Greetings. First of all, I want to thank you all for joining this fantastic course. My name is G.S. Raju, and I serve as a faculty member at the University of Texas MD Anderson Cancer Center, and I want to thank Dr. Mergener for giving me this opportunity. Today, I have the distinct honor and a very special privilege of introducing my mentor and friend, Dr. Nageshwar Reddy, who is well known to all of us as NAGI. NAGI serves as the chairman of the Asian Institute of Gastroenterology, Hyderabad, India, which provides world-class healthcare to the common man. I must add here that NAGI and his exceptional team developed a crown jewel of healthcare service and also built a temple of learning that will nurture the future generations of physicians from India. NAGI made huge contributions to therapeutic endoscopy, authored several hundred papers, wrote several book chapters and books, organized hundreds of live endoscopy workshops, gave several named orations around the world, and also served as the president of the Indian Endoscopy Society, as well as the World Endoscopy Organization. For NAGI's extensive services, the President of India bestowed upon him the honor of Padma Shri and Padma Bhushan. These are the equivalents of the United States Presidential Medals of Freedom. For NAGI's exceptional contributions to endoscopy, the ASGE honored him with the Master Endoscopist Award, as well as the International Service Award during the last 10 years. And this year, Dr. Klaus Mergener will bestow upon him the highest ASGE award, the Schindler Award, and the Crystal Awards during the DDW. Hope you all join us for that celebration. And one more thing, NAGI has the rare distinction of being the only Indian physician to be included as a fellow of the American Association for Advancement of Science. NAGI, you are a great role model to me and to many around the world. And on behalf of the ASGE, we want to thank you for your services, and we look forward to your lecture, the keynote lecture today, Five Decades of ERCP Lessons Learned. NAGI, the stage is yours. Thank you. Thank you, Subhraj, for your very kind introduction. And of course, I'm honored and humbled. I'd like to also thank ASGE for this invitation to be a part of this very important learning webinar. In fact, when we were asked to do this, the time was not too short, because with these webinars, one can do things very quickly. And I'd like to thank Todd for also getting together. And of course, we've had a very nice webinar yesterday, hopefully continues today. My task is to talk on five decades of ERCP and what are the lessons we learned from this. I have no financial disclosures regarding this. In fact, among all the gastrointestinal interventions, ERCP is potentially the most dangerous, but also extremely useful. For the last five decades, there's been a dramatic change in the way ERCP is practiced from being a purely diagnostic procedure to becoming a therapeutic procedure. I think this is a marked change. And what has happened over the last few years is what I'm going to take you through the journey of ERCP. The first ERCP was actually done in 1968, reported in 1968 by the surgeon William McCoon in Washington. He took four hours to cannulate the pancreatic duct and subsequently did 50 cases, reported this, and lost interest in ERCP, mainly because, of course, he was a surgeon busy with so many other things. It was 1970 that Itaru Oi, a young Japanese physician who fortunately had a father-in-law who had an endoscopy company, was able to modify the endoscope into an oblique wing one and started showing that you can consistently cannulate the pancreatic duct and the bile duct using this scope. And this is when the conventional ERCP actually came forward. In fact, in 1972, the term ERCP was first coined by Peter Cotton in a paper that was titled Cannulation of Papilla Vata via Fibro-Optic Deodorant Scope. A Lancet main paper, you can imagine with this title, and if you send a paper with this title, even the local newspaper wouldn't take it. So that was how the early stage of ERCP started. The first therapeutic ERCP procedure was done, simultaneously reported from Germany and Japan by Meinhard Klassen and Kawai. There are very interesting stories regarding this, and I could get access to some of this. In fact, Kawai never himself did an ERCP in his life. It was Nagashima, his assistant, who did all the ERCPs, but the hierarchy system in Japan resulted in his name coming first. Everybody thought he had done. Nagashima, of course, was bitterly repentant until then because he was never recognized. But Klassen and Dembling did their first ERCP. They locked the room, so nobody actually knew who did the first spintrotomy. Later on, I had an opportunity to ask Meinhard Klassen, and he said actually he was the one who did the