Operative report ERCP

What is ERCP ?

The provider performs a diagnostic procedure that combines upper endoscopy and retrograde (reverse) injection of contrast material, a type of dye, into the biliary ducts to obtain fluoroscopic images of the gallbladder, pancreas, and bile ducts.

Operative report 1

Preoperative Diagnosis

1. Distal common bile duct lesion with indeterminate biliary stricture.

2. Abnormal ampulla of Vater suspicious for adenoma.

Postoperative Diagnosis

1. Distal common bile duct lesion with mild distal biliary stricture.

2. Enlarged ulcerated ampulla with adenomatous appearance. Pathology pending.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Brush cytology of distal common bile duct lesion.

3. Endoscopic forceps biopsy of abnormal ampulla.

Indication

The patient presented with abnormal liver function studies and imaging demonstrating a distal common bile duct lesion with possible biliary stricture. Upper endoscopy also demonstrated an enlarged, abnormal-appearing ampulla suspicious for neoplasia. ERCP with tissue sampling was recommended to establish a definitive diagnosis. The risks, benefits, and alternatives, including bleeding, perforation, cholangitis, pancreatitis, and adverse reaction to anesthesia, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced under direct visualization through the esophagus and stomach into the second portion of the duodenum. The major papilla was identified.

Inspection demonstrated a markedly enlarged ampulla of Vater with a broad-based polypoid configuration. The mucosa appeared adenomatous with superficial ulceration involving the apex of the ampulla. No active bleeding was present.

A sphincterotome loaded with a guidewire was advanced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Cholangiography demonstrated mild dilation of the common bile duct measuring approximately 12 mm with a short distal narrowing suspicious for an indeterminate biliary lesion. No filling defects or choledocholithiasis were identified, and contrast drained freely into the duodenum.

A cytology brush was advanced across the distal common bile duct lesion under fluoroscopic guidance. Multiple brush passes were performed across the narrowed segment to obtain adequate cytologic specimens. The brush was withdrawn and the specimens were submitted for cytologic examination.

Attention was then directed to the abnormal ampulla. Standard endoscopic biopsy forceps were advanced through the duodenoscope, and **four representative biopsies** were obtained from the abnormal ampullary mucosa, taking care to avoid injury to the biliary orifice. Minor oozing occurred following tissue acquisition and resolved spontaneously without requiring endoscopic hemostatic therapy.

Multiple attempts were made to selectively cannulate the pancreatic duct; however, due to distortion of the ampullary anatomy, pancreatic duct access could not be achieved. No pancreatogram was performed.

The biliary tree demonstrated excellent drainage at the completion of the procedure. Air was aspirated from the stomach and duodenum, and the duodenoscope was withdrawn.

The patient tolerated the procedure well without immediate complications and was transferred to the recovery area in stable condition.

Findings

* Enlarged polypoid ampulla with adenomatous appearance and superficial ulceration.

* Mildly dilated common bile duct with a short distal biliary lesion/possible stricture.

* Brush cytology successfully obtained from the distal common bile duct.

* Four forceps biopsies obtained from the abnormal ampulla.

* Pancreatic duct cannulation was unsuccessful.

Specimens

1. Brush cytology from distal common bile duct lesion.

2. Ampullary forceps biopsies ×4 submitted for permanent pathological examination.

Implants

None.

Check your answer

• 43261 – ERCP with biopsy (includes the ampullary biopsy).

• Brush cytology performed during the same ERCP is generally considered part of the ERCP service and is not separately reported.

Operative report 2

Preoperative Diagnosis

Suspected sphincter of Oddi dysfunction with recurrent biliary-type abdominal pain.

Postoperative Diagnosis

Elevated basal sphincter of Oddi pressure consistent with sphincter of Oddi dysfunction.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Sphincter of Oddi manometry.

