So, good morning to all the audience there in North America, good afternoon in Europe and it's actually very late in the evening in Asia, it's 11 o'clock in the night. So we have a live demonstration of four very interesting cases. Thank you Todd, Shan and Amita for moderating. We basically decided to mix two ERCP cases with two endoscopic ultrasound. The initial plan was only ERCP but we decided to give US also because the program contains both. The two ERCP cases we have are the first case what I am doing now demonstrating. This was an 80-year-old female patient who had fever with obstructive jaundice and weight loss of two months duration. Her labs demonstrated a leukocytosis, a very abnormal liver function test, elevated CA-99. In view of the severe cholangitis, an NBT was placed, breast cytology was taken, showed adenocarcinoma. A PET-CT score showed local infiltration because of the age and the cardiopulmonary contraindications for surgery. She was offered palliation. So today we are going in and you can see both the MRCP picture here, the previous drainage with the cholangioscopy and the plan today is first to assess the anatomy because of an emergency ERCP that was done earlier, we didn't have a proper anatomy. If you look at the MRCP, Todd, you will notice that the right and left tuck seem to have a little separation. So we want to assess the anatomy before we do RFA. So we can get back now to our present picture if you have. We have gone in now as we are waiting for you and what we did was we injected some contrast and you can see the pluroscopy picture. You can see that the left and right ducts are just joining. It's actually, we thought it was type 2 but probably starting to become type 3a. We have the static picture can be put up, you'll see better. The one down the panel, yeah, now you can see when we injected some contrast, you can see very nicely the left hepatic duct and the right anterior is joining. So this raises, I think, Todd, several important questions that were being discussed by the audience when we were discussing earlier. One is, of course, regarding RFA, which we'll show you now immediately, and also regarding the need for two stents and how do we put one beside each other. So what is your opinion, Todd, on this? Yeah, so I just want to make note that Amrita Sethi is also one of our panelists and moderators and acknowledges she's here with us as well. So yeah, so the question is, goes back again to whether or not to place bilateral plastic, bilateral metal, of course, and then do you do side by side or you do stent in stent. And as was mentioned in the talks, there's obviously lots of advantages to metal. Reintervention is the more difficult problem, as pointed out, especially, well, the reintervention is difficult when they don't come out of the papilla and if you do the stent in stent, because then you have to work across one stent to get to the other stent if it becomes occluded. So I think it's somewhat dealer's choice. I imagine you're going to put bilateral metal stents in this case, what I think you're going to do after you do the RFA, right? Yeah, we'll do the RFA. I'll just show that and then of course the stent point. I'd also like to introduce Dr. Santosh, our anesthetist here, he's in charge. Of course, Todd, you know Santosh, he's been here for a really long time. So he'll be there for doing the anesthesia part and Mr. Srinivas is a technician. So we'll start with RFA and what I'll do is, I'm just putting the RFA catheter on the guidewire here, if you can focus down and see, this is the RFA catheter which comes from a company called StarMed, it's called Eldra. It has four steel rings that you see here, these are the electrodes, the current flows in between these two, creating a radio frequency ablation current. It goes on an O35 guidewire. I'm going to now, this is a very tight stricture, so that'll be good for RFA. What we're going to do is, if you can actually look at the RFA generator, that's more interesting. Our camera will focus on the RFA generator now. You can see the RFA generator here, which is an intelligent generator. And as I'm going through, you can see the fluoroscopy picture of the four steel electrodes are quite visible there. I go to the area of the actual main stricture here to introduce the RFA there. The stricture is about three centimeters long as we measured it, and the RFA probe that I'm putting in gives about 2.5 to 3 centimeter RFA ablation. Now, if you actually look at the RFA generator, we're switching it on now. What we do is we give two minutes ablation time, 10 watts, but more important is the temperature. Look at the temperature, it's very varying. We want the temperature to be between 75 to 80, and that is what this intelligent machine does. It doesn't bother about the wattage, we're not bothered about how much watts are going in, because what do you bother about temperature? Temperature should be between 70 or 75 to 80. This is when actually coagulative necrosis occurs. The older machines which didn't have this temperature control had a problem, because then you're actually using temperatures which were getting very high because the wattage was constant. Here you can see the wattage can go down to zero, the