ERCP. In fact, the first spintrotomy were done on patients who had very closely related to medical field. This is because most people would refuse an ERCP at that time. The first patient of ERCP in Germany was a nurse working with Klassen, and the first patient in Japan was actually a medical student who had an impacted stone which was removed by ERCP. So these were examples. In fact, Meinhard still carries his slide telling people that the CBD opening was still open for the surgeons at that time because at that time, endoscopic spintrotomy was considered a dangerous procedure. These were all the pioneers in 1970 who were not only exceptional endoscopists, outstanding educators, but I think very courageous innovators because doing an endoscopic spintrotomy was against the surgical principles at that time. In fact, Claude Liguery, who did the first ERCP in France, spintrotomy in France, tells me that immediately after he did the spintrotomy, he was called to the office of the director of the hospital and told that he must resign from his job because the surgeon said that he did a very dangerous procedure and therefore he had to resign and go into private practice. You can recognize many of the pioneers here including Michel Cramer and all of them were responsible for taking ERCP forward. ERCP was a dangerous procedure, therapeutic ERCP at that time because when they did a spintrotomy, they didn't remove the stones. The stones were left in place because there are no baskets of balloons at that point of time. Dietmar Wobbs, a German endoscopist, realized this and what he did was invented this nasobiliary catheter. So, all patients with CBD stones after spintrotomy would have a nasobiliary catheter put in, flushed out till the stones completely got flushed out. Otherwise, the mortality was up to three percent after the spintrotomy and this could be avoided with this nasobiliary catheter. I think this was at that time a major invention. The first biliary stenting was done in 1979 by Nip Sohendra in Germany. In fact, what Nip did was to take the nasobiliary tube which Wobbs was using and just cut it at the tip and that became a stent and you can see a very small stent probably must have got blocked within a few weeks but at least it was a small step towards establishing endoscopic biliary drainage. The centers at Germany, Belgium and Amsterdam were the ones which were the center of ERCP at that point of time and you can see this was Kees Hubriski again one of the leaders who was the inventor of the needle knife. There were many people who used to go for observation to see Kees how he does his ERCP. In fact, he was not only a phenomenal endoscopist but he showed that economy of movements were very important at ERCP. He would have very few movements just put his scope on the belly and within a few minutes he'll be in the bile duct and in case he couldn't get in he would do a needle knife spintrotomy and almost always got in and that's how this came and still the controversy of needle knife spintrotomy continues to this day whether it should be done when it should be done and so on. The first live demonstration of ERCP was in New York in 1973 and you can see the four the gang of four who were responsible for it. It are O.E. Classen, Peter Cotton and McRae. In fact, after the first demonstration of this ERCP when they went out for the dinner the New York society didn't have money to pay for the dinner. That was the state of endoscopy societies at that time. Of course, this changed a lot since then. The state of ERCP was quite obvious by this in 1978 in United States when Geenan called together all his all the friends who are doing ERCP. We were just four American endoscopists at that point of time just as recently as 1978 who were capable of doing an endoscopic spintrotomy and the combined series was only 62 cases. You can see Geenan here along with his nurse and Maynard Classen and you can see everybody without the gloves because the concepts of infection and so on when they're still. For the next few years ERCP underwent a series of progression in 75 to 80 was a purely diagnostic procedures. 