Indication

The patient presented with recurrent biliary-type abdominal pain despite prior negative imaging studies. Laboratory evaluation demonstrated intermittent elevation of liver enzymes, raising concern for sphincter of Oddi dysfunction. ERCP with sphincter of Oddi manometry was recommended to directly measure sphincter pressure and determine the need for therapeutic intervention. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, and anesthesia-related complications, were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced under direct visualization through the esophagus and stomach into the second portion of the duodenum. The major papilla was identified and appeared grossly normal.

A guidewire-assisted sphincterotome was advanced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Contrast injection demonstrated a mildly dilated common bile duct without filling defects, strictures, or evidence of choledocholithiasis. Contrast drained freely into the duodenum.

Following completion of the cholangiogram, the guidewire was maintained within the common bile duct. A triple-lumen sphincter of Oddi manometry catheter was advanced over the guidewire and positioned across the biliary sphincter under fluoroscopic and endoscopic guidance. Correct catheter position was confirmed.

Station pull-through manometry was performed with sequential pressure recordings obtained from the distal common bile duct, sphincter segment, and duodenal lumen. Multiple reproducible measurements were obtained after stabilization of the pressure tracings. Basal sphincter pressure was noted to be persistently elevated above normal limits with intermittent high-amplitude phasic contractions, consistent with sphincter of Oddi dysfunction. No technical difficulties were encountered during pressure acquisition.

After completion of the manometric evaluation, the catheter was withdrawn. Repeat fluoroscopic imaging demonstrated adequate drainage of contrast from the biliary tree without evidence of obstruction or contrast extravasation. No sphincterotomy, stone extraction, dilation, biopsy, or stent placement was performed during this procedure.

The stomach was decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well without immediate complications and was transferred to the recovery area in stable condition.

Findings

* Grossly normal major papilla.

* Mildly dilated common bile duct without filling defects or obstructing lesion.

* Successful biliary sphincter of Oddi manometry.

* Elevated basal sphincter pressure with abnormal phasic contractions consistent with sphincter of Oddi dysfunction.

Specimens

None.

Implants

None.

Check your answer

43263 – Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi.

This code already includes the diagnostic ERCP (cannulation, contrast injection/cholangiography as part of the procedure). You do not separately report 43260 when sphincter of Oddi manometry is performed because 43263 is the more comprehensive ERCP code.

Operative report 3

Preoperative Diagnosis

Chronic calcific pancreatitis with obstructing pancreatic duct calculus causing pancreatic duct dilation and recurrent pancreatitis.

Postoperative Diagnosis

Same.

Procedure Performed

Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy and endoscopic extraction of pancreatic duct calculus.

Indication

The patient has chronic calcific pancreatitis with recurrent episodes of abdominal pain. Cross-sectional imaging and MRCP demonstrated a dilated main pancreatic duct containing an obstructing calculus within the pancreatic head. ERCP was recommended for therapeutic decompression of the pancreatic duct by removal of the obstructing stone. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, infection, and anesthesia-related complications, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced under direct visualization through the esophagus and stomach into the second portion of the duodenum. The major papilla was identified without evidence of active inflammation.

A guidewire-assisted sphincterotome was advanced through the working channel, and selective cannulation of the **main pancreatic duct** was successfully achieved. Contrast pancreatography demonstrated a dilated pancreatic duct measuring approximately 7 mm with a single filling defect consistent with an obstructing pancreatic duct calculus located within the pancreatic head. The upstream pancreatic duct was mildly dilated without evidence of duct disruption or contrast extravasation.

A pancreatic sphincterotomy was performed over the guidewire using electrocautery to facilitate endoscopic access to the pancreatic duct. There was no immediate bleeding or perforation.

Following sphincterotomy, a retrieval balloon catheter was advanced beyond the pancreatic duct stone. The balloon was inflated and withdrawn through the pancreatic duct. The calculus was mobilized into the ampulla but remained impacted. A Dormia retrieval basket was subsequently advanced over the guidewire and opened beyond the calculus. The stone was securely captured and carefully withdrawn through the pancreatic sphincterotomy into the duodenal lumen. The calculus was completely extracted without fragmentation.

