Welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's webinar. My name is Ellie Vergara and I will be the facilitator for this presentation. Our program tonight is entitled Evolution and Cases in Endoscopic Retrograde Chalangiopancreatography ERCP. Please note that this presentation is being recorded and will be posted on GI LEAP, ASGE's online learning management platform. You will have ongoing access to the recording in GI LEAP as part of your registration. Before we get started, please note a number of features in tonight's platform so you are aware of the many resources available to you during and after tonight's program. Currently, you are located in an auditorium. As you enter the lobby, you should note meeting information, which has tonight's agenda and a few recent reference articles on ERCP from GIE and Video GIE. There is also a satellite symposia section with a recent satellite symposia recording you can access. In the resource room, you will find a number of options, including Video GIE Meet the Master Videos, History of Endoscopy section, a gaming section, as well as access to ASGE guidelines and GI LEAP. In the networking lounge, you will find Access Link to complete an evaluation survey for tonight's webinar. We would appreciate you completing this as it only takes a couple of minutes or less. Finally, I would also guide you to the virtual exhibit hall, where there are a number of exhibitors providing information and resources, including an ASGE booth. If you have any questions, swipe your virtual badge and a representative will get in touch with you. Thank you for noting all these features available to you during the webinar and anytime following the program. Now it is my pleasure to introduce Dr. John Martin. Dr. John Martin is a gastroenterologist specialist in Rochester, Minnesota and affiliated with Mayo Clinic and St. Mary's campus. He has extensive experience with pancreatic disease and advanced endoscopic procedures. It is our great pleasure to turn tonight's presentation over to Dr. Martin. Dr. Martin. Ellie, thank you very much. It is an absolute pleasure to be here and a privilege to have you join us for what I consider to be fun. I thoroughly enjoy ERCP. It is the majority of what I do in my clinical practice and a lot of our ERCP is for various purposes above the bifurcation. As a result, intrahepatic ERCP ends up consisting or making up the majority of the ERCP I do. I consider it to be an excellent challenge. There is always something new every day. You never get tired of it. There are some techniques that I wanted to share with you this evening that I think are enjoyable to know, understand, and perform well. You can really help some patients by using these techniques, which are techniques that require some facility with a particular couple of devices that I will be sharing with you. I also wanted to throw some fun in there. History is always fun. A few years ago, we had a big year in ERCP where it hit its golden anniversary. I'm going to start out with some fun in sharing that with you as well. We will take questions at the midpoint of the technical presentation and then at the end as well. To let you know, I have no financial relationships with commercial support to disclose with respect to this evening's presentation. There are some objectives that we have listed to discuss clinical indications where ERCP is an effective procedural intervention. Comparing contrast adverse events endoscopists should manage. We will emphasize that less this evening than originally planned because I wanted to give you a little bit more of a technical experience because I saw some interesting cases over the past couple of weeks and really want to spend more time on that. Of course, we'll apply these new techniques to managing biliary disease endoscopically. Today's focus techniques include selective branch duct access via the techniques of spinning and darting the guide wire, a hydrophilic guide wire. These are angled wires that are coated with a slick hydrophilic glycate material. In order to use these techniques, you really truly need to use a hydrophilic guide wire, not just a Teflon guide wire that has a hydrophilic coated tip. In order to use guide wire navigation to particular upstream duct, you really need to be able to take an angled guide wire, not just a straight one, and spin it, dart it, and loop it in order to get targeted access where you need to drain above the hilum of the liver. We'll also use these devices and techniques to help us achieve transcystic drainage of the gallbladder, which in our practice we find ourselves asked to do more and more for patients who the surgeon's team will not do well by going to the operating room for an emergency cholecystectomy, which is likely to turn into an open procedure and where they might be better served with ERCP gallbladder drainage, either temporarily or long term for various and sundry reasons. We'll also focus on targeted suprahilar drainage and complex hilarbilary restrictors using these guide wires, using targeted guide wire navigation that