80 to 85 and spintrotomy was introduced, tenting came in, therapeutic procedures made a big wave. 85 to 90 was the era of definitions. Definition of complication, definition of different ERCP observances. After this came the cost-benefit ratio whether doing this procedure was good enough. Of course, quality parametrics, the cannulation rates and all came in a little later and finally true randomized control studies comparing ERCP within itself and ERCP with the surgery came only started after 2000. So it's still relatively very anchored. Now if you look at ERCP literature, the first case reports came in 1970. Observational studies later on and RCTs, the first RCT was done in 1989. Actually it was for gallstone pancreatitis and compare this with what happened in medicine. The first RCT was in 1948. The first RCT in gastroenterology was an ulcerative colitis true love in 55. So we are much behind the regular medical and gastroenterology but paradoxically if you look at what happens in innovations in ERCP, most of the innovations occurred in the 1970s when ERCP was just coming in when these masters who were there were actually doing all the work. It was later more gradual and of course you had many more RCTs and regulatory phenomena coming in. Now the reason why it's so difficult to do research in ERCP is obvious from this 2002 NIH had a big evidence-based conference on ERCP and you can see of 22 years of ERCP they could just get 149 articles which were suitable for inclusion in quality review evidence. The reason why it's difficult to do research in ERCP is quite obvious because it's operator dependent, there's so much of heterogeneity and quite obviously if you look at what happened in acute biliary pancreatitis this is clear. You can see there have been so many papers whether you should do intervention in patient acute biliary pancreatitis, when you should do the intervention and so on and so many studies ultimately the last one the Dutch pancreatitis study published just last year in the Lancet all with different contradictory reports. In fact it started with saying a very positive report from Leeds followed by negative report from Germany and so on. The reason why it's difficult in ERCP to do standardized research is because of the difference in timings, exclusion criteria, endoscopy expertise, this is the main thing. Endoscopy expertise with ERCP is very variable from different groups of people and the heterogeneity of these groups makes it much more difficult. If you look at how ERCP is progressing it seems to progress in 10 years intervals. The first therapeutic ERCP is in 70s, the plastic stents came in 80, self-expanding metal stents in 90, covered stents in 2000-2010, cholangioscopy was first introduced and of course we go beyond this now to see what's going to happen. In the 70s and early 80s Peter Cotten used to come up with this famous slide that ERCP is 1% frustration and 99% perspiration. This was right. At that time we had very primitive fluoroscopy machines, we had scopes with very narrow vision, fiber optic scopes. It was not only very difficult, it was very hard work, a lot of radiation involved and so on but this has completely changed now. We've mainly changed not only because we have better fluoroscopes, better scopes and so on and for the younger generation who never experienced that previous generation gap, you'll realize that there's been a tremendous change and the most important is the new accessories that we have. These new slippery guide wires, clever spinotomes, intelligent cartridges have all made ERCP extremely easy but you must remember that we evolved from a difficult stage and this is an example of the early 80s when I was doing my first ERCP, a patient with large CBD stone got stuck here at the ampullary region. The patient had to go with the endoscope to the theater where the surgeon operated and to remove the stone, the basket and the endoscope. At that time we didn't have these mechanical intertripters, they hadn't been introduced commercially and after this we had to stop ERCP for six months, still we got the first salvage mechanical intertripter and only then we restarted again getting this emergency mechanical intertripter. Just to show you the hardships we went through, in fact the surgeon who operated on this patient was quite happy to demonstrate that ERCP was ineffective and the surgery is the best solution for these patients with CBD stones. This was about 40 years or back but I think still there's this subtle rivalry that exists between medical, surgical, all the teams are getting better now. CBD stones have become extremely easy to treat now, even very large CBD stones you can do balloon dilatation, you can bring out multiple large stones, you can do laser dystrophy, mechanical and so on. So that 99% of CBD stones are treated endoscopically, a vast difference from what happened some years back. Pancreatic endotherapy came a little later and this is the work again from Belgium from Michelle Kramer and Jack Davia and their unit which actually propagated the concept of extracorporeal shock with the TRIPSI and removal of these stones and this is now practiced in selective centers in some countries with very high efficacy. The first report of this patient 1976 with Michelle Kramer actually gave me this exercise. You can see the stone impacted at the pancreatic duct was removed and the patient on follow for many years was doing extremely well. But again introduction of modern extracorporeal shock