A repeat pancreatogram demonstrated complete clearance of the filling defect with free drainage of contrast from the pancreatic duct into the duodenum. Multiple balloon sweeps were performed, confirming no residual pancreatic duct calculi or debris.

Because of mild manipulation of the pancreatic duct and to reduce the risk of post-ERCP pancreatitis, a 5 French × 5 cm temporary prophylactic pancreatic duct stent was placed across the pancreatic sphincter with the distal end extending into the duodenum. Final fluoroscopic imaging confirmed satisfactory stent position and unobstructed drainage.

The duodenum and stomach were decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well without immediate complications and was transferred to the recovery area in stable condition.

Findings

* Dilated main pancreatic duct containing a single obstructing pancreatic duct calculus within the pancreatic head.

* Successful pancreatic sphincterotomy.

* Complete endoscopic extraction of the pancreatic duct calculus using balloon and Dormia basket.

* Completion pancreatogram demonstrated complete ductal clearance.

* Successful placement of a temporary prophylactic pancreatic duct stent.

Specimens

None.

Implants

One 5 Fr × 5 cm temporary pancreatic duct stent.

Check your answer

43264 – ERCP with endoscopic removal of calculi or debris from the biliary or pancreatic duct(s).

43274 – ERCP with placement of endoscopic pancreatic duct stent (if separately reportable based on current CPT/NCCI guidance and payer policy).

Operative report 4

Preoperative Diagnosis

Choledocholithiasis with obstructing distal common bile duct calculus causing biliary obstruction.

Postoperative Diagnosis

Same.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Endoscopic biliary sphincterotomy.

3. Mechanical lithotripsy with fragmentation of common bile duct calculus.

4. Endoscopic extraction of biliary stone fragments using Dormia basket.

Indication

The patient presented with obstructive jaundice and right upper quadrant abdominal pain. MRCP demonstrated a large impacted distal common bile duct stone measuring approximately 15 mm that was considered too large for primary extraction. ERCP with mechanical lithotripsy and stone extraction was recommended. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, retained stones, and anesthesia-related complications, were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was advanced through the esophagus and stomach into the second portion of the duodenum. The major papilla was identified.

A guidewire-assisted sphincterotome was introduced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Cholangiography demonstrated a dilated common bile duct measuring approximately 14 mm containing a single impacted distal common bile duct calculus measuring approximately 15 mm. No additional filling defects were identified.

A standard biliary sphincterotomy was performed using electrocautery to facilitate therapeutic intervention.

Initial extraction using a retrieval balloon was unsuccessful because of the size of the calculus. A Dormia basket was advanced through the bile duct and opened beyond the stone. The calculus was securely captured within the basket. Because the stone could not be withdrawn intact through the distal common bile duct, a mechanical lithotripter was attached to the basket assembly. Gradual controlled tension was applied, successfully crushing the calculus into multiple smaller fragments under fluoroscopic guidance without evidence of duct injury.

Following successful lithotripsy, the basket was repeatedly advanced into the bile duct, capturing and removing the fragmented calculi. Additional balloon sweeps were then performed from the hepatic bifurcation to the ampulla, removing residual stone fragments and biliary sludge. Multiple extraction passes were completed until no additional debris was recovered.

A completion cholangiogram demonstrated complete clearance of the common bile duct with free flow of contrast into the duodenum. No residual filling defects, contrast extravasation, or evidence of duct injury were identified.

Excellent biliary drainage was confirmed. No biliary stent was required because complete duct clearance had been achieved.

The stomach was decompressed, the duodenoscope was withdrawn, and the patient tolerated the procedure well without immediate complications.

Findings

* Dilated common bile duct containing a single impacted 15 mm distal common bile duct calculus.

* Successful biliary sphincterotomy.

