication of the role of urgent ERCP in acute gallstone pancreatitis.11 This proposal went against the dogma of the time that "nothing should be done" to such patients for 6 weeks after an attack of pancreatitis, which we never understood nor accepted. Despite many publications on this topic from other parts of the world, controversy reigned, but guidelines were subsequently written, which included an endoscopic approach to gallstone pancreatitis.12FIGURE 4: Top Row: (A) Dr Conel Alexander (deceased), Consultant Physician with an interest in Gastroenterology, Leicester General and Royal Infirmary, UK. (B) Dr John Hearnshaw (deceased), Consultant Physician with an interest in Diabetes, Leicester Royal Infirmary, UK. (C) Professor John Swales (deceased), Department of Medicine, Leicester Medical School, UK. (D) Professor Sir Robert Kilpatrick (deceased), Dean of the Leicester Medical School, UK. Bottom Row: (E) Mr Ken Wood (deceased), Consultant Surgeon and Dean of Postgraduate Studies, Leicester Royal Infirmary, UK. (F) Professor Peter Bell (retired), Department of Surgery, Leicester Medical School, UK. (G) Mr David Lloyd (current), Consultant Surgeon, Leicester Royal Infirmary, UK. (H) Professor John Neoptolemos, formerly of Leicester Royal Infirmary; currently Professor and Chair of Surgery, Liverpool Medical School, UK. All are reproduced from the author's image collection.Given that we had very few ERCP-related devices in the early 1970s, the subsequent history of endoscopic accessories is really important to appreciate because it has shaped progress and has been largely ignored. None of the plethora of reports of ERCP studies that started to appear in the 1980s would have been possible without the development of specialized accessories, initially hand-made in pioneering centers in Erlangen, Amsterdam, Hamburg, London, and Japan. This was followed by the "new" companies of Wilson-Cook Medical (founded 1983) and Boston Scientific Microvasive (founded 1984), with innovation driven by industry giants like the late Don Wilson of Wilson-Cook (Figure 5A) and John Abele of Boston Scientific (Figure 5B) collaborating with device-designing clinicians like Nib Soehendra (Figure 5C), Peter Cotton (Figure 2A), Kees Huibregtse (Figure 5D), Meinhard Classen, and Ludwig Demling (Figure 6), and a cosmopolitan pantheon of many others, namely Michel Cremer, Joseph Leung, Lazlo Safrany, Kazuei Ogoshi, Keichi Kawai, Jerry Siegel, David Zimmon, Joe Geenen, Jack Vennes, Steve Silvis, Claude Liguory, and Aksel Kruse. The lingua franca of this tower of Babel was, of course, "endoscopes".FIGURE 5: (A) Don Wilson (deceased) and David Carr-Locke at Mr Wilson's retirement event (1997). (B) John Abele, Cofounder of Boston Scientific Corporation. (C) Professor Nib Soehendra (retired), Endoscopist Extraordinaire, Hamburg, Germany. (D) Professor Kees Huibregtse (deceased), Academic Medical Center, Amsterdam, Netherlands. All are reproduced from the author's image collection.FIGURE 6: Professsors Ludwig Demling and Meinhard Classen performing their first ERCP in 1973, Erlangen, Germany. Reproduced from the author's image collection. Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography.I recall that my first sphincterotome in 1975 was hand-made in Erlangen, (Figure 7A), the European birthplace of ERCP, and supplied to me by Dennis Pyser, who was also an agent for Erbe Elektromedizin GmbH electrosurgical generators, based then as now in Tubingen, Germany. The "compact" (ie, not floor-standing) Erbotom (Figure 7B) was the first generator dedicated to endoscopic applications, and the company has subsequently continued to innovate and dominate the field of endoscopic electrosurgery. My first duodenoscope (Figure 7C) was not electrically insulated, and it took me more than a few electric shocks and burned eyebrows before we could solve the completion of the circuit back to the generator without passing through the endoscopist!FIGURE 7: Dr Carr-Locke's ERCP and sphincterotomy equipment 1975, Leicester Royal Infirmary: (A) Erlangen sphincterotome, (B) Erbotom electrosurgical generator. (C) First duodenoscope 1975. Reproduced from the author's image collection. Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography.Albert Reddihough at KeyMed, UK would soon also become a dominant force in providing Olympus fiberoptic endoscopes and a range of accessories designed in Japan. As the 3 principal duodenoscope companies—Olympus, Fujinon (now Fujifilm), and Pentax—introduced endoscopes with larger instrumentation channels, a wider range of therapeutic procedures became possible, and the availability of the first self-expanding metal stents from Medinvent, Lausanne, Switzerland (subsequently Schneider, then Boston Scientific) designed by Hans Wallstén (Figure 8A) in 1986, transformed the management of malignant biliary obstruction.13 The cost of providing an ERCP service to a large population and advancing the subspecialty with new technologies in the UK National Health Service in the 1970s and 80s was such that I was forced to seek outside funding from generous supporters like George Davies, Chairman and CEO of Next (Figure 8B).FIGURE 8: (A) Hans Wallstén (deceased) Lausanne, Switzerland. (B). George Davies (in 1985), businessman and entrepreneur. Reproduced from the author's image collection.It was clear by the early 1980s that ERCP was destined to become the standard for evaluating and treating biliary, pancreatic, and papillary/ampullary disease. A decade later, MRI cholangiopancreatography was, thankfully, to begin usurping the role of ERCP as a diagnostic modality,14 and therapy became the focus for ERCP. The ERCP family of techniques became an integral part of gastroenterology practice and training with the establishment of dedicated advanced endoscopy training fellowships throughout the world. Contemporaneously, endoscopic ultrasound evolved from a purely diagnostic to an increasingly therapeutic technique as appropriate accessories were developed, although the availability of equipment and training prolonged the timeline. Endo-hepatology is now the preferred term for the endoscopic ultrasound (EUS)-based interventional discipline that can be used to perform diagnostic procedures like liver elastography and liver biopsy, the assessment of ascites and paracentesis, evaluation of the portal circulation, and even traditional vascular access and purely