with the TRIPSI machines, operator expertise that has come in, we have now achieved extremely high results of pancreatic endotherapy using this combination. Again, if you look at practice of ERCP in different parts of the world, you realize it's so variable still because in many centers in the western world, ESWL is still not practiced as a part of pancreatic endotherapy. So these variations tend to still continue. The first metal stand for CBD was actually put by Eckhart Frumgauer in Germany. This is the first report and these stands actually look pretty dangerous. You can see a spring stand that was the first time put in and I remember sometimes the bile duct mucosa would get inside and that can produce catastrophic results. Of course, progress has occurred since then, progress in metallurgy, progress in chemical engineering and so on, producing these fantastic self-expanding metal stands. We have a variety now, so much so that we started using them in a variety of situations. For example, even in terminal carcinoma patients, we no longer put plastic stands, we tend to put metal stands as this dust study has very clearly shown. And even for benign biliary strictures, increasingly we're starting to use this completely covered self-expanding stands rather than multiple plastic stands. So what has happened is plastic stents are slowly going into the graveyard of endoscopy x-rays, and there's a new dawn with these metal stents that are coming in. So every day you have a new variety coming in, new functions that have. The other thing that ERCPs have done over the last few years is take advantage of developments that have occurred in other specialties. For example, in a patient with a high-large tumor, we would never do an ERCP without an MRCP as a GPS to guide us into which particular duct to go to, and you can see here, clearly this shows us that you have to stent both the ducts. So this is something that is becoming a part of ERCP practice. Similarly, we're taking advantage of advances that are occurring in other fields. For example, radiofrequency ablation, commonly used in hepatocellular carcinoma, is now being used in ERCP. In a patient with cholangiocarcinoma like this, we just don't just palliate with metal stents. In addition to palliating them, we also use radiofrequency ablation. And now there are randomized control studies to suggest that in patients with cholangiocarcinoma, the use of radiofrequency ablation, along with metal stents, can increase the stent patency, can also increase the survival in these patients. So I think much progress is being made. If you don't look at the past, and one dramatic change that has occurred in ERCP is the diagnostic ERCP has gone off completely. In fact, this is 1992 when ERCP was at its peak. You can see Michelle Kramer with Peter Cotton. Peter Cotton's car was named famously ERCP-1. He was so proud of that. In 2003, Peter Cotton's car broke down. Ironically, the same year, the diagnostic ERCP was completely taken off. So I think we know that there are two reasons why this death knell of diagnostic ERCP has occurred. First, of course, we have better non-invasive diagnostic methods. For example, secretine MRP and EUS not only give us an accurate diagnostic imaging of the pancreatic ovulatory without the potential for complications of ERCP. Also, we came to realize complications of ERCP. This very famous landmark paper in 1996 by Marty Freeman brought awareness about the complications of biliary spintrotomy in not only academic centers, but in private practice. And we realized that 10 to 15% of the patients can have complications, right, from pancreatitis to perforations, cholangiitis, and so on. Subsequent studies that have occurred have shown very clearly that ERCP, one of the major advances that have occurred, is that we can now actually stratify our patients' risk factors. And then, depending upon which risk factor a patient has, we can actually decrease our ERCP complication rates by excluding these patients. For example, their patient-related risk factors, technique-related risk factors, volume-related risk factors, and so on. So, we now know that doing an ERCP in a suspected SOD in a young female patient with normal bilirubin, the chance of post-ERCP pancreatitis is extremely high, and therefore these are excluded. I think all this knowledge over the last few years has given us the ability to decrease post-ERCP pancreatitis, which can be catastrophic. So, erectilinear myxin, pancreatic stent in high-risk cases, and IV hydration has resulted in an average drop of post-ERCP pancreatitis from 9% to 2% in most units, at least in us. So, I think this is a major advance that occurred. Now, the complications also, we learned how to deal with them as they come. This was a patient with choledocal varices with CBD stones. We're