Welcome to University of Colorado, but I have excellent team supporting me about people I need all the help I can get here. This is a patient who, I don't know if you're able to see the thing. Yeah. So, what we have is a large kind of eggshell shaped stone right below where the duodenoscope crosses the bile duct and an attempt at ERCP was done, sphincterotomy, metal stent placement a few weeks ago, but conventional stone method extraction methods were unsuccessful. So they were referred for cholangioscopy. And so right now we, the ampulla is sort of, I don't know if you can appreciate it, it's about a two and a half centimeter filling defect or two centimeters of filling defect right below the duodenoscope crossing the bile duct. And so if we, if we can go to the side quad image and unfortunately my duodenoscope position is quite challenging, partly due to anatomy. And there is a peri-ampullary diverticulum here that I think is contributing to the difficulty. I've already fallen out a couple of times. I lost my spy image here. So if you can put the spy image on the right side of the monitor, thank you. So right now you can see, I have a laser fiber, it's a 272 micrometer fiber that the green light is basically not the laser, it's just the aiming beam. And I have it through the working channel of the, of the cholangioscope, go ahead and irrigate a little bit. And sometimes stones that are impacted in the distal bile duct can be a little difficult to position. And so I don't have a clear, full view of the stone. I kind of do there, but I'm afraid if I move too much, I might fall out of the duodenum. I don't know if you can appreciate a little bit of an unstable position here. I'm almost in the post vulvar duodenum with the duodenoscope, but you can appreciate this pigmented stone quite large in this patient. The laser was- It's almost the entire lumen, right Raj? I'm sorry? It looks like it's filling the entire lumen. Yeah. It looks like it's impacted and therefore attempt at getting a basket around it was not successful the last time that procedure was done. So this is a good case, I think for introductal lithotripsy where conventional methods are unsuccessful. And- Rajeev, this is Alessandro. So you have a very tough position with your duodenoscope. Do you think this can be the case of getting out from somebody who has moving the cholangioscope? So doing this procedure in two endoscopies rather than one? Oh, you know, we haven't done that since the mother-daughter stuff, we've been using mostly single operator. But this is very tough and I see you unstable completely. Yeah, it is unstable. Yeah, I appreciate you bringing that up. But I think that irrigate here a little bit. I think we have enough visual. What I'm hoping is that with some breaking up of the stone, which I'll start to do here in a second, that it might allow for some improvement. We've briefly seen the stone before. You what? Yeah, we've briefly seen the stone before entirely. Now we can see the problem. Now you see a little better? There it is. The angulation, yeah. Is that a little better? It's a great view, Raj. This is Linda. Okay. All right. Raj, for those of us who don't have laser, can you just comment a little bit about the technique of doing this? Yes. So we try to get the fiber, you know, we use an aqueous medium to deliver the energy. It is a pulse laser. This is a 100-watt homeo laser. And the power setting is 18 watts and 1.5 joules, 12 hertz right now. We're using 272 micrometer fiber. And really the energy and the electrons are sort of excited. And it's really a burst of energy that goes through the aqueous medium that allows the fracturing of the stone. Irrigate a little bit. And then to avoid the injury to the clangoscope, we do try to have the, due to my limitation in the position, I'm unable to get the blue coated part out of the scope. But we'll see if we can get a better view here to break up the stone. I don't know if you can appreciate the in-room camera showing the torquing of the body here and the duodenum. So it's not just, it's not just the spy scope. It looks very challenging, yeah. And can you also comment on EHL versus laser? Yeah. So I think for difficult stones that we know that we're going to do introductable lithotripsy, we tend to, we lease our laser. So we need to advance, give advance notice about 24 hours or so irrigating. And I would say that for difficult stones, laser is preferred because you can use just one fiber as opposed to EHL after about 1,600, 2,000 shock deliveries, it fails. And then you need to irrigate here. And then you need to replace the probe. So there's costs associated with it, though we have EHL handy, kind of in the unit. So we can always use it as a, as a technique if we weren't anticipating lithotripsy up front. But if we know we are, then we tend to go with laser due to alteration in power. There's, there's retropulsion changes that you can make that allows for less