endoscopic studies and therapies, for example, the assessment of portal hypertension, ablation of esophagogastric varices, creation of intrahepatic portosystemic shunts and many others.15,16 The introduction [This will be discussed comprehensively in detail in a forthcoming essay in this series on the history of gallstones, by Frank Lemmert (Lammert F. Gallstones: The thing in itself. Clin Liver Dis.2022;20:57–72)] and dramatic burgeoning of laparoscopic cholecystectomy from the early 1990s, just after my move to Brigham and Women's Hospital, Boston, in 1989, launched a new era of minimally-invasive surgery that also gave us, at least initially, many new bile leaks to treat.17 Developments in surgery, endoscopy, and interventional radiology spawned centers and multidisciplinary collaborative groups of hepatic, biliary, and pancreatic specialists with a common interest—to provide the best available approaches to benign and malignant pancreatic and biliary diseases. In their wake came dedicated professional societies, such as the International Biliary Association, which in 1994 merged with the World Association of HepatoPancreatoBiliary Surgeons to become the International HepatoPancreatoBiliary Association, of which I was its first President from 1994 to 1996 and founding editor of its journal, HPB [HPB, the official journal of the International Hepato-Pancreato-Biliary Association, Americas Hepato-Pancreato-Biliary Association, Asian-Pacific Hepato-Pancreato-Biliary Association, and the European-African Hepato-Pancreato-Biliary Association]. The accelerating growth of ERCP-related publications in a little over 5 decades (Figure 9) is a reflection of the acceptance of the procedure and its integration into modern medicine. Whereas ERCP cannot solve all pancreatic and biliary problems, the technical, clinical, and pathological knowledge that this technique has engendered in many centers has led to the growth of other modalities. Such modalities include the so-called "SpyGlass choledochoscopy", whereby a thin fiberoptic/now video device is passed through the narrow instrument channel of a duodenoscope permitting direct inspection inside the common bile duct.18 In parallel with the stunning advances in instrument engineering—namely a fully integrated digitalized catheter access and delivery system, with 4-way steering, wider field of view (from 70 to 110 degrees), superior visual resolution from an integrated digital sensor, and a single-use duodenoscope to eliminate probe reprocessing and image degradation because of repeated use19—naturally came new technical jargon and acronyms, for example, single operator peroral cholangioscopy, SOC or POC, while the first-generation systems are now referred to respectfully as "Legacy Systems".19 In addition, as mentioned above, various enhancements of endoscopic ultrasound15,16 provide synergistic or alternative approaches to the diagnosis and therapy of hepatobiliary disease.FIGURE 9: Histogram of the growth in a number of ERCP-related publications from 1970 through 2019. Calculated and devised by the author, using published data derived from PubMed©. Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography.Those of us involved in the early development of ERCP and its associated techniques are proud to have seen its evolution and acceptance as a standard of care for so many patients worldwide. SERIES EDITOR'S POSTSCRIPT Approximately 50 years ago, when I was a senior resident at the now-demolished Middlesex Hospital, I first became aware of David Carr-Locke's forays into the sacred territory of Abraham Vater's diverticulum (which is usually misrepresented as a papilla or ampulla) and Ruggero Oddi's sphincter. It seemed then that the UK epicenter for upper endoscopy, and especially ERCP, was located in Fitzrovia(one of the capitol's most historic areas, Fitzrovia is prestigious and perfectly located for all that Central London has to offer. Once the dwelling of thought leaders like Thomas Paine—the English-born American political activist and theorist, philosopher and revolutionary—and George Orwell, and, in the bygone Bohemian era it was home to writers Virginia Woolf, George Bernard Shaw, Arthur Rimbaud, and others. Fitzroy Square is still one of London's most famous green spaces), where the Middlesex Hospital once stood. And so, when the ERCP activities in Leicester Royal Infirmary became known as a result of abstracts and presentations at national meetings, interest was piqued into the identity of the new kid on the endoscopy block, so to speak. David Carr-Locke grew up in Melksham on the River Avon, a town that was mentioned in the Doomsday Book, and is in the land-locked county of Wiltshire in the UK. After preclinical studies at Cambridge University UK, he fulfilled his clinical education at the Middlesex Hospital —where else? A favorable research fellowship experience at the New England Baptist Hospital in Boston, MA, was the prequel to his migration from Leicester Medical School and the Royal Infirmary to the Brigham and Women's Hospital, Harvard Medical School, Boston MA in 1989 as Director of Endoscopy. This position was followed by professorial leadership positions at the Beth Israel Medical Center, Albert Einstein College of Medicine, the Icahn School of Medicine, Weill Cornell Medical College, and New York Presbyterian Hospital—all in New York. His tally of lectures, video presentations, varied publications, ERCP-related pioneering techniques, and a slew of trainees and presidential roles in national and international clinical, endoscopic, and scientific professional societies is legion. And yet these myriad activities have not precluded his collaboration with gastrointestinal scientists and pathologists—2 of whom are authors in this series—in the in vivo microscopic investigation of the submucosa of the digestive tract, utilizing confocal laser endomicroscopy that provides real-time histologic imaging of human tissues at depth of 60–70μm during endoscopy.20 Given David's attributes (including having twice as many letters after his name than in it), is it any wonder that this essay is a scholarly tour de force in which the historical evolution of ERCP is embellished with lavishly illustrated biographies of endoscopists, digestive disease physicians and surgeons, and stepwise innovative advances in endoscopy engineering.
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