temperature is still maintained at 75. That's important. You can see the height. Is that Celsius or Fahrenheit? Fahrenheit would be with the t-shirts off. I think that's Celsius. So that's very hot. Yeah. Yeah, it's hot, but when you actually don't use this and do a direct RFA, we found the temperature goes to 100, and this produces a scar, and further impedance becomes high. You can see impedance also there, 59, 60. The impedance should be lower than 100 most of the time for effective RFA ablation. So this machine monitors the impedance, the wattage, the temperature, and of course time is set to two minutes. This is the timing that we set. So you're going to do each side separately, since they're separate stretchers? No. Well, I'm just wondering, because you said that you think, so because the stretcher technically is above, is on the other side of wherever you are, just barely, right? Because they don't connect, right? I'm just wondering, so you're going to completely treat one side and mostly treat the other side, but leave a little bit maybe above it, or do you think it transfers over to the other side? No, I think this transfers to the other side, and because if you look at the structure on the right, junction of the right and left hepatic artery, it's a very, very short structure there. Right. You have to be very careful about the right hepatic duct, because the hepatic artery is very close there. Right, right. Can we switch back to a floral image? Yeah, thank you. Yeah. Yeah, because there have been, I think, I don't know if they've been reported, but I know when we were at Mayo, we had an hepatic artery pseudoaneurysm after RFA. Yeah. That's probably been reported, so that's a good point, yeah. Yeah. Just a couple of practical questions for you that actually also came up on the chat during the lectures. You have two wires in place, and in some cases, we talked about during the lecture, even going into three ducts, if indicated. Is there anything that you think about, particularly when you're going to do an intervention like RFA, or you're planning to place the metal stents in terms of the size of the wires you use? I'm assuming you're using long wires if you're using an RFA catheter. Yeah. Amrita, here, everything is long wire. We don't use short wires at all. This has been a tradition for very long. In fact, if we use the short wires, our technicians feel pretty insulted. They don't want short wires to be used. So that's the reason why we're using the long wires always. And I think, for me personally, I'm more comfortable with the long wire if you're a good technician here. Yeah. That's important to remember for those of us who do work primarily with short wires, that if you are going to be doing interventions like RFA, that that requires the long wire. And what about dilating before either placing the RFA catheter or a stent? So this is a very important point, that before placing the RFA catheter, we should never dilate. Because the RFA catheter principle is that the stricture has to be very tight around for proper RFA. But after the RFA is given, in this case, for example, if you want to put two stents, we have to dilate. So before putting in a stent, I always tight strictures, I dilate. But for RFA, we never dilate. So that brings us to the size of this probe, Nagi. Is that an eight and a half French? It's seven French. It's a seven French probe. Yeah. But you don't want to ideally dilate to anything more than three or four millimeters at the most. Yeah. So if you, when you're doing an RFA, you don't want to dilate because invariably, even a tight stricture, this probe is very narrow and tapered. So it goes inside. There's no problem. But if you try to put a stent, what happens is after RFA, it becomes a little soft. It's easier to dilate it after that. So I'm now dilating the left side. I'm using, yeah, so. Nagi, Horst is speaking. Yeah, hi Horst, you're still there. You already mentioned that this is probably a type 3a. That means you have not opacified the posterior right lobe. Yes, yes. You will proceed even to stenting. Yeah. And I assume this can be done because the volume of the anterior and left is enough to have an appropriate liver function. Yeah, that's a good point, Horst. So what we estimated that if you do light anterior and the left together, we're draining around 70% of the liver. The one which we are not going to drain is about 30%. So this may be good enough for palliation. And so for people in the audience, I think they are referring to the volume of the liver and not just the volume of the duct. So that's really important to correlate on CT and not just on radiographic images or MRCP alone. Yeah. So what we are going to do now is to go to the right side and dilate the right also, because I'm going to see that there's going to be difficulty in passing a stent through the right side because it's quite narrowed. I'll have to achieve adequate dilatation there. In this case, I'm going to use one stent after another stent. The options are between one stent and two stents beside each other. So I'm taking the option that both Horst and Jack had described to put one stent after another stent. And the important thing when you're doing this is to see that you