I just described to you, selective branch opacification, so only injecting contrast into ducts that we've already deemed to be the duct that we want to be in and also have already gotten good guide wire access to, and only then will we opacify, because we do not want to take ERCP contrast, which has entered the mouth and the gut and is therefore contaminated, and inject that with a sugar solution of contrast, iodinate, contrast is iodinated sugar obviously, and injecting that with bacteria into ducts that we're not going to be able to drain, and so we avoid that risk of causing iatrogenic liver abscesses by getting guide wire drainage to the duct that you're going to drain, and only then putting in the contrast in that duct only, and then getting your stent in there. We'll talk about endoscopic management of cholecystitis as I suggested to you via ERCP access to the cystic duct, and then transcystic gallbladder stenting with one or more stents, and then just for fun we'll take a quick look at biliary RFA or radiofrequency ablation in the treatment of biliary neoplasia. This is not a standardized technique, but it's one that we're using more and more and that we've published about, and I just wanted to quickly share that device and technique with you in case you're interested. But first let's have a little fun with history. I imported some slides that I made almost exactly three years ago in March of 2018. 2018 because 1968 was the nascence of ERCP, so ERCP was celebrating its 50-year anniversary in 2018, and so I prepared a lecture that was part of our ASGE ERCP master class at the IT&T Center. So I'm going to share with you in the next couple of minutes just a few slides from then. So were you around in 1968? If you were, what were you doing and what were you seeing? Well, it was a year that transformed the nation in many ways. If you're American, your country was in the thick of the Vietnam War, and there was a lot of upheaval socially about whether that made sense or not and why we were involved. At the same time, we were not only going around to the other side of the world, but also getting ready to go to the moon, which happened the very next year. Not only were the Beatles hot, but so were the Rolling Stones, and General Motors' answer to Ford's Mustang, the Camaro, first came out in 1968. But what was even more important than all of that, of course, was that 1968 is when ERCP was first performed and described, although not yet called ERCP. And it wasn't this fancy fiber optic duodenoscope that Bill McCune used to do the procedure. He actually wasn't a gastroenterologist or a surgeon. He was actually an OB-GYN. And I've never been able to figure out what an OB-GYN was doing trying to get into the bile duct or the pancreatic duct. He did do it through the mouth, and he used a device called an ITER duodenoscope to perform both pancreatography and cholangiography, believe it or not. And this barbaric looking device here, which actually is made in our favorite city of Chicago, in this building, which still stands, this is a type of semi-flexible gastroscope that was manufactured and used in the 50s and 60s, made in Chicago on Clyburn Avenue. And that was what he used to cannulate the bile duct and the pancreas duct at none other than GW, George Washington University. So he used this ITER fiber optic duodenoscope, was really actually a gastroscope, but he got it down there far enough. And even back then, he said that ERCP slowly grew to an established technique due to the honesty and persistence of endoscopic pioneers. And that is still the case today, because we all know as endoscopists that persistence frequently pays, and that is to the advantage of your patient. But what was big about ERCP was it becoming not just a diagnostic device that could show you what the bile duct and the pancreas duct looked like, but that you could actually use it to fix the bile duct or the pancreatic duct. And that happened in 1974. And if you were around then, what were you doing? I remember actually, I was in grade school and Richard Nixon ended up resigning because of the Watergate mess. Alexander Solzhenitsyn was writing the Gulag Archipelago about the various prison camps across the Soviet Union. Leonard Skinner was hot with Sweet Home Alabama, but Patty Hearst, the rich daughter of the big publisher in California, was in hot water because she had been kidnapped and then joined the SLA, ended up becoming a criminal herself. Six years after the Camaro was brought out, it looked really different. It was a lot bigger and turned into a hatchback or at least a fastback. And Hank Aaron, as you may know, beat Babe Ruth's record, which was a big deal. But again, not as big a deal as ERCP, becoming way better with sphincterotomy and turning into a therapeutic procedure. And what was doubly interesting about this happening was that ERCP and sphincterotomy was described by two different groups on two opposite ends of the earth during that same year of 1974. Keiichi Kawai's group in Japan published about sphincterotomy in GIE, ASGE's own