Okay, welcome. My name is actually Evan Fogel. I'm here with my partner, Dr. Mark Gromski. Welcome to Indiana University. I think we have a fascinating case for you today and I'm going to start with a brief case presentation. This is a 58-year-old man with a history of alcoholic pancreatitis a few decades ago, but for the last 20 years or so, he's really not had any pancreas problems whatsoever. He currently denies alcohol use and he's really had no use for many years. For the past few weeks prior to presentation, which was a month or so ago, he complained of some mild left upper quadrant pain and some early satiety with weight loss only in the last month. Outpatient workup included a CT scan and MRI in late January of this year. Here are a few representative slices. You can see this fluid-filled collection in the left upper quadrant, a markedly dilated pancreatic duct here, and this multi-septated cystic structure in the head of the pancreas. The axial images show the same thing. Again, this large fluid-filled structure measuring nearly 12 centimeters diameter, a markedly dilated pancreatic duct, and again, the cystic structure in the head of the pancreas. In mid-February, he had acute worsening of his abdominal pain with subjective fever. He was then referred to our emergency room for expedited workup. At presentation, his white count was over 17,000. His liver tests were still normal. Renal function was preserved, and his lipase was 376, with normal, upper limit of normal being 59 in our institution. A CT scan was then repeated on February 15th, and a multidisciplinary discussion was held with one of our compatibility surgeons. This is a CT scan from February 15th. Again, you can see the cystic structure in the head of the pancreas, and this well-demarcated fluid-filled structure in the left upper quadrant with the corresponding axial images here. An EOS was then done. The first image on the left shows the impression on the posterior wall of the stomach. Aluminum-opposing metal stent was then placed with fluid exiting the stent. A double pigtail plastic stent was then placed to secure the position. And an FNA was done of the cystic structure in the head of the pancreas, but the fluid was too thick to be aspirated into the syringe. Following the EOS, the patient's symptoms dramatically improved. His pain was better, now able to tolerate an oral diet, and he was discharged on the following day. The tail of pancreas cyst was 37. Amylase was markedly elevated at 48,900, and two bacteria were isolated in culture from that tail of pancreas cyst. The head of pancreas cyst cytology was hypocellular, with both mucinous and epithelial cells found, but no evidence of high-grade dysplasia or cancer. This is a CT scan from this morning in follow-up. You can see, again, the cystic structure here in the head, a markedly dilated pancreatic duct, and the left upper quadrant collection is now markedly decreased in size with the lumen-opposing metal stent in place. On the coronal images, it looks like the pancreatic duct here in the head is entering the cystic collection. Pancreatic duct here, superiorly, now communicating with this left upper quadrant collection with the metal stent in place. You can see it better here on the right, the main duct entering this fluid collection, which is being drained by the lumen-opposing metal stent. That brings us to today. Mark, why don't you tell us what your goals are, what you hope to accomplish today at ERCP? Yeah, thanks, Dr. Fogel, and thanks for the opportunity. Today, the goal is to do a pancreatogram to assess the suspected... I suspect we'll find a head of pancreas stricture where the pancreatic duct is being obstructed by that head of pancreas cyst, and then also assess whether there's an ongoing fistula from the tail of the pancreas to the fluid collection, which I now have the lumen-opposing metal stent in draining. And also, depending on what the pancreatogram shows, we may do a single operator pancreatoscopy to ensure there's no changes of main duct IPMN. That's our game plan for today. Michael, quick comment. Are you surprised that on the follow-up imaging, there's not more air in the collection? And the fact that you don't have air... let's say you did have air in the collection, but no air in the cysts in the head would suggest that they don't communicate, right? Communicate, right? Would be one thing to think about. The other would be, could this all be IPMN, even the cystic lesion that you drained, because the amylase is going to be high, and I get the CEA wasn't that high. So you're thinking that what's in the head is different than what was in the tail, in terms of the two entities? Yeah, I think it's unknown at this time, but that's the primary hypothesis. I think based on what we find today will help to determine the surgeons what surgery they may need to do and what timing thereupon. But the low CEA and the infection led me to believe that this is probably, in my opinion, a cyst blowout, a pseudocyst. Right, from what's going on in the head, right? Which, like you said, could be a completely separate process, not inflammatory, but actually neoplastic, because