movement of the stone. And so I think there are some advantages there. The other thing with the laser fiber is that you can, if the tip breaks off, you can still deliver energy through it. And I'm just trying to think what I can do here to change my position. Let's see, if I go further away and, oh, okay, irrigate here. So I think there are some advantages of laser over EHL, you have to get a special certification from the hospital for the use of laser. How much is it to lease it, Raj, do you know? Do you know? Yeah. So for the 100 watt laser for one case, I believe it's about $800. About $800 irrigator? We think that's the case. That includes the laser, the technicians that come in to support the case. You guys have laser? We don't. So we rely on EHL. I see. Yeah, I think an EHL fiber is probably $500. Raji, it looks like you are always tangential to the stone. Yes. Is there any way you can change the position? Is there any trick you can tell us? The only thing I'm wondering is we change the patient position, but, or I can try long, I could try long to adenoscope position, and so, but I'd have to come out and re-engage. Dr. Shah, this is a nice demonstration, we will go to Dr. Ginsberg from University of Pennsylvania, then we'll come back to you after. All right, sounds good. Hopefully, I'll get better position by then. Thank you. Dr. Shah, you are back on? Yeah. So I basically, I'm almost post-pyloric, or around the pyloric here, my adenoscope view. And I had a good view here off camera, here, get here. Raji, is your patient supine or prone? They are prone. And I had a good view here when you're off camera, and I started doing lithotripsy. And now I am, oh, there's a stone, okay. I'm basically in the stomach, my duodenoscope, irrigate here. I don't know for how long we'll get a view here, we're trying to clean it up a little bit for you. So we can direct this, lithotripsy, can you hear me okay? Yes. Okay, so I'm still in the duct, the duodenoscope is kind of, we probably should put the laser on standby until I get a better image, okay. And the problem at this point is the control over the spigot, so. Yeah, I agree completely. We had a reasonable view, there we go. So right now, the duodenoscope is in the stomach, I see a stone here, kind of in the center, I'm going to see if I can get the laser fiber out, because it has retracted, go ahead and put the aiming beam back on, that's the green light. And we'll see if we can do stone therapy, is it? And how close do you typically have laser to the stone? You know, a millimeter away is pretty good. Sometimes there's contact that's unavoidable, if you put the laser on, you know, contact then contact of the stone, it can kind of bore a hole. And so a little bit of that is okay, but too much of it, you're not going to get good fragmenting. And so I am literally in the stomach here, but we're going to we're going to break this this thing up. So go ahead and turn on, okay. And right now, I would say the laser is a little close to the little too close to the spy scope, but I'm going to take what I can get here. And that's, I may have fallen out. For the audience, this was a common problem with laser on standby, with pancreas, laser on standby. And so what I'm going to do is I'm going to reposition, probably try long position to see if that might give me a better angle, I want to take out the extra air in the stomach because that can alter your stability at the papilla as well. So if that happens, definitely decompress the stomach, see if that can improve your endoscope position at the papilla. And I've tried even off camera to be to optimize my position with short position, if I can't get a good long position, what I might do is, is off camera, we'll switch to a, we'll have to switch the patient position. That's always a favorite thing to do for our nursing and anesthesia staff in the middle of the procedure. So I'm not making any friends this morning. But as the patient prone or supine, sorry, they're semi-prone, right, okay. So I'm free handing into the duct here, we'll see if that improves the position. That's a great point about decompressing the stomach, though, I mean, you know, when working with fellows, they're having a hard time struggling. And then, you know, I take the scope and I come back to the stomach, completely flatten it out. And then things, you know, change and get much easier a lot of times. The other thing is, I think we all tend to forget, or at least I can speak for myself, how much we're actually putting our finger on the air button, you know. I agree. Yeah, I agree. And before you know it, you know, I've almost told the companies, they should have a beep beep sound every time you're pushing on the air button to remind you that you're insufflating. But like a floral button, right, right, right, yeah, yeah, I totally agree. Yeah. This is good discussion. Dr. Shah, we'll come back to you, we'll go to Indiana. Yeah, absolutely. Okay. So