journal, Gastrointestinal Endoscopy, which of course is an English language journal. And Meinhard Klassen in Germany published in a German language journal, and they published it during the same year. Who were these men? Well, this is what Meinhard Klassen looked like back then. This is what he looks like now. And so that's Meinhard publishing in Germany. And this is Keiichi Kawai today. He published in the ASGE journal the same year, and this is what he looked like in 1974. And this Congress, World Congress in Mexico City, World Congress of Gastroenterology in 1974 was actually when the term ERCP was actually coined and agreed upon by the then world experts or burgeoning experts who were pushing ERCP into the realm of practice. The first sphincterotome, here's a picture of it in the ASGE article by Keiichi Kawai. It looks like a homemade needle knife, and that's what they use to perform the sphincterotomy and get get a stone out of the duct. Amazing stuff. And of course, we didn't have video. We didn't even have video attachments for the eyepiece. And so this is how ERCP was done. It's almost unimaginable that the nurses and techs wouldn't be able to see the image that the endoscopist was seeing, but could still assist in the procedure. Almost unthinkable today. Here's Peter Cotton. Many of you know, he retired recently. Next to him is Jack Venice, who was at the University of Minnesota. Both of them went to Japan to learn ERCP from Kazuo Ogishi in Niigata, Japan. Both of them consider Dr. Ogishi to be their teacher, as many early ERCP mavens in the West considered Dr. Ogishi here to be their teacher who taught them ERCP. As many of you know, Peter Cotton retired recently, but never forgot his teacher. Both of them are still alive and well and still take great interest in ERCP, although they don't perform it anymore. All right. Hope you enjoyed a little bit of ERCP history. Fun to know where things come from. As fun as it is to see where we're taking it next. The techniques I'm going to show you today really require you to use a hydrophilic guide wire. These wires are coated with a slick glycate material from stem to stern. Because they are slippery, sometimes it's hard to really be able to manipulate them if your gloves are wet. So you really need a piece of cloth, like a three by three or a four by four, or something similar to dry your fingers just enough to be able to spin this. If you're manipulating the wire yourself, or your nurse or tech will need to dry their fingers. But you can't let the wire get too dry, because if it gets dry inside the catheter, it gets sticky and you need to remove it and wet it again. So it needs to be wet inside the catheter and the tip needs to be wet too to get across the stricture. But the end where your fingers are darting and spinning, it needs to be dry. So holding a little cloth in your hand can help with that. These come in all typical wire diameters. 0.018 inch is the narrowest. 0.025 and 0.035 is what you're looking at here, which is sort of, as you know, the standard ERCP wire. The thinner ones are useful for tighter strictures. Usually once you get across the stricture, those narrow gauge wires are so hard to see fluoroscopically that you'll ultimately exchange them out for the thick wire once you've gotten access. So spinning these often, what you'll do is you'll lay the wire between your index finger and your middle finger, and then put your thumb on top of it, and then hold it sideways and run your finger over the wire back and forth, back and forth. And then you'll get it spinning like a helicopter, just like you're seeing here. And every time you spin it, every revolution of that angled wire is an additional chance for you, just by chance, to try to get into that duct that you want to get into. There are different degrees of angulation of the wire. We tend to stock the 0.035 wire in a 90 degree angle, which is what you see here, because the 90 degree angle toes in and allows you to loop it a little bit more easily. The 0.018 inch wire, we, in our unit, stock it in a 45 degree angle and a 70 degree angle, depending on how easily you want it to loop. When I use it as a finder wire to try to get into the papilla and a small papillary orifice, or to get across a really, really tight stricture in a narrow duct, I usually tend to choose the 45 degree angle. I find that the 70 tends to loop a little bit too easily in that situation. That's just my own personal experience. We're going to talk about some of these particular characteristics of these wires as we proceed. I also wanted to talk a bit about this stent that you see here. This is called a wedge stent. As you can see, it has side holes all along it. It's almost a little bit like a percutaneous gallbladder or biliary drain that the interventional radiologist uses. This stent is actually indicated for pancreatic stenting. It's marketed as a pancreatic stent, but we use it off-label many times when we are stenting ducts above the hilum. We believe, in our experience, that these side holes, multiple side holes, keep us from jailing