of the fact that it was so thick and mucinous. Yeah, right. The fluid was completely different from the two categories. I sent fluid off with my 19-gauge needle from the tail, and it was super thin and looked completely different from the head. Right, right. And I'm sorry, I don't recall, the cyst in the head, I assume, did not change before and after the lambs went in? Correct, correct. The cyst in the head did not significantly decrease in size after the lambs went into the tail collection. So we're addressing the major papilla right now, it's a native papilla. During our last intervention, we did not do an ERCP. A little bit of wire, Judy. So our goal here is pancreatic cannulation, obviously, based on what our plans are. Mark, what catheter are you using here? So I'm using a tapered tip, a regular catheter with an O2-1 guide wire. So Mark, this is Alessandro from Milano. It looks like you're approaching the papilla for pancreatic cannulation with the scope in the long way. Is that correct? Correct. So at this point, we're in a relatively short position. As you can see, the papilla is up a little bit in a little bit of a proximal location than usual. That might be because of the cyst changing the anatomy. Can we rotate, Jim? So we've seeded in something, and I'm going to rotate my fluoroscopy. Good. Try wire, Judy. Just nice and easy. Inject a little bit here. Stop. Rotate back the other way. Hard RPO, please. Now, we know that the head of pancreas duct is quite abnormal. And so it wouldn't be surprising to see it fill a large structure at the head. Now, do you typically use an O1-8 wire when you're doing pancreatic work, or more so in this case, because you're expecting some issue? So I'm using an O2-1 wire here. I usually use an O2-1 wire for pancreatic work. Let's go back. LPO, please. Get a better angle. We're still a little hindered here with contrast from today's CT scan on your way. MAG-1. As you can see, as Dr. Fogel said, we've got contrast in the kidney from the CT scan. Inject a little bit here. Keep injecting. I think that's going to fill something. There you go. Keep injecting. Stop right there. Can we go any further LPO? RPO. So at this point, we're having a little bit of difficulty getting our right images. So I'm going to adjust my scope to gently go into a little bit of a longer position here. That's very important for the younger people is that a lot of times if you can't get the fluoro, you manipulate the scope, either pushing or pulling back. Good. Right there. Injecting here, Judy. Yeah, that's a great demonstration of how moving the scope out of the way allows you to see now all the contrast there in the head. Right. But obviously, you have to do it very slowly so you don't lose sight of your ampulla and then fall out of position or something. Shot. I think you've seen now. Yeah, there's a lot of defects in that duct ahead of you, Mark. Looks that way. Let's try a little gentle wire, Judy. I'm going to pull back gently as you're advancing. good, good. So it's very possible we're filling that head of pancreas system. What I'm going to do, advance a little bit more wire, Judy. Good. Now, let's start injecting here. Very good. Shot. There we go. We've got duct upstream coming off. Yeah. It looks like a filling defect, maybe, right? Yeah. So let's pull wire back, Judy, and let's see if we get lucky and get into that upstream duct right there. Injecting, injecting, injecting. Oh, you're seeing the duct upstream now. Yeah. Shot. It's very nice. Let's go ahead and loop the wire, Judy, and I'm gonna go back into the short position to give myself a little more finesse if we can. Good. I'm gonna gently come back into the short position. That a long stricture there that you're seeing? Let's rotate back to RPO, please. Is the question further upstream over the spine? I think that's underfilling at this point. Hard to say. Do you think at the spine there that's the cyst or a hugely dilated upstream duct? I think that's a hugely dilated upstream duct. And this is a pain because only a mother could love. But actually, I like it a little better in the long position. Keep that wire in, Judy. There you go, there you go. Now, I'm gonna pull back gently as you go in, Judy. Keep going. See if it'll bow in. Yeah, you've got a loop that you backed your wire into that's gonna be tough to follow. Yeah. So pull back, Judy, a little bit, and we'll see if it flips in. Keep pulling back. Oh, that's all right. Okay, back in with that loop. I'm gonna go back in the long position. Yeah, long position sometimes make the duct more safe. You try to elongate the pancreas, pushing down the scope. Okay, try there. Straighten the wire. Wire in. Just looping in that cyst cavity now. I think the takeoff was inferior on the screen there. Yeah. Wire in, Judy. Do we have our 025 angled wire that we can go ahead and get on wire? I'll stay off. I'll stay here and we'll switch for an angled wire now. We're going to switch to an 025 angled wire to try and use the angled component of the wire to get into that component. It looks like the takeoff is in the inferior aspect of that large complex cystic collection in the head