there it is. Yeah. Dr. Shah, you're back. Your patients as a difficult case, so I think what you can see on fluoro, is this live fluoro that they see? Do you think we should try it? So you can see my long position now. That's a crazy position you're in. Crazy position. So I'm glad most of my patients are on the back. Crazy but effective, eh? It's working. You know, this kind of position would, it would shorten the endoscopist's career for sure. puts on this, on the laser energy pedal, as well as the fluoro periodically irrigated. And usually what I'll ask the technician or nurses, in this case we have nurses that help us with our cases, is to just to think about irrigating whenever they don't see a good image. And so I just try to minimize the amount of irrigation we gave pre-procedure antibiotic as well, to reduce the risk of cholangitis, which is a known increased risk with cholangioscopy. And I agree with the other comment about avoiding cholangioscopy in the setting of cholangitis, because of the fluid irrigation that we need to do to visualize our pathology. Also probably you don't want to increase the intraductal pressure to make cholangitis worse, would be the other reason not to do it. Yeah, you never want to do cholangioscopy in the setting of acute cholangitis. And Raj, are you gonna give any post-procedure antibiotics or just this one dose pre-procedure? I just do one dose pre-procedure. If I'm dealing with intra-hepatic strictures or stones, then we will. But for extra hepatic duct stones, we'll leave a stent in place, because this large of a stone, even if we can successfully fragment it completely, we're not gonna get all the fragments out today. That would be impossible. A question for all the experts. A question for all the experts. Since it is going to be a potential risk for post-ERCP cholangitis, do you think that there's a good indication for disposable scopes? So doing a spyglass in combination with the disposable ERCP scopes, or we're not ready for that? You can just do in-room camera and spy, please. I think the question, Alessandro, might be if you are suspecting they have multidrug-resistant organisms, of course, that would be a really good indication to use a single-use endoscope. Yeah, and I think if the patient were immunocompromised, that might give me some pause to think, okay, maybe I should use a disposable duodenoscope in this situation as well. Okay, thanks. And Raj, just curious in terms of the consent process for the- You're on mute. You're on mute. Can you hear me, Raj? I'm sorry, Linda. Go ahead. Oh, sorry. Just in terms of a question about the consent process for a patient like this, where you have this huge stone, you know it's gonna take multiple sessions. I'm assuming there's a conversation saying that, oh, it won't be one and done, but we'll be bringing it back for a few ERCP sessions to try to clear everything out. So we have our published data of about 300 extra hepatic bile duct stones over about 11 years. And the majority of them are, meaning complex stones, sorry, where they require more than just balloon or basket extraction. And in that case, we had about 90% of stones that were referred to us that were completely cleared with one session. About 10% required more than one session. And so that's the data I kind of quote them as our experience with that. And so I definitely, it's a very good point to set expectations because patients just think, well, you have a stone, you take it out, you're done. Right. But depending on the complexity of it, I do set the expectations low. And in this case, I told her pretty much guaranteed you're gonna have another procedure. Now they don't care if another procedure is introductal lithotripsy or stone fragment removal. They just care that they have to come back. So I just tell them that there's a very good chance we're gonna put a stent in. But that 90% is really just clearing the duct. It doesn't mean that we don't do another procedure after to clear fragments. So under promise and over deliver. I've learned that after so many years. I wish I learned that earlier. I agree, me too. Now there's a question from the audience. What are the risk factors of duct mucosa or wall injury by the laser? It's real. You know, we try to do this under direct or we do this under direct visualization. But if you notice the periodic cleaning out here of the duct just so that to avoid mucosal trauma. There's a lot of room in this duct. It's a huge duct. Unlike pancreatic duct stones where the duct is narrower. You know, six to eight millimeter, for example. And there's less margin for air. We try to just keep in the middle of the lumen. But yes, that can happen. I mean, if you have visualization. Sundeep Patel from San Antonio has good animal data. It was published in GIA several years ago. Looking at how much time can a laser contact a normal porcine mucosa cause damage like through and through preparation. And the contact time was about