* Successful mechanical lithotripsy with fragmentation of the impacted calculus.

* Complete removal of all stone fragments using a Dormia basket and balloon extraction.

* Completion cholangiogram confirmed complete duct clearance without residual stones.

Specimens

Biliary calculi submitted for gross examination only.

Implants

None.

Check your answer

43265 includes the subsequent extraction of the fragmented calculi (e.g., with a Dormia basket or extraction balloon). Do not separately report 43264 (stone extraction) when the stone is first fragmented and then removed during the same ERCP, as the extraction is integral to 43265.

Operative report 5

Preoperative Diagnosis

1. Choledocholithiasis.

2. Obstructive jaundice.

Postoperative Diagnosis

1. Choledocholithiasis.

2. Benign distal common bile duct stricture.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Endoscopic biliary balloon dilation of distal common bile duct stricture.

3. Endoscopic extraction of common bile duct calculus.

Indication

The patient presented with right upper quadrant abdominal pain, obstructive jaundice, and abnormal liver function tests. MRCP demonstrated choledocholithiasis with suspected distal common bile duct narrowing. ERCP was recommended for definitive diagnosis and therapeutic management. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, and anesthesia-related complications, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was advanced through the mouth into the second portion of the duodenum, where the major papilla was identified.

A guidewire-assisted sphincterotome was introduced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Cholangiography demonstrated a mildly dilated common bile duct measuring approximately 12 mm with a 10 mm distal common bile duct calculus. A short benign-appearing distal common bile duct stricture measuring approximately 8 mm in length was identified immediately distal to the calculus. Contrast passed slowly through the narrowed segment without evidence of complete obstruction.

Because the distal stricture would likely prevent safe extraction of the stone, a 6 mm × 4 cm controlled radial expansion (CRE) biliary dilation balloon was advanced over the guidewire and positioned across the stricture under fluoroscopic guidance. The balloon was gradually inflated to the manufacturer's recommended pressure and maintained for approximately 60 seconds. The balloon was then deflated and withdrawn. Repeat cholangiography demonstrated satisfactory expansion of the distal bile duct with improved luminal caliber and unobstructed passage of contrast.

Following successful dilation, a retrieval balloon catheter was advanced proximal to the calculus. The balloon was inflated and withdrawn, mobilizing the stone into the distal common bile duct. A Dormia retrieval basket was then advanced beyond the calculus, opened, and used to securely capture the stone. The calculus was withdrawn through the previously dilated distal common bile duct and extracted intact into the duodenal lumen.

Multiple additional balloon sweeps were performed from the hepatic bifurcation to the ampulla, removing a small amount of biliary sludge. A completion cholangiogram demonstrated complete clearance of the common bile duct, free flow of contrast into the duodenum, and persistent improvement in the caliber of the distal common bile duct without residual filling defects or contrast extravasation.

Excellent biliary drainage was confirmed. As the duct was completely cleared and the stricture appeared adequately treated with balloon dilation, biliary stent placement was not required.

The stomach was decompressed, the duodenoscope was withdrawn, and the patient tolerated the procedure well without immediate complications.

Findings

* Single 10 mm distal common bile duct calculus.

* Short benign-appearing distal common bile duct stricture.

* Successful balloon dilation of the biliary stricture.

* Complete extraction of the common bile duct stone using retrieval balloon and Dormia basket.

* Completion cholangiogram demonstrated complete duct clearance with excellent biliary drainage.

Specimens

Common bile duct calculus submitted for gross examination only.

Implants

None.

Check your answer

43264 – ERCP with removal of calculi/debris from biliary or pancreatic duct(s).

43277 – ERCP with trans-endoscopic balloon dilation of biliary or pancreatic duct stricture.

Coding Note: In this scenario, the balloon dilation was medically necessary to treat a true distal common bile duct stricture before stone extraction, making it a distinct therapeutic intervention rather than simply facilitating stone removal.