removing the CBD stones, and as we're removing the CBD stones, the pigment stones that are coming up, you can see the gush of blood because we've actually injured a choledocal varice inside. Earlier on, these patients were rushed to surgery or angio, but very difficult to treat there, but now we don't have to worry. Even in a patient like this, all we have to do is put a completely covered, self-expanding metal stent, and the bleed stops instantaneously. So, we are now, as endoscopists, develop this ability to tackle post-ERCP complication problems. I think that is an important advance that occurred in this field. All this has resulted in a drop of diagnostic ERCP dramatically, and these are statistics from U.S. gastrocenters, but therapeutic ERCP has increased, and the ERCP itself has remained in terms of volumes at a particular level for very long now because of this. I think this gets us to the point that ERCP is most dangerous for those who need it least. This is the most important message we have learned in the last two or three decades, that we should do ERCP very selectively only when there's a strong indication. I think this is something that keeps coming up very frequently. The developments also can be very slow in ERCP area. This is in 1988. You can see Fritz, along with Horst Neuhaus here, very young at that time, doing a mother and baby scope. Fritz is actually testing out the EHL probe on his lips, which can be dangerous, and he puts it on a stone. You can see how it's actually able to fragment, and you can see a very young Horst Neuhaus with Fritz doing this. I got this video from Horst, and you can see what has happened. It took almost 30 years for cholangioscopy to come. This is Horst in one of our workshops. Of course, he has aged comfortably, but his skills have increased, and you can see that he's using the spike cholangioscope to do cholangioscopy. Of course, much, much progress has occurred in this area also. The development can be slow because some of these technologies that are going to be introduced are going to come in slowly. But when they occur, they can dramatically alter the scene. This is what has happened. For example, the new generation single-operated cholangioscopes, the digital variety, not only are we getting better visions, but of course, it has increased the ability to do therapeutic procedures in CBD. There's a large CBD stone, a ratio of more than one to the CBD. We don't now try and waste our time with mechanical lithotrips and all. Of course, it's very easy to go into the cholangioscope and do a laser-guided lithotripsy in these patients. Several studies have shown the advantage of lithotripsy using this, or in our center, more and more extracorporeal shockwave, instead of mechanical basket extraction, which can be quite painful. But there is a twist to the tale here. The twist to the tale is that diagnostic ERCBC is coming back a little. This is because of diagnostic cholangioscopy. These are images of two patients who have cholangiocarcinoma, mid-CBD stricture, and both the patients, we are not able to come to a conclusion, could be malignancy in both. But when we did cholangioscopy, you can see on this patient is actually a B-cell lymphoma, biopsies from this, and this patient actually had a tuberculous node, which ruptured into the CBD. You can see the caseous material coming out, positive for AFB, and both of them were again treated medically without the need for surgery. We can't reach the papilla for some reason. At some point of time, we used to go to percutaneous PTBD and drain the bile after two procedures. Slowly there's a transition from this into endoscopic ultrasound. So we can't reach the papilla or can't cannulate the papilla for some reason. Most endoscopy units are now switching on to endoscopic ultrasound to finish the procedure. The reason why I'm telling you this is that endoscopic ultrasound is to be a salvage procedure for ERCP. But now increasingly, the endoscopic ultrasound, ultrasonologists are challenging the ERCP saying that this could become a primary procedure too. We can do hepatico-gastrostomy or paludoco-deodenostomy. And even without ERCP, we can plan for a primary bleeding drainage. Two recent papers, one from Shyam Vajrani's group in Orlando, another one from Park's group in Korea, showed in a randomized controlled trial that they produced less complications with endoscopic ultrasound, primary bleeding drainage. They didn't even attempt ERCP in these patients. Are we still there? I don't think. Fortunately for us, pancreatic bleeding endoscopy is becoming a common ground where ERCPs are also trained in endoscopic ultrasound. So they have the ability to mix and do this. But right now, I think still ERCP is a primary modality of draining the bile duct. We come to this important question