of the pancreas there. And then it leads to a very dilated upstream duct. It does look like to me there's filling defects in the dilated pancreatic duct, which raises our concern that this may be a main duct IPMN, a mixed type IPMN. Yeah, I really like the angled wire when you're in this kind of situation where you can fork and hopefully get it to go the way you want it to. Dr. Fogle, this is a good demonstration. We will come back to you. We will go to Dr. Shah from University of Colorado. All right, thank you. So we've been struggling a little bit as we were before. You can see our floral image there. We have a wire which is looped within the cystic cavity in the head of the pancreas. Unfortunately, we haven't been able to find the upstream duct with the wire despite using that angled wire. So the plan now, Dr. Gromsky is going to proceed with pancreatic sphincterotomy. Hopefully, can you show us the endoscopic image as well? Hopefully you can appreciate. We've seen on several occasions while we were away just globs of mucin exiting that major papilla. Mark, what's your plan now? At this point, we're going to do a pancreatic sphincterotomy. We can be fairly generous because the duct is big. Are we hooked up? Awesome. And then what we'll likely do, if after that we're not able to get favorable angles, we'll probably go in with a spy scope with direct pancreatoscopy and see if we can see the take off at that point and get a little better direction. And so that'll be our game plan at that point. Is there an advantage to actually getting the duct reconnected, if you will, or is it more that you can decide where the IPMN ends and begins for the surgeon? You have the tail drain probably through the axios and the stomach, but I guess you'd want to get a lay of the land. It sounds like we're pretty sure there's going to be IPMN in there based on everything you said. Yeah, exactly. Great point. We know this is IPMN, probably main duct IPMN. The only thing it'll help us with is, like you said, the cut for the surgeon, so we can quantify exactly how far up the dilated main duct is to get for the cut, but they can also do that intraoperatively. And so it's not a huge deal. Likely what we'll do is, if we're not able to access the duct to kind of get our stent up into the dilated main duct, we'll put a one or two double pigtails transpapillary. We've got the tail draining, that ought to be plenty to get this patient safely to surgery without another hospitalization or pancreatitis. Right. There was a question from the audience here, what's the minimum diameter of the pancreatic duct in order to perform spyglass pancreatoscopy? Good question, so the spy catheter is just a little bit over 10 French in size, and so the duct should be at least, in my opinion, three to four millimeters in diameter to be able to accommodate the duct. Sometimes, you know, if we're working on stone clearance in the pancreatic duct, then, you know, we'll need to dilate strictures and things like that, but the actual duct itself should be at least three millimeters, preferably four. Yeah, and not only is it, like you said, the diameter, but it's not, there's no taper on it, so it really makes it functionally almost seem a little bigger, you know, so like if you have a stone in the genu with a downstream duct that's really decompressed, it can be hard to get, let's say, up to that stone on one occasion, you might have to put a seven French stent in and let it dilate up a little bit and then come back to do the spy a second time. Mark, for those in the audience who are watching who may not do pancreatic sphincterotomy, is your technique similar, different from how you typically do a biliary sphincterotomy? Yeah, so a lot of it depends on the size of the pancreatic duct in the head of the pancreas. I don't want to overcut based on the size of the duct. And then also, I'm aiming in a more straight up from 12 o'clock to even one o'clock position for my cut. And so those are usually, go up a little bit here. As you can see, it's cutting right through mucin, which is we don't see every day. Go ahead. And that'll be all we need there. That'll be plenty to accommodate a couple double pigtail stents. And so at this point, we're going to likely introduce the spy scope and just see if we can look for upstream duct. But like Dr. Barron said, if we don't, what we'll do is we'll put a couple double pigtail stents in and go from there. Can I make a question, please? Hello, can you hear me? Hello? Yeah, so can I make a question? So for all you experts, do you think the spyglass with all these mucinous contents can have a problem in aspirating the mucinous and find the right way to go to the duct? Good question. I think it's going to be a challenge, similar to if we have cholangitis in the bile duct looking for stones, we tend not to do spy and cholangitis anyways. But anytime there's debris, we oftentimes don't get a good view. So this may be a limiting factor for us. And you're not scared of putting a lot of fluids with a spyglass inside the cyst to increase the pressure of the cyst? Well, we've got the sphincterotomy now and it's in communication and draining