have adequate lumen. Otherwise, it'll be difficult to push the second stent through. So I'm going to dilate the right side also and using the same Titan balloon, which is through the long wire. The short wire, I sometimes find it difficult. And you'll see this difficulty coming up when we're doing the stenting because many of the recent stents are all short wire stents, the metal stents. You don't get enough pressure to push, especially in the high-large region. That is a problem that we have. Whereas with this long wire, the assistant gives you the pressure with the wire so you can easily negotiate the tight strictures. Will your plan be to leave both stents intraduodenal or intraductal? Intraduodenal. My plan is to leave both intraduodenal. So I require to probably put in a longer stent in both sides. Yeah. And how do you determine the diameter? Now we are through. How do you determine the diameter of the two stents that you'll use? Is it dependent on the product? The choice is between a 10-millimeter and 8-millimeter diameter stent. To a large extent, I look at the lower end of the CBD also. If the lower end of the CBD is big, not very small, then I tend to use 10 mm on both sides. Otherwise, I tend to use 8 mm. If the lower end of the CBD is especially narrow, sometimes putting in two 10 mm stents can produce severe pain in this patient. So I tend to use a smaller diameter. There are no studies which have compared 8 mm with 10 mm in terms of stent patency. So we're not sure whether we are benefiting by giving the 10 mm. But if the lower end is narrow, it may be worthwhile to think of 8 mm both. Aghi, there was a question from the audience. I'm assuming you've given pre-procedure antibiotics. With this kind of anatomy, with the right posterior not being drained, will you prolong the course of antibiotics or just pre-procedure is enough? No. I think in a case like this, a complex hyaluronic stricture, we, of course, give pre-procedure antibiotic. And we also like to... Actually, these patients tend to give antibiotics for at least 48 hours after the procedure. The reason is that we have found that sometimes, especially when there's a resistant infection, you get into a severe problem. So I tend to give 48 hours after the procedure also. And then choice of antibiotics tends to be according to your culture data locally. Our microbiology department, of course, constantly monitors the bacterial picture that happens. And mostly we use third-generation cephalosporins. In our patients. But sometimes we'll have to use imipimin group of drugs if you have a resistant bug. But most often, it's a third-generation cephalosporins. We use quinolones also occasionally, especially in dive cases. But in cases like this with severe cholangiitis already there, we tend to use a third-generation cephalosporin. Okay. Nagi, we're at about 15 minutes. We're excited to see you deploy your stents. Should we go to another room and come back or stay here? No, just another five minutes. Yeah. So what we're going to do is, again, in this case, I'm going to use stents which are on the guidewear, long guidewear. So quickly, it'll just take me another two, three minutes to finish it off. I'm going to remove this balloon because I have maybe a minute now. Can you remove? So I'm going to remove the balloon, the titan balloon, which I've used. So I'm going to use an uncovered stent. Again, the principle that Jack and Horst were telling you earlier, very important. I'm going to use an uncovered stent. This is 10 centimeters, right? 10, 8, sorry. I'm just saying if I had to use a longer stent. 10, 10 is there? I think we have to use a 10 centimeter, 10 mm stent because I'm going to use a stent from Tevo. Boston, it's okay. First one, we'll use the Boston stent. The left side, we have to use a little longer stent. So I'm going to use a microvasive stent, which is 10 centimeters, 8 centimeters. Yeah, yeah. There's another peculiar thing, Sean. I don't know whether you noticed. If different companies, the same length stents are different. Boston 8 centimeter length stent is much longer than Tevo 8 centimeter. I don't know, or even a Wilson Cook stent, which is 10 millimeter. For some reason, I think they're designed in a way where the lengths appear different when they completely expand. The Americans. With the tailors and with stent designers, tailors of different sizes do the same thing to us. Yeah, yeah. I think it's also the Americans don't understand the metric system still. I'm using a microvasive stent, which is actually 8 centimeter. Hopefully, I cross across and get... So one of the things that happens when you use this stent is that, of course, you don't have the guide wire to help you out. So you have to go a lot by fluoroscopy picture. And you can see the stent that's coming out here. I'm just going in now. I'm going in, going in. And of course, you can see the fluoroscopy. But you can also see that the air goes off in the lumen there. Nagi, any strategy to which side you do first? Yeah, generally, I would do the left side first. In fact, I thought this was going on the left side, but he's giving me the right side wire. So I like to do the left side first. So Amitabh, good thing, reminded me of that. The reason