side branch ducts and recruit drainage from multiple ducts and complex hiler strictures. The other thing about this is because this is a sort of a silicon elastic type of substance that this wire or this stent is made out of, it tends to take bends very, very easily. Unlike straight, hard stents like a Cotton Leung stent or an Amsterdam type stent, they won't try to straighten themselves out at a tight bend in the duct, which you'll frequently find when you're trying to get across the hilum into the left duct and won't ratchet itself out. I'll show you an example of that later on. Even though they're indicated for the pancreas, we frequently use them in the bile duct. They come in an eight and a half as well as a 10 French size. They're soft and pliable, multiple side holes. They're somewhat compressible. They have a tapered tip, so only the guide wire comes out of the tip. The stent guide ends right here, and then the wire continues out the tip. The stent and the guide, as you can see, go into the stent together. The gray thing or the black thing here is the stent guide. The purple thing is the stent pusher. This stent fits right over the guide, and then once the stent is put onto the guide, the nurse or the tech will bring the pusher right up to where the stent is, and then this is ready to be placed over the guide wire here into position in your access duct. There are a number of caveats that I think are useful for you to remember in dealing with complex hyaluronic acid or drainage. There is a lot more to think about when you're stenting above the hyalum than when you're doing work just at the common bile duct. You know, when you're doing work at the common bile duct, that's a difficulty level one or two ERCP. Above the hyalum is three or four, and there's a reason why that is. You really need to plan ahead, particularly when you're dealing with a bismuth three or bismuth four complex hyaluronic acid, because you're not going to want to opacify ducts that you're not going to be able to get a stent in. And just because you could get a stent into the branch duct doesn't mean that you could get multiple stents in the common duct. I'll explain that more in a second. First, you have to obtain good cross-sectional imaging. As gastroenterologists, we're most comfortable interpreting coronal images and not just looking at axial images like a radiologist. Either get a good coronal reconstruction CT scan or an MRI MRCP to help you decide where you're going to get the biggest bang for the buck when you go for a duct with a stent, because you're only going to be able to get two or three stents in max. No common bile duct is generally able to accommodate more than two or three good stents. And sometimes the common duct, the native diameter is narrow, and you're only going to be able to get one stent in there. And if that's the case, you want to make that one stent count. So you need a good cross-sectional imaging study to help you decide before you do your ERCP exactly which duct are you going to target. And then you're going to cannulate, get your guide wire into that exact duct. Then you're going to opacify that wire access duct. Then you're going to stent it and avoid polluting the parts of the biliary tree that you're not going to be able to stent. So review those cross-sectional, get them first, review those cross-sectional images, and have your game plan for drainage decided before you do your procedure. And don't forget about giving patients pre- and post-procedure antibiotics in these situations. Even if you think that you only opacified the duct that you stented and that you're going to drain it completely, how do you know that you didn't get a little bit of contrast into the other side or into some branch that's not communicating with the stent that you placed? Give them an antibiotic intravenously before the procedure. Give them three days of an oral antibiotic afterward. Your patient will thank you and you'll thank yourself. And again, targeted access with your wire. How do we do this? How can you confirm that you're in a large duct? When do you opacify? How much do you opacify? We've answered some of these questions already. How? By looking at a good cross-sectional imaging study and deciding where you're headed first and getting that wire access. You can tell that you're in a large duct, actually, before you even put contrast in it. Because if it's a large duct and you're using an angled guide wire, you can loop that guide wire into the end of that duct where the tip of the guide wire is. And if that loop looks pretty big, that loop is the size of that duct at the location where the loop is. So if that loop makes a loop that's about, you know, say three, four millimeters in diameter, that's big enough to accommodate a 10 French stent. You know that's going to be a big duct. Then you can safely push your catheter up into that area and slowly opacify it. Don't blast the contrast. You don't want it going into areas that are not contiguous with what you're going to stent and therefore won't drain. So when you opacify is