Operative report 6

Preoperative Diagnosis

1. Distal common bile duct obstruction.

2. Obstructive jaundice.

3. Suspected benign papillary stenosis.

Postoperative Diagnosis

1. Distal common bile duct obstruction secondary to papillary stenosis.

2. Successful endoscopic biliary sphincterotomy.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Endoscopic biliary sphincterotomy.

Indication

The patient presented with obstructive jaundice, right upper quadrant abdominal pain, and elevated liver function tests. MRCP demonstrated distal common bile duct obstruction without evidence of choledocholithiasis. ERCP was recommended for evaluation and therapeutic biliary decompression. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, and anesthesia-related complications, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced under direct visualization into the second portion of the duodenum. The major papilla was identified and appeared mildly stenotic without evidence of tumor or inflammation.

A guidewire-assisted sphincterotome was advanced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Contrast cholangiography demonstrated mild dilation of the common bile duct and common hepatic duct with an abrupt narrowing at the distal common bile duct near the ampulla, consistent with papillary stenosis. No filling defects, choledocholithiasis, or biliary leak were identified.

Because the distal obstruction was caused by narrowing of the biliary sphincter, a biliary sphincterotomy was performed. Using the sphincterotome with electrocautery, the biliary sphincter was incised in the 11 o'clock direction in a controlled fashion. The incision was gradually extended until an adequate biliary opening was created. There was immediate free drainage of bile and contrast into the duodenum. Mild self-limited oozing from the sphincterotomy site was observed and resolved spontaneously without the need for endoscopic hemostasis.

A balloon catheter was then advanced into the common bile duct, and several balloon sweeps were performed to confirm ductal patency. No stones, sludge, or debris were recovered. A completion cholangiogram demonstrated free flow of contrast through the enlarged biliary orifice without residual obstruction, filling defects, or contrast extravasation.

The stomach was decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well without immediate complications and was transferred to the recovery area in stable condition.

Findings

* Mild dilation of the common bile duct secondary to distal papillary stenosis.

* No choledocholithiasis or biliary mass.

* Successful endoscopic biliary sphincterotomy with immediate biliary decompression.

* Completion cholangiogram demonstrated free drainage without residual obstruction.

Specimens

None.

Implants

None.

Check your answer

43262 – ERCP with endoscopic sphincterotomy (papillotomy).

Operative report 7

Preoperative Diagnosis

1. Malignant hilar biliary stricture (suspected Klatskin tumor).

2. Obstructive jaundice with bilateral intrahepatic biliary ductal dilation.

Postoperative Diagnosis

Same.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Balloon dilation of hilar biliary stricture.

3. Placement of right hepatic duct biliary stent.

4. Placement of left hepatic duct biliary stent.

Indication

The patient presented with progressive jaundice, pruritus, and abnormal liver function tests. MRI/MRCP demonstrated a high-grade hilar biliary stricture involving the hepatic duct bifurcation with marked dilation of both the right and left intrahepatic biliary systems, suspicious for hilar cholangiocarcinoma. ERCP was recommended for biliary decompression by bilateral hepatic duct stenting. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, stent migration, and anesthesia-related complications, were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced into the second portion of the duodenum. The major papilla was identified.

A guidewire-assisted sphincterotome was advanced through the working channel, and selective cannulation of the common bile duct was successfully achieved. Cholangiography demonstrated a tight hilar biliary stricture involving the bifurcation of the common hepatic duct with separate obstruction of the right and left hepatic ducts. Both intrahepatic biliary systems were moderately dilated.

A hydrophilic guidewire was carefully negotiated across the stricture into the right hepatic duct under fluoroscopic guidance. A second guidewire was subsequently advanced across the hilar stricture into the left hepatic duct, achieving stable bilateral access.