out the tail as well. I anticipate it's all communicated. And so it could be an issue where we kind of clean the mucin out of it a little bit, but I'm hopeful it wouldn't cause pancreatitis in this situation since we have conduits on both ends. This is good demonstration, Dr. Gramsci. We will come back to you in a few minutes. Okay, welcome back. So Dr. Gramsci completed the sphincterotomy, passed the spy out the duct, and you can see here we're getting beautiful images, intraductal. Mark, why don't you tell us what you're seeing there? Yeah, so I'm still in this complex cyst in the head, off on floral. Oh, lovely. Those papillary projections there, right? Exactly. So right now we're in the cyst and we believe this is probably the takeoff of the pancreatic duct, but it's quite possible it may just be another projection of that complex cyst conglomeration. But you can see this is a great example of these papillary fish egg type projections, pretty much diagnostic of IPMN. And so we probably will biopsy this before the end of the procedure, but we just wanted to show everybody a good example of IPMN changes on pancreatoscopy. Gorgeous view of them. Yeah. And we're going to continue to work this area to see if we can get a guide wire upstream, floral, into the pancreatic duct. We may not have success. We're not going to be exhaustive because as the discussion was before, it probably won't make a huge difference in the patient's ultimate game plan because they can do pancreatoscopy intraoperatively. But this is a very nice diagnostic addition that we did. And as you can see from the endoscopic images, as we inject, mucin just pours out. And so it's basically lavaging that cavity. Yeah. And have you given antibiotics and indescent to the patient? Yes, exactly. So we're giving indescent. The patient will have a trans-papillary pancreatic duct stent and antibiotics will be given or are given for the procedure and then also will be given for three to five days after the procedure. Don't you think you might be a little bit high for the takeoff where it goes back over with your scope? Because I thought it was kind of a little bit lower. Yeah, this is what we were internally debating. Floral. And there are a lot of these little honeycomb appearance coming back. And so it's quite possible we won't find the actual orifice. But we wanted to maintain that position to get our biopsies and put our double pigtail stent in. Thank you. Yes. Great case. All right, let's get the spy bites off. So it'll be interesting to see what they end up doing surgically. Certainly at least a whipple, but we don't know the extent. I guess they would want to explore the other part if you can't get there at the time of surgery, right? Just to see. Yeah, so our our surgeons have started using actually the surgical spy scope intraoperatively to give them a good impression of where they should cut the duct. And so I anticipate that's what we'll that's what we'll end up doing. Right. And how many bites are you going to try to do with the spy bite here? Well, the spy bite, you know, doesn't give us a huge amount of tissue. And so we're pretty convinced with the diagnosis based on the prior mucin on the FNA and based on our endoscopic appearance and the obstruction of the pancreatic duct. And so I'm going to do probably four to five spy bites, I'm guessing. Probably won't change the ultimate course for this gentleman, regardless, don't you think? Mark? Right. Yeah. I think he's going to need surgery regardless. Yeah, regardless, the patient needs surgery. So. Of course, sometimes with this angulation, the spy bites, the endoscopic forceps have trouble coming out of the scope. And so I'll have to change my position, straighten the angles out a little bit. Sometimes we even have to come all the way out, which isn't the most appealing thing. Yeah. Any other tips or tricks for trying to advance that very thin spy bite out? It all has to do, in my opinion, I think with the angle of the elevator, and then also the angle of the, you know, cholangioscope coming out of the elevator and the distal tip of the scope. And so all of those, I try to neutralize and unlock all of my wheels and relax my elevator. Those are the main tips that I do. Sometimes when you're in the bile duct, you have to go really proximally way above the stone. If you're doing lithotripsy and then try to advance it while you're withdrawing the scope, right? So it's almost like an exchange and you can get it to come out that way. But I agree with everything you said about how to, and sometimes, like you said, you just have to pull it all the way into the scope and have it, the mother scope, and then have it straight and then advance to the tip and go back in. Yeah, I've had success with what you just said, Todd, just kind of advancing the spy scope way up. And then, like you said, almost doing an exchange to get the spy bite to come out as you're pulling the spy scope back. Right. So I think we will have to bring the scope all the way out to be able to advance the spy bites. You can see now the post sphincterotomy papilla has that fish mouth appearance with with mucin coming out of