after you've gotten a wire where you want to get it, where you plan to get it, and confirm that it's a large enough duct for you to want to stent so that you drain a large enough area of the liver to get rid of the jaundice that you're trying to get rid of. You opacify enough to see the confluency of what you're going to drain. No more than that in these situations. What type of stent? Plastic or metal? Well, you know that that can be complicated, okay. I think in this day and age when so many patients are, who have hiler tumors, like patients with hiler cholangiocarcinoma, METs from colon cancer in particular, METs from pancreas cancers even, many of these patients are living longer and so putting in one or two hiler metal stents, they may outlive the durability of those stents. Then trying to put plastic through metal or doing metal and metal when you've done Y configuration metal stenting can be difficult or problematic. So a lot of this depends on understanding what's the nature of the tumor. Don't be shy about asking your oncologist or the onc surgeon who sent you the patient, how long do you think this patient's going to live? What's their life expectancy? You know, with most colon cancer patients, it's going to be years even with METs. Don't put metal stents in the hilum in those patients. You know, they're going to be around for years or if they're patients who are transplant candidates, they're going to need brachytherapy. You need to remove stents to do brachytherapy. If you've put in an uncovered metal stent, you're not going to be able to remove that to do the brachytherapy. And of course you shouldn't be using covered metal stents at the hiler bifurcation or you're asking for a liver abscess because that covering is going to jail various branch ducts that insert to the bifurcation. You don't want to do that. How large are the ducts that you're interested in stenting? Well, we talked about looping the guidewire to find that out. And of course you'll already know ahead of time how large because you already got a good coronal CT or an MR, MRCP or both. We talked about how to know whether it's large enough. Ah, don't forget about this. You have a big necrotic tumor mass or an atrophic lobe, stay out of that. You don't want to put contrast, much less a stent in there. Uh, those areas will become infected. They'll abscess and you'll be to blame. Do not stent atrophic lobes. It's not going to do the patient any good and it could do them some harm because remember that that becomes a wick for food and, and bacteria, uh, from the GI tract lumen straight up to that lobe, which is, uh, atrophic, uh, not perfused well, and maybe not even making any bile. Necrotic tumor masses speak for themselves. That's dead tissue. There's no circulation. White cells can't get there very well to combat infection. Uh, and if you stent through that kind of thing, you could end up with an infection. Avoid that. Uh, there are different kinds of plastic stents. There are the straight type, hard polyethylene, uh, like, uh, we're all used to using, uh, but they're also those silicon elastic type stents that I just showed you, which you'll see in some video in a moment. We just talked about metal stents at the confluence. They're advantageous if, if you think you put them in once and the patient will not basically not outlive them. But if you think that there's going to need to be a revision or replacement in the future, you may, uh, have less enthusiasm for metal, uh, and may want to go for plastic where you can, uh, revise things. That's really the bottom line. I'm happy to take questions on that if, uh, if you have any. So what if you're deploying more than one stent? Well, the order of which duct you're going to stent is going to make a difference. I would say always pick the side that's the hardest to get into, or the, uh, uh, the duct that's hardest to get into. If you're trying to do bilateral drainage, one in the right, one in the left, it's usually the left that's more angulated and harder to get into. So hit the left first. How many do you, how many stents do you need to put in? Well, it depends on how many you need to put in to get adequate drainage. You're probably going to need to drain 30 to 50% of the liver mass in order to correct jaundice, uh, enough to get the patient to chemotherapy, if that's what you're trying to do or to get rid of their cholestatic pruritus. So you're going to want to choose the biggest confluent system that you can pick and try to get into that, and then see if there's room to put in more. Go for the biggest bang for the buck, the largest drainage field that you can drain with one stent, uh, before you decide where to put in the second or the third. Okay. Um, and always remember the number, ultimately the number of stents of what size or what diameter you can get into various suprahylar ducts really depends on how large in diameter the common bile duct is. The patient has a native narrow common bile duct. That's only big enough for one 10 French stent. Well, you're not going to be able to drain both the