Because of the severe narrowing at the hepatic duct bifurcation, a 6 mm controlled radial expansion (CRE) biliary balloon was advanced sequentially across the hilar stricture over each guidewire. Balloon dilation was performed under fluoroscopic guidance with satisfactory expansion of the strictured segment and improved passage through the bifurcation.

Attention was first directed to the right hepatic duct. Over the guidewire, a 10 French × 12 cm plastic biliary stent was advanced across the hilar stricture with the proximal end positioned within the right hepatic duct and the distal end extending into the duodenum. Fluoroscopy confirmed satisfactory deployment with immediate drainage of bile and contrast.

The guidewire within the left hepatic duct was maintained. A second 10 French × 12 cm plastic biliary stent was advanced across the hilar stricture into the left hepatic duct. Final fluoroscopic imaging confirmed appropriate positioning of both stents with satisfactory bilateral biliary drainage.

A completion cholangiogram demonstrated decompression of both the right and left intrahepatic biliary systems with free drainage of contrast through both stents into the duodenum. No contrast extravasation or immediate procedural complication was identified.

The stomach was decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.

Findings

* High-grade hilar biliary stricture involving the hepatic duct bifurcation.

* Moderate dilation of the right and left intrahepatic biliary ducts.

* Successful balloon dilation of the hilar biliary stricture.

* Successful placement of one biliary stent into the right hepatic duct.

* Successful placement of one biliary stent into the left hepatic duct.

* Excellent bilateral biliary drainage following stent deployment.

Specimens

None.

Implants

1. 10 Fr × 12 cm plastic biliary stent placed in the right hepatic duct.

2. 10 Fr × 12 cm plastic biliary stent placed in the left hepatic duct.

Check your answer

43274 – ERCP with placement of endoscopic biliary stent.

+43276 – ERCP with placement of each additional biliary or pancreatic duct stent (used for the second stent placed into the left hepatic duct).

Operative report 8

Preoperative Diagnosis

1. Malignant hilar biliary stricture with previously placed left hepatic duct biliary stent.

2. Persistent right intrahepatic biliary obstruction.

3. Obstructive jaundice.

Postoperative Diagnosis

Same.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Removal of previously placed left hepatic duct biliary stent.

3. Placement of new common bile duct (CBD) biliary stent.

Indication

The patient has malignant hilar biliary obstruction and previously underwent left hepatic duct stent placement for biliary decompression. Follow-up imaging demonstrated persistent obstruction of the common bile duct with adequate drainage of the left hepatic system through the indwelling stent. ERCP was recommended for removal of the existing left hepatic duct stent and placement of a new common bile duct stent to improve overall biliary drainage. Risks including pancreatitis, bleeding, perforation, cholangitis, stent migration, and anesthesia-related complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced into the second portion of the duodenum. The major papilla was identified. The distal end of a previously placed plastic biliary stent was visualized protruding from the papilla.

Using a rat-tooth forceps passed through the working channel, the indwelling left hepatic duct plastic stent was securely grasped and carefully withdrawn under continuous endoscopic visualization. The stent was removed intact without complication.

Selective cannulation of the common bile duct was then achieved using a guidewire-assisted sphincterotome. Cholangiography demonstrated a patent left hepatic duct following stent removal and persistent narrowing of the distal common bile duct with mild proximal biliary dilation. No choledocholithiasis or contrast extravasation was identified.

A guidewire was advanced through the distal common bile duct into the proximal biliary tree under fluoroscopic guidance. Over the guidewire, a 10 French × 9 cm plastic biliary stent was advanced and deployed across the distal common bile duct stricture. The proximal end was positioned above the narrowing within the common hepatic duct, and the distal end extended appropriately into the duodenum.

Final fluoroscopic imaging confirmed satisfactory stent position with immediate drainage of bile and contrast through the newly placed stent. A completion cholangiogram demonstrated excellent decompression of the biliary system without residual obstruction or evidence of bile leak.

The stomach was decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well without immediate complications.

Findings

* Previously placed left hepatic duct plastic stent successfully removed intact.