now because ERCP is such a potentially dangerous procedure. Training is very important. The training, I think when you say ERCP and what Peter Cotten again has put it very nicely, is ensuring really competent practice. This should be a part of ERCP quality and safety. Doing the right things, indications can of course be taught, cognitive sense. Training should include doing it right. And of course, you require expertise in that. And how do one develop expertise in ERCP? Unfortunately, the virtual or computer simulators which are used for colonoscopy, for endoscopy is not very good for ERCP. Our experience with many of these computerized simulators have not been very satisfactory. They don't give the right feel. They don't give the right angle and so on. Of course, one could work on animal models. But again, animal anatomy is not appropriate to what we do normally in human beings. And this is one of the limitations. Most people would learn ERCP in initial days is to be small conferences like this. I remember they were there in the UK, in Brussels, in Hong Kong, just to attend and watch how things are being done, very informal. Then it became bigger conferences. But these are just inspirations for doing the procedure. It doesn't actually teach you the technique. We are getting better now with simulators like this. And this is the Dido Ivo simulator from Italy, which is now available, which actually enhances the skills of cannulation techniques. And a recent study, which looked at naive endoscopists, whose skills could improve when they use this, compared to those who haven't used this when they're doing an ERCP. So I think this is an area which is going to develop further. We are getting many more better simulators. In fact, 3D printing now has enabled the ability to get more and more of this. And hopefully training in ERCP will become more structured. That also is extremely important. And what about the future of pancreatic endoscopy? A few minutes on the distal wisdom that you had gained for a long time. One of the major problems in recent years is altered anatomy. And this altered anatomy is because of surgeries, obesity, rheumatic, gastrointestinal, gastrointestinal asthma, and so on. So therefore, our conventional route to ERCP is going up. There are in these cases several ways to approach the papilla. Laparoscopic-assisted ERCP has several limitations, not only difficulty in going through the long loops, but inability to use the standard accessories in most of these patients. Of course, lap-assisted ERCP is very attractive, but you have to get a surgeon to help you out. You can put your scope through laparoscopic route. And the U.S.-guided gastropexy has been increasingly described in the field of U.S. or pancreatic endoscopy, where you puncture the stomach, get inside, and you can do an endoscopy, or even like shown here. So there are several routes we have on guidance to the papilla in those patients with altered anatomy. And this is going to be an increasing challenge that we have to tackle in the future. Of course, with these resistant endococci organisms, with reports of them playing up in daily press, with, of course, regulatory agents taking it very seriously, ERCP infections came into news for some time now. I think this is a problem that we have to look into very carefully. This led to the use of single-use duodenoscope, the Xcel scope, which is now currently available. Fairly good optics can be used like the standard duodenoscope, but it's disposed of. There are now several centers in the world which have started using this. The problem is the cost. Can we, as an endoscopic community, afford the cost of this scope versus very well-reusable, very well-cleaned reusable scopes? And this debate is going to go on in the future. This is a debate which we have to look into carefully. I think all the societies have to look. In my opinion, there may be a place for disposable scopes with limited indications. For example, in ICU settings, patients with multidrug-resistant organisms or immunosuppressed patients, their use would increase if the price of the scopes would come down. But the majority of the centers will still use reusable scopes. This would be the standard of care. They're getting modified to decrease infection. There are several new modifications in terms of changing the tip of the scope and changing the elevator. So many new developments are coming in this area. This is what we should look forward to. But very interesting, there are some companies are looking at this very carefully to develop scopes which have a combination of endoscopic ultrasound and ERCP capabilities. So you can do both. And as I said, the new breed of pancreatic endoscopes are demanding this. And hopefully, this is something that we should see in the near future. But in the