five seconds. And that was a porcine biodex can be a little thinner than a human one. So I use that as a reasonable rule. I mean, if you're seeing a little bit of blood, you're getting some mucosal trauma. Not all blood is transmural damage and you'll be okay. And then you can stent the patient if you do identify a leak post-procedure. I would say it's uncommon. I've had a couple of two or maybe two of those in my time, two or three. One was with EHL, one was with late, and one was, or sorry, two are laser. And all of them, you're able to stent across and do okay. So it is a real concern. You have to keep it under good visualization while you're doing it. There isn't data that I'm aware of with EHL on mucosa as there is with laser. Yeah. And what kind of stent did you place in those situations, Raj? Did you put a fully covered rather than a plastic? Let's see. One was in the PD. I just put a plastic stent across. And then the others in the bile duct, just anything to divert the flow. Yeah. So I don't think I needed to put a metal stent in. I think I just put plastic stents in and they're fine. It's sort of like a bile leak, you know, like I mean, a cold post-coli leak. I mean, you just gotta divert the flow. So you don't necessarily need to put a covered stent in, in my opinion. Yeah. Agree. We have a question of, why does it take so long to dissolve a stone? Wow. This is about as fast as it is. For considering the stone, I'm actually really pleased about- Fascinating question. Yeah. I would say that this is breaking up really well in my experience. And I'm not just saying that cause we're doing the case right now, but I'm pretty happy with this. Yeah, this is actually pretty fast to me. Yeah. That question was like- You can do this in an hour slot. I usually put about two hour slot. It's not great for revenue generation, but it's good for getting the job done for the patient. But I usually have a two hour slot. Yeah, go ahead. The question was like when you have something in the microwave oven and asking, why can't it go faster? Oh, like that. You know, we can- Yeah, that's a good point. Yeah, I don't know. You know, I'm a vegetarian. So things that I cook are a lot faster. Good point, good point. So right now I'm pretty happy with the way it's fracturing. The one point I would make, if you try to bump up the power a little too much, too fast, it can burn out the fiber. And then sometimes that can become problematic. So even with EHL, I usually try with medium power with EHL. With laser, I'll do sort of a medium power and then work your way up. I think it just gives a little more lifespan for the fiber as you're utilizing it. Go ahead. It makes sense to inject some contrast medium and see how is the filling effect now? Yeah, I think we will do that. I feel like that we still have some room to break up the stone. Unless you're interested in looking at it now, are you guys transitioning to another room? Yes, we are, Dr. Shah. I mean, as you continue to work on the stone. Give me the contrast off camera and then you guys come back to me or whatever you want to do. Yeah, we can come back to you in a few minutes. We'll go to India now. That sounds good. Thank you. Dr. Shah, we are back. And, okay. We've done more fragmentation and we just ran into a little bit of bleeding that has led our, probably there's some mucosal trauma that we were talking about to avoid. That does happen, not uncommonly. And so I'm just trying to get a better clear image to show you. We haven't done the contrast injection yet because it just felt like there's so much stone to still treat. But we may be doing it shortly to show how much stone is left. Especially since visualization is somewhat limited right now. So in order to do that though, it does gum up the working channel of the Spice Scope. A lot of fragments were coming out. I don't know if you can see the end of view, but a lot of fragments were coming out of the, let's see here. Here we go here. Of the bile duct in the duodenal view, there's stone there. So I think what we'll do, we would have to take the laser out, which I'm okay doing. In fact, in order to get the laser out, just like the issues with the spi-bite forcep, sometimes you have to come all the way out or go all the way up to the bifurcation to smoothly advance it. So what we're gonna do is let's go ahead and take this, go and put the laser on standby. So Raj, if you feel like you've gotten pretty good fragmentation, when would you go back to say large papillary balloon dilation or mechanical as an adjunct to what you're doing? I mean, obviously you want to get the smallest fragments possible, but do you ever say, well, we got it small enough where we can now grab it with a mechanical lithotriptor or we can probably, like I said, sweep it with a big dilation or? Yeah, I completely agree, Todd, that you can put it there. In our data of about 300 patients, we had about 99% stone clearance rate and about 