* Mild distal common bile duct stricture.

* Successful placement of a new common bile duct plastic stent with excellent biliary drainage.

* Completion cholangiogram demonstrated satisfactory biliary decompression.

Specimens

Removed left hepatic duct plastic biliary stent (gross examination only).

Implants

One 10 Fr × 9 cm plastic biliary stent placed within the common bile duct.

Check your answer

43275 – ERCP with removal of foreign body and/or change of stent(s).

43274 – ERCP with placement of endoscopic biliary or pancreatic duct stent.

Coding Note: The physician removes an existing stent from one biliary duct (left hepatic duct) and places a new stent into a different biliary duct (common bile duct) during the same ERCP session.

Operative report 9

Preoperative Diagnosis

1. Multiple benign biliary strictures involving the common hepatic duct and left hepatic duct.

2. Recurrent cholangitis.

3. Intrahepatic biliary ductal dilation.

Postoperative Diagnosis

Same.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Transendoscopic balloon dilation of common hepatic duct stricture.

3. Transendoscopic balloon dilation of left hepatic duct stricture.

Indication

The patient has a history of recurrent cholangitis and benign multifocal biliary strictures. MRCP demonstrated significant narrowing involving the common hepatic duct and an additional stricture within the left hepatic duct with proximal intrahepatic biliary dilatation. ERCP with therapeutic balloon dilation of both strictures was recommended to restore biliary drainage. The risks, benefits, and alternatives, including pancreatitis, bleeding, perforation, cholangitis, and anesthesia-related complications, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was introduced through the mouth and advanced into the second portion of the duodenum. The major papilla was identified.

Selective cannulation of the common bile duct was successfully achieved using a guidewire-assisted sphincterotome. Cholangiography demonstrated a short benign-appearing stricture of the common hepatic duct measuring approximately 1 cm in length with moderate upstream biliary dilation. A second distinct stricture measuring approximately 8 mm in length was identified within the left hepatic duct with associated dilation of the left intrahepatic biliary radicals. No filling defects or choledocholithiasis were identified.

A guidewire was advanced across the common hepatic duct stricture under fluoroscopic guidance. A 6 mm × 4 cm controlled radial expansion (CRE) balloon was positioned across the narrowing and gradually inflated to the manufacturer's recommended pressure. Balloon dilation was maintained for approximately 60 seconds before deflation. Repeat fluoroscopy demonstrated satisfactory expansion of the common hepatic duct with improved contrast flow.

The balloon catheter was withdrawn while maintaining guidewire access. A second guidewire was advanced selectively into the left hepatic duct across the more proximal stricture. The dilation balloon was repositioned across the left hepatic duct stricture and inflated in a similar fashion under fluoroscopic guidance. The balloon remained inflated for approximately 60 seconds before being deflated and removed. Repeat cholangiography demonstrated significant improvement in the caliber of the left hepatic duct with free drainage of contrast into the common bile duct.

A completion cholangiogram demonstrated successful dilation of both strictures, improved opacification of the intrahepatic biliary tree, and excellent drainage of contrast into the duodenum. No contrast extravasation or immediate complication was identified. As biliary drainage was satisfactory following dilation, no biliary stents were placed.

The stomach was decompressed, and the duodenoscope was withdrawn. The patient tolerated the procedure well without immediate complications and was transferred to the recovery area in stable condition.

Findings

* Benign common hepatic duct stricture successfully treated with balloon dilation.

* Separate left hepatic duct stricture successfully treated with balloon dilation.

* Improved biliary drainage following dilation of both strictures.

* No choledocholithiasis or biliary leak.

Specimens

None.

Implants

None.

Check your answer

43277 – ERCP with transendoscopic balloon dilation of biliary duct stricture (first stricture).

43277-59 – ERCP with transendoscopic balloon dilation of second, distinct biliary stricture during the same session (modifier 59 appended to indicate a separate stricture).