long-term future, this is the side I often show. I often show that maybe we don't have to be an endoscopist to do a good ERCP. This is an important World Cup match against Germany. The endoscopist is sitting and watching a very interesting match. He doesn't want to give up. And hopefully, it will be developed. We are paying to make the capsule. The capsule goes inside, goes into the bile ducts, and then, of course, looks at the bile ducts. Actually, some of these capsules are available to have some capabilities. The ultrasound imager goes on a broadband. You can see the TV. The capsule has a small robot coming out of it, a mini robot that is already available. You can go and actually open up the capsule with it. Then go inside, and other things that you can do with the remote control. And then, of course, at the initial moment, you see the parachute that comes out, and the bile ducts are taken off. Of course, technologies that are going in different paths, not that they're going to be in our lifetime, are potentially possible. It's important for the endoscopist to be on the broadband. The last important goal is to get to that point. This is what may occur, but not in a lifetime, I said. Finally, a few lessons that I've learned. Always, I think it's important that you should be humble as an endoscopist. ERCPs, especially, after celebrating 100,000 ERCP, the next one, we couldn't do cannulation of the CBD. I think taking what Michelangelo said after his last sculpture, that he's still learning. Even if he can say this, you can imagine what endoscopy, especially in ERCP, humility, I think, is very important. We realize that no papilla is the same. Even after doing many, many cases, one can still fail. I always dream of a papilla. This is from Guido that I borrowed this slide. A papilla, before a workshop like this, which is wide open, there's tea stones coming out, but this doesn't always happen. Very early on in my ERCP career, I learned this from this lowly asciariasis, when you're trying to cannulate the papilla. The cannulation rate of asciariasis of the bile duct is 100%, because if it goes into the pancreatic duct, it is killed by the pancreatic juices. Always 100%. I tell my fellows sometimes that if you want 100% cannulation rate, just try an asciariasis tip of your sphincter, it will go in always. You can see how it did. It didn't go in immediately. Just palpated the papilla, carefully saw around it, looked at the direction of the bile duct, and then actually went inside. The other lesson that I learned, and one of the most important thing is that in ERCP, you can do a lot of things, but you should not always do this. You can have an amyloid subnormal, doesn't mean you should do an amylectomy. Similarly, you can have sometimes a pancreatic duct which is dilated, doesn't mean you have to stent the pancreatic duct. So can is not equal to should, because it can produce more damage to the patient. And finally, Michel Kramer was one of my favorites, somebody who I learned a lot from. He, of course, unfortunately died a few years back. And when he died, I looked at his charts, and these are the first charts that he had ERCP carefully recorded. And you can see this chart he had in French, but the first few cases he failed, but he didn't give up, indicating persistence is very important. But he was very honest about what he recorded, about his failures. There was a death following valium, but all this is recorded. So I think this is a very important lesson for all endoscopists, particularly those doing ERCP, that persistence and honesty are two important features that should become inculcated in practice. And finally, I think I'd like to end with this slide. This is a very famous slide called The Doctor. This is Sir Luke Fields, whose daughter was dying at that time, in 1887 of a diarrheal illness. The doctor here didn't have magic pills, he didn't have diagnostic scans, he didn't have any way to investigate it. But you can see the extreme empathy that he shows towards his patient. And the painter was so impressed that he painted this. And I think to some extent, ERCP is an art that you can learn from practice. It's a science that you can get from textbooks and journals and so on. But it is empathy that is very important, that you can only learn from watching masters, how they're dealing with the patients. And this, I think, is a very important part of ERCP, which we often forget, just because there's a hole, doesn't mean we should go inside and do whatever possible can be done. ERCP is a combination of all this. And I think to be a good endoscopist, a good ERCP, you must persist on this. Thank you very much for your attention.

Dr. G.S. Raju

Dr. Nageshwar Reddy

gastroenterology

Asian Institute of Gastroenterology

therapeutic endoscopy

ERCP

patient well-being