right and left side, unless you're going to put a seven French into the left and a seven French into the right, which is going to give you poor, uh, durability of patency because it's such a narrow stent. So you might be better off draining one side if you can do that with a 10 French stent and do it confluently. Uh, so remember, always take into consideration what's the size of the extra hepatic bile duct when you're planning, uh, what you're going to do to target drainage for the ducts above your complex hyaluronic structure. Now, if you're deploying more than one stent, it's frequently useful or necessary or both to perform balloon dilation, especially after you get that first stent in, you're probably going to want to dilate beside the first stent because it will make it much easier for you, uh, to get into the other side and put a stent there. And also it may help prevent my in-migration, migration inward of the first stent that you placed when it experiences friction with you inserting the second stent. This can be a big problem. And speaking of in-migration of the already placed first stent, how do you avoid that? Well, we just talked about dilating with a dilation balloon. Also lubricate your first stent and your second stent. Okay. I know that the scope manufacturers tell you that they can't guarantee, uh, you know, perfect, uh, decontamination if you use a non-hydrophilic lubricant. Uh, but sometimes to get the job done, you may need to use, uh, a lubricant. You can get olive oil that comes in single use packets and lubricate with that. One of my teachers, uh, even uses a liquid dish detergent, uh, because they will not let him use a hydrophobic substance, uh, in his lab. And of course, uh, soap is hydrophilic. And so he uses that, but frequently, if you lubricate the first one and the second one and any subsequent one, there'll be less friction. Uh, and you'll experience less migration. You may want to choose a longer stent for your first stent so that it's proximal tip either hits up against a tight turn in a duct, or if it's the wedge stent, like I showed you before, uh, those come in a length that's 22 centimeters long. And, uh, if you, uh, don't, uh, or if you cut it so that the tip hits up as far as it can go into the duct that you're, uh, stenting, uh, then it can't migrate in any further. All right. Let's transition to a few cases here. Here's a 54 year old woman with adrenal cortical carcinoma that's metastatic to the hilum. She's got a large liver metastasis. She had good performance status and quality of life until the onset of jaundice. Now she's got intractable paritis from that jaundice. She also can't get her chemotherapy unless her belly gets below two. So the oncologists have asked, uh, for a biliary stent placement. So, uh, here's a few months ago, November, 2020, an MR, you can see the size of that mass, and she already had left ductal dilatation. Uh, at that point, you can see though that the left system looked quite confluent, which means you can probably get one stent in there and drain the whole thing. Uh, by last month, you can see the tumor mass is much larger, but there's still a fairly big confluent drainage field in the left. You don't see much dilated in the right, other than what's near the tumor, which is a no-no. And then this right posterior system, which doesn't look, uh, is hugely confluent, right? So here's a papilla that looks normal. We get in with a papillotome, perform a sphincterotomy, uh, and here's a little bit of video. I first tried a 0.35 inch, uh, uh, hydrophilic, uh, angled guide wire, but that guide wire was even too thick. Uh, these adrenocortical, uh, carcinomas are extremely hard cancers, uh, hard substance cancers. So I switched out to the 0.018 inch guide wire. It has a little gold tip on it because the wire itself isn't very radiopig. It's kind of hard to see. I've inflated an eight and a half millimeter balloon on this occlusion balloon catheter in order to use it as a fulcrum to sort of be able to rock the tip of the catheter, which is right here, back and forth, uh, to try as I spin and dart this guide wire, loop and unloop it to crawl up that left duct that I wanted to get into. And I know from the images that this is a confluent system. So now I've gotten the wire way out to the periphery of that left duct. I'm happy with that. And what I'm going to do, this is a 4.6 to six French passage tapered catheter dilator. And I am putting this up there, not just to dilate the stricture, but I'm putting it up there because this is one of the few devices that will go well over a, an 0.018 guide wire, but we'll also take an 0.035 guide wire. So if I can get this dilator up over that wire, I can pull that skinny wire out and put my thicker wire back in and do my work, uh, with a more radiopaque guide wire. So here you go, here's the 0.035 wire. And I don't want the stent to have to take that kind of a crazy turn cephalad. And so I will spin this wire and loop it and such ultimately in order to get it back in the same lateral duct on the left there that I had