it. So now I have the forceps out of the, and I leave them just a smidge out so that it doesn't. Dr. Gromsky, as you're working on this, we will go to Dr. Raj Shah from Colorado, then we'll come back to you after in two minutes. Great. Thank you. Thank you. Okay. Welcome back. Thanks. Since you left us, Dr. Gromsky did manage to take some spibite biopsies of the papillary fronds that we all saw very nicely. He has placed a single double pigtail stent into that cystic cavity transpapillary. He has since removed the axial stent that was draining the tail collection, and has placed one double pigtail stent through that. So Mark, why don't you tell us what you're doing now? Yeah. So my game plan is I'm not sure how long it's going to be until the patient has surgery, so I want to remove the luminoposing metal stent just so that it's not in too long and have any risk of bleeding or anything like that. So I'll put a number of double pigtails across the track to make sure that that tail collection is okay, and those double pigtails can stay in a while. And then I'll likely do one more double pigtail. We just reserved it to go live with you guys, but we can do one more double pigtail transpapillary, and that'll be all for this case. Can you comment? Because you alluded to that. Can you comment on the risk of bleeding with leaving a LAMS in too long, and how long is too long? Yeah. So I mean, it's so generally my rule of thumb is about six weeks is what my comfort level is. You know, after that time, I believe the data and our experience is that you can start to have the stent either dig into the gastric mucosa and cause an ulcer, or cause ulcers from the tract, either, you know, as the cyst is decompressing and rubbing against it from the internal flange, or as you remove it at the tract, good back tension floor out. And so that is, and so generally four to six weeks is my timeframe where I like to have them out. That's a little bit variable, but like I said, I don't, I don't really want this patient to have to do another endoscopy procedure, and I don't know when this will go to surgery. And so that way we know they won't have to come back for another endoscopy. Yeah. I mean, I think that, I, you know, again, I think it's very important because as the collection collapses, as you were saying, it could rub against the wall, cause pseudoaneurysms, which can then, you know, have terrible bleeding and whatnot. We tend to be a little bit more conservative and try to not leave them in more than three to four weeks. And I think if it's a simple pseudocyst, it's different, right? If you happen to use lambs in a simple pseudocyst, cause those drain very, very quickly. So probably want to remove them even faster in a simple pseudocyst. Right, exactly. This one's been in actually just only about two weeks or maybe even a little less than two weeks. And so, you know, this was a simple collection, as you mentioned. So that's why the timeframe was about two weeks for us. So it's not uncommon, you know, for us to bring folks back in two weeks to do something like this and also to expedite their care. But agreed, once the issue has been resolved, i.e., you know, the pseudocyst has been drained, then we feel comfortable exchanging that for our plastic double pigtails. Right. And the double pigtails can stay in there forever. I mean, I know this patient's going to surgery, but if they weren't. So now we're going to place one more trans-papillary double pigtail stent. And this is just to facilitate drainage of the head area with all that mucin. You can see that magic mark at the beginning of the pigtail. That's what our nurses tend to do at our institution. Usually we place one mark halfway along the stent, just so we sort of get a ballpark as we're deploying the stent, you know, where we are. And then a second mark at the beginning of the proximal pigtail, just to, again, help us gauge where we are when we deploy the stent. Yeah, that's a good point, because they don't come with those marks on there that we're seeing. Right. So we do the same, so we can have a visual of where we are endoscopically. One of the worst things you can do is, you know, from a time perspective, is, you know, to kind of have the stent be deployed inside your collection or inside of the duct itself, and then you have to go fish it out. And so those marks certainly help us to know when we're going to do our deployments. It helps to expedite the procedure, because it only takes the nurse 10 seconds to do the mark, but if you have to go back in and fish out a stent, that takes 10 minutes away from your day, at least. Dr. Fogle, this has been a great demonstration. Do you have any closing remarks? Well, I hope we demonstrated some interesting techniques. We don't see interductal images of IPMN every day, so hopefully that was a good learning experience for some of you, and we appreciated the opportunity. Thank you. Thank you. Thanks to the organizers for the opportunity to let us present this.

alcoholic pancreatitis

fluid-filled collection

dilated pancreatic duct

cystic structure

left upper quadrant pain

lumin-opposing metal stent

Indiana University