why I do the left side first is that left side, the most difficult side, the curve is on the left side. So I like to do the left side first. So we're going to change that. I like to do the left side first because what's your policy? Yeah, same. I choose the more difficult one to access, which is normally the left, unless the anatomy is a little different. And especially if you choose a Y configuration, if you're going to go through the meshes of the stent, that left angle will allow you to go through the meshes easier. Yeah, okay. So we'll go to the left side. I think this is a very important point. Good it happened because for the audience, at least they'll now remember that you have to go to the more difficult side, the left side first, and then the right side. But also the longer side is usually the left side. When you're in the longer stent, you're usually the left side, the longer side. So now I'm going to go that way. There's a question about whether the patient is supine or prone. The patient is prone. Maybe the patient is prone. So many, many people would do their hylar tumors on supine position, but we prefer the prone position. Only if you don't know the anatomy well and you're trying to look at the anatomy, then we'd like to use the supine position. Otherwise, I tend to use the prone position. This is a policy in the department because we don't intubate this patient. I know in Jack's unit and maybe Hoss also, they're using more the supine position because they're intubating the patient. So for the audience, the reason you know that as well is because Dr. Reddy has already mentioned that that's the right anterior. By being prone, you know, the right side that's filling with contrast is because the patient is prone. So you can see now that I'm deep in the left hepatic duct. So we can start now. And this is what I wanted to tell you about, that you can see that even the 8th is fairly big for this patient. We are short statured. Indians are short statured. And even the 8th becomes a little more bigger than what you anticipate. I'm going deep into the left hepatic duct. And now we can start opening the left duct. You can start opening now. You can see this shortens a little. And I'll start. Wait, wait. As you're opening, I like to adjust the lower part. Yeah, just wait. Yeah, keep opening, keep opening. So there are three radio opaque markers, as you guys can see. It's coming down to what's called the point of no return, where you cannot apparently recapture, but you still can in most cases recapture if needed. Okay, then keep down. We have come to the point of no return. Now getting to the point of no return, after which you can't adjust the stem. So I'm quickly going to now open the stent here. Okay, okay, okay, okay. Open, yeah, it's open now. Now what I'll do is quickly get on to the next wire and start. I'm removing everything here, including the wire and the stent. And then I'll put in the next stent, which is going to be a long wire stent. I'm using a Tebung stent. Just two different companies are compatible. There's no problem. So this time we're going to ask for a short 8cm stent. Shan, I didn't get you. I didn't hear you. So you're going to still use an 8cm on the right side? Yeah, so on the right side, I'm going to use an 8cm stent, but this is going to be a Tebung stent. So the 8cm Tebung stent is much smaller than the 8cm microwave stent. I don't know why. This is the stent that I'm using. It's the same nitinol uncovered stent, but the other thing you can see when you're using this long wire stent, the lumen is quite clearly seen. The lumen of the duodenum, you don't lose the air there. And this is, again, the problem with the short wire stent that we demonstrated earlier. You tend to lose the lumen. And then the stent is just going through. This is the difficult stricter area, but you can see it has gone in now. And then... Yeah, it's also important to remember that these stents foreshorten. So when you start to deploy, it's always better to deploy more approximately instead of leaving it exactly where you want the stent to end, as he's doing now. So you can see now I'm deep in the right depth. And I'm going to... With this stent, the lower end is not so clearly visible. And there's no reconstrainable part. So be careful when you're actually deploying it. Okay. So now I'm just going to deploy. I'm just pulling back, looking at the low... You're putting a little... Are you putting tension on the catheter? Yeah, I'm putting tension on the catheter. Maybe you can see the external camera on that. You can see the external camera. Okay, so I'm just pulling back, pulling back, and now it's deployed. Both are deployed now. You can see that quite obviously. And the fluoroscopy picture, please. Fluoroscopy. Yeah, you can see both the stents in place. Okay. Beautiful. Okay, thank you. I think we should go to the next case. We've had a lot of discussions too in this case. The next case is going to be done by Dr. Sandeep and the anesthetist is Dr. Upendra there. And it's going to be an endoscopic ultrasound-related case. Fantastic, Nagi. Thank you. We'll see you in a little bit.

ERCP

endoscopic ultrasound

obstructive jaundice

radiofrequency ablation

stents

fluoroscopy