gotten, uh, that initial wire in. And there we have it looped. So you see how big the, uh, the, uh, duct is way out there. Uh, so then we're going to, uh, so we've got an 0.035 wire up there. I know it's looped in a nice big duct. So I'm going to put a catheter up there and start injecting it. And you will see that this is a confluent system. I'm going to speed it up a bit. You can see this, that's what it looks like. So then ultimately, uh, we will balloon dilate this stricture. And I think you can see the balloon going up there. And you can see how tight that waste is there. And we do a few serial inflations to get this thing dilated. And then there goes our stent. And you can see we're having quite a struggle down here, pushing that stent across that stricture, because even after a balloon dilation, man, that is tight. But look, all these left ducts are confluent. They're all going to drain, particularly with this stent, because it has multiple side holes in it. Uh, and as you're going to see here, that's what it looks like when we're done. I'm sizing this up by putting the balloon catheter beside it and the skinny wire to see if it's even possible to get a second stent in there. Uh, and I, I can see that the, even the skinny wire just loops out and I absolutely can't get a catheter up there. So that is the drainage that we got. And this lady's jaundice actually, uh, went away with that. Here's another complex hyaluronic stricture drainage case. This is a 36 year old woman, this time with a cholangiocarcinoma, 36, very sad. And she has a huge liver mass affecting the right lobe, but she has good performance status and quality of life. And the surgeon actually thinks he can do a right lobectomy, uh, or even a right lobectomy and the caudate lobectomy along with it, uh, and get her a successful resection. But he wants her to get neoadjuvant chemotherapy. So he needs that bilirubin down below too. And he also wants a stent in the left side, which is a side that he's going to preserve because he needs that stent in the left duct as a tactile marker for his surgery. Interesting, right? So here's this huge mass. And as you can see, uh, elsewhere, uh, that mass, uh, uh, effect area has been, uh, stented with a straight, uh, plastic stent. This is the mass. This is a dilated left duct, a saccularly dilated left duct. Uh, and what we want to try to do is to get in that left side. That's what the surgeon wants. So as you can see, the hard straight stent had been put in, uh, elsewhere before, as you can see, it's partly out migrating, which is why it's not draining very well. And as you can see, one of the dangers of straight stents at the hilum that are very long, particularly 10 French, is that they want to straighten themselves out because they're stiff. And I've actually seen these migrate far enough out that they actually puncture and perforate the contralateral duodenal wall. Now, if you find that you can remove that stent and use a hemostatic clip and close it because the hole is only about three millimeters in diameter, but still you want to avoid that kind of a consequence if you can help it. In fact, it's out migrated so much that it's kinked itself to try to curve to the shape of the duodenum. So what we did was we got up there with this balloon catheter, and what I'm doing is spinning an 035 angled hydrophilic wire, and I am trying to choose from various ducts. Uh, and those various ducts I'm sizing up with the balloon catheter to see which is one that's large enough that the stent could actually sit in it, and one that isn't so curved that it would be tough for the stent to get into. So there I'm doing the balloon dilation, and I'm placing the stent now. And this is the same stent with multiple side holes. And there you have it. That's what the surgeon will use to help perform the resection for this young lady. And this is just a little video of what the stent looks like as it's going in. I think you can appreciate that some force is necessary to get across this stricture, although the cholangiocarcinoma is not as hard as the adrenal. You can see that side hole there as the stent's going in, and you're likely to see another one right there. And there we go. The stent is in. Okay, so here's some additional pictures. Here's one in the left and one in the right. In this situation, I'll usually access the left, get that stent, and make sure that tip hits up here so that when I push the right stent in as the second stent, it doesn't make the left one in migrate. It helps to balloon dilate before you place the second stent. We talked about that. Sometimes, remember, about 10 or 15 percent of the time, the right posterior duct, if you want a stent that actually comes off the left main. So don't forget about that variant anatomy. That can certainly exist. Okay, before I move on to gallbladder drainage, any questions? Yes, Dr. Martin, we have a question. Do you have any tips for beginning to learn appropriate biliary stent lengths for fellows? Yes. Remember that now this is a little bit different topic from what we're talking about