Coding Note: This operative report documents two anatomically separate biliary strictures (common hepatic duct and left hepatic duct), each requiring independent guidewire passage, balloon positioning, and dilation. This supports reporting 43277 for the initial stricture and 43277-59 for the additional distinct stricture

Operative report 10

Preoperative Diagnosis

1. Chronic calcific pancreatitis.

2. Dilated main pancreatic duct.

3. Two dominant pancreatic duct strictures involving the pancreatic head and proximal body.

Postoperative Diagnosis

Same.

Procedure Performed

1. Endoscopic retrograde cholangiopancreatography (ERCP).

2. Pancreatography.

3. Balloon dilation of pancreatic duct stricture at the pancreatic head.

4. Balloon dilation of pancreatic duct stricture at the proximal pancreatic body.

5. Placement of two parallel pancreatic duct stents.

Indication

The patient has chronic calcific pancreatitis with recurrent abdominal pain despite medical management. MRCP demonstrated a dilated main pancreatic duct with two dominant strictures involving the pancreatic head and proximal body resulting in impaired pancreatic drainage. ERCP with pancreatic duct dilation and dual stent placement was recommended for ductal decompression. Risks including pancreatitis, bleeding, perforation, infection, stent migration, and anesthesia-related complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the endoscopy suite and placed in the prone position. General endotracheal anesthesia was administered. A formal procedural time-out was performed.

A therapeutic side-viewing duodenoscope was advanced into the second portion of the duodenum. The major papilla was identified.

Selective cannulation of the main pancreatic duct was achieved using a guidewire-assisted sphincterotome. Contrast pancreatography demonstrated diffuse dilation of the main pancreatic duct measuring approximately 8 mm with two dominant benign-appearing strictures, one involving the pancreatic head and a second involving the proximal pancreatic body. No contrast extravasation was identified.

A hydrophilic guidewire was advanced across both strictures into the pancreatic tail under fluoroscopic guidance.

A 6 mm controlled radial expansion (CRE) balloon was advanced over the guidewire and positioned across the distal pancreatic head stricture. Balloon dilation was performed under fluoroscopic guidance and maintained for approximately 60 seconds before deflation. The balloon was then repositioned across the proximal body stricture, and a second balloon dilation was performed in a similar fashion with satisfactory expansion of the narrowed ductal segment.

Following successful dilation, two guidewires were maintained within the pancreatic duct. Over the first guidewire, a 5 French × 7 cm pancreatic duct plastic stent was advanced across both strictures with the proximal end positioned within the pancreatic body and the distal end extending through the major papilla into the duodenum.

Over the second guidewire, a second 5 French × 7 cm pancreatic duct plastic stent was advanced in parallel to the first stent across the same strictured segment. Final fluoroscopic imaging confirmed satisfactory side-by-side positioning of both stents with restoration of pancreatic duct drainage.

Completion pancreatography demonstrated improved ductal caliber with prompt drainage of contrast through both pancreatic duct stents. No evidence of ductal injury, perforation, or contrast extravasation was identified.

The stomach was decompressed, the duodenoscope was withdrawn, and the patient tolerated the procedure well without immediate complications.

Findings

* Diffusely dilated main pancreatic duct.

* Two dominant pancreatic duct strictures involving the pancreatic head and proximal body.

* Successful balloon dilation of both pancreatic duct strictures.

* Successful placement of two parallel 5 Fr pancreatic duct stents with excellent pancreatic drainage.

Specimens

None.

## Implants

1. 5 Fr × 7 cm pancreatic duct plastic stent.

2. 5 Fr × 7 cm pancreatic duct plastic stent.

Check your answer

• 43274 – ERCP with placement of endoscopic pancreatic duct stent.

• +43276 – Placement of each additional pancreatic duct stent during the same ERCP.

• 43277 – ERCP with transendoscopic balloon dilation of pancreatic duct strictur