The Digestive System Service of the Ibiza and Formentera Health Area, headed by Dr. Maite Novella, added endoscopic retrograde cholangiopancreatography (ERCP) to its service portfolio in August 2018 at Can Misses Hospital. Until then, patients requiring this procedure had to be referred to Son Espases and Son Llàtzer hospitals.
This endoscopic intervention is carried out on a scheduled basis to treat various diseases of the bile ducts and pancreas.
The practice of ERCP requires a multidisciplinary team made up of a doctor, nurse and nursing care technician from the Digestive System Service, who carry out the endoscopic procedure; a doctor and a nurse from the Intensive Care Medicine Service, who are in charge of sedation and monitoring the patient’s vital functions during the intervention; and a Radiology technician, who is in charge of controlling the radiological image during the procedure.
Since August 2018 to date, 109 procedures have been performed. The initial plan was to perform between 40 and 60 procedures per year. However, during the period of consolidation of the technique, the a priori more complex procedures were referred to the reference hospitals. Likewise, during the periods of greatest intensity of the COVID-19 pandemic (March-May 2020 and January-March 2021), the number of procedures performed was reduced, given the impossibility of having Intensive Care Medicine staff to sedate patients due to the high workload of the Department. As a result, the number of procedures planned was not achieved.
However, we are now in a position to reach the initially planned rate, with between one and two procedures per week, which is expected to reach half a hundred procedures per year.
The success rate of the procedure during this period is over 85%, and the transfer of 93 patients to Palma has been avoided.
The duct that carries bile to the intestine from the gallbladder and liver, called the common bile duct, and the duct that carries pancreatic juices to the intestine, technically known as the duct of Wirsung, come together at one point to empty their contents into the duodenum, which is the first part of the small intestine. This site is called the papilla of Vater and has a sphincter or circular muscle, which opens and closes when bile and pancreatic secretion needs to be discharged into the duodenum.
The purpose of ERCP is to cannulate the papilla and access one of the two ducts (common bile duct or Wirsung) with a small plastic tube (catheter). An endoscope, called a duodenoscope, is inserted through the mouth to reach the papilla. Cannulation of the papilla and the desired duct (common bile duct and/or Wirsung) is one of the most crucial points of ERCP. This manoeuvre is very complex, which is why ERCP is considered one of the most difficult procedures in the field of gastrointestinal endoscopy. Once the papilla has been cannulated, a radiological contrast agent is injected via the catheter to visualise the ducts, which can be observed with fixed X-rays or dynamically (fluoroscopy). Next, a cut is made in the area of the papilla that includes the sphincter to increase the size of this orifice and thus allow access to different materials through it in order to solve the associated pathology.
The pathologies that most frequently require this procedure are choledocholithiasis (presence of stones in the common bile duct) and stenosis or narrowing of the common bile duct. ERCP allows these pathologies to be resolved by removing the stones or, in the latter case, by inserting plastic or metal tubes (prostheses or stents).
The implementation of ERCP at Can Misses Hospital required the coordinated work of the heads of the Digestive System and Intensive Care Medicine departments – Dr. Maite Novella and Dr. Paz Merino, respectively – the support of the Hospital’s Management and Administration in training the endoscopist and endoscopy nurse in charge, and the fundamental support of Dr. Carlos Dolz of Son Llàtzer Hospital and Dr. Carmen Garrido of Son Espases Hospital.
Dr. Juan Antonio Lucero Pizones, a doctor from the Digestive System Service, specialised in the practice of this test, highlights “the benefits of ERCP as one of the least invasive ways of treating obstructive and lithiasic pathology of the common bile duct, although it is one of the most complicated endoscopic digestive procedures”.
Dr. Maite Novella, for her part, highlights “the increase in the quality of care that the intervention has meant, as it has made it possible to treat more than one hundred patients at Can Misses and prevent them from being transferred to the Son Espases and Son Llàtzer hospitals, and the effort made by the Digestive Service to take on this extension of the portfolio of services”.
According to Carmen Santos, managing director of the Health Area of Ibiza and Formentera, “we continue to work to increase the portfolio of services of the Health Area of Ibiza and Formentera and increase the autonomy and resolution capacity of Can Misses Hospital, which will avoid transfers to patients from the Pitiusas Islands”.