Fusion™ Cytology Brush

Melissa Clark RN, BSN, LCGRN, Carolina's Medical Center - Charlotte, NC USA

On June 23, 2004, only four weeks after Fusion had been launched, Carolina's Medical Center would present its first challenge for the new Cook Endoscopy biliary equipment. A 39-year-old female presented to the hospital with complaints of nausea, vomiting, and left upper quadrant pain. To further complicate the case, the patient was 28 weeks pregnant with her fourth child. Dr. Scott Brotze, a physician with Charlotte Gastroenterology and Hepatology, was assigned to the case through the hospital staff services. For Dr. Brotze, this would be his first Endoscopic Retrograde Cholangio-pancreatography (ERCP) with Fusion. Three elements to ensure a successful ERCP included Dr. Brotze receiving an in-service on Fusion, implementation of appropriate Radiology guidelines, and completion of therapeutic intervention.

First, Dr. Brotze received an in-service about Fusion explaining the use and benefits of the new product. One of the many key benefits of Fusion is the ability to reduce the amount of fluoroscopy used during a procedure. By utilizing the external markers on the equipment to perform an Intra Ductal Exchange (IDE), the physician can significantly reduce the amount of radiation exposure to the patient and health-care workers.

Next, lead barriers were placed appropriately according to Radiology guidelines prior to the initiation of the procedure. Pulsed fluoroscopy format would be used. The risks and benefits of the procedure were explained to the patient with verbalization of understanding. The decision was made to use moderate sedation during the procedure to maintain comfort and tolerance.

Finally, the procedure was initiated. Dr. Brotze began the procedure using an Olympus TJF 160-F Duodenoscope advancing to the second portion of the duodenum to reveal the major papilla. The major papilla appeared enlarged and inflamed. A Fusion sphincterotome and a Fusion .035 ultra short wire guide preloaded into the IDE port were used for initial cannulation. The physician gained access to the common bile duct (CBD) and wire guide placement was achieved. A cholangiogram was performed by injecting half-strength contrast into the biliary system. The cholangiogram revealed a dilated duct to 12 millimeters with multiple CBD stones. A sphincterotomy was made for a total cut length of 12 millimeters. The first IDE using only external markers would be performed to switch over to a multi-sized 8.5-15 millimeter stone extraction balloon. The use of external markers during the IDE was successful. The stone extraction balloon was advanced to the bifurcation of the common hepatic duct. The first balloon sweep removed several 5-7 millimeter stones. Due to the irregularity of the stones, the balloon would have to be replaced three times. All Intra Ductal Exchanges were performed by using the external markers. At the conclusion of the case, there would be an estimated 12-15 stones removed from the CBD. The total amount of fluoroscopy used during the procedure would be an astonishing 1.3 minutes.

As a result, Dr Brotze, a first time user of Fusion, proved that utilizing the external markers during IDE may reduce the amount of fluoroscopy needed during an ERCP. Performing an ERCP is difficult under normal circumstances despite the added risk of pregnancy. This new technology brings added benefits to provide a more safe and efficient procedure for the patient and health-care workers. With these new advances, Fusion will become the standard for ERCP.