20% of those patients did require combined treatment, combined options. So like large balloon, go ahead and inject, large balloon dilation, mechanical lithotripsy and SPI or a combination of thereof. So yeah, absolutely. Just because we commit to introductory lithotripsy doesn't mean that there isn't other adjunctive measures. Absolutely. So that may be the case here. So here you can see a bunch of fragments. Let me see, can you see the fluoro image? Yeah, we saw it. Oh yeah, you see a bunch of fragments there. So that actually looks pretty good. Yeah, but no big stuff there. No big stuff. So what we may do is then switch over to a balloon and wire, which we have set up. Every once in a while, I'm still surprised that the very distal duct irrigate here to see if there's anything surprising. Because the one thing I can't stand doing is taking the clandestine scope out and then having to reintroduce it. That's such a hassle. The other thing for the younger endoscopists to remember, excuse me, is sometimes you get so many of those stones fragments that you suction that they get stuck under the elevator. And all of a sudden you realize you can't get any more devices out because the elevator won't fall back down. And you have to pull the scope out and clean up the elevator. Can you put the fluoro as a bigger image? And Raj, there was a question from the audience here. For just 30 seconds, yes. Now that there is some mucosal injury, is it safe to retrieve the stones with balloon or basket in the same setting? Yes, sorry. So the question is balloon or basket and what? Oh, the question from the audience member was, now that there is a little bit of mucosal injury, is it safe to retrieve the stones with balloon or basket? Is it safe to retrieve the stones with balloon or basket in the same setting? Yeah, I think so. I think so. There's nothing too big of a defect. It was just very self-limited oozing of blood, which I'm not concerned about. I think it's okay. But I understand the point. You may not wanna do over dilation or something that may promote that, promote the injury to getting worse. So certainly if you have any concerns about that. But I think this compliant balloon, the extraction balloon, the compliance of it is, it's pretty gentle. I mean, it can cause some ductal damage, but I think you're okay. I won't over inflate, but why don't we go to like 12, this is a 12 to 15 balloon. And then right now is the image, is it a quad, a side quad with, you can get rid of spy. So just have like the endo camera and fluoro, please. And then. Yeah, so let's switch it over where you can, they can see endo too, cause we're gonna take some stone fragments out. So right now I'm just doing some segment sweeps from the very distal duct to mid. Go ahead and go up here. A lot of the, there's such a distal stone. We're getting flushed out with irrigation. You can just do the original quad is okay. If the spy is blank, that's okay. That way they can see the camera. You don't have to reconfigure it. So I'm just going up to mid. Okay, go ahead and go ahead and turn. So again, going very distal to all the way proximal, getting a lot of these fragments out. I think you're gonna clear this one out today. Can you see my hands now? Yeah, here we go. Okay, so I just wanted to show for maybe fellows or junior folks or people newer to ERCP. So I make sure my dials are unlocked. I bring the balloon as tight toward the stone or pillow as I can, and I lock it with my pinky. And I don't know if you can appreciate, can you put the camera down just a little bit more so you can see my right hand? And so I'm basically put, yeah, that's good. That's perfect, thank you. So you're pushing in and just a gentle clockwise. That's all, there you go. Look at that, that's nice. So we'll capture that balloon down. And so that's the maneuver to really try to get the tip of the duodenum scope forces, go to 12 here, the tip of the duodenum scope force is parallel to the axis of the bile duct. That's what that maneuver does. You just wanna be sure your dials are unlocked when you do it, because it can cause some damage. So it's a pushing in and a clockwise. Yeah, that may not come, let's see. It might be a big fragment. So I'm locking my, there we go. Nice, nice. And as Raj said, you wanna start distal and work your way up approximately. Dr. Shah, this is great demonstration. So we will come back to you for final images. We'll go to Dr. Shah from Johns Hopkins. All right, thank you. We have a quick final image from Colorado, Dr. Raj Shah's final fluoroscopy images. So we have the images here. This shows a beautiful fluoroscopy image. Dr. Todd Barron, do you have any comments on this? Oh, no, it's beautiful. It's a great outcome. And I'm sure the patient will be greatly appreciative. Yeah, that's gorgeous, wow. We should all go get laser now.

cholangioscopy

stone removal

bile duct

laser fiber

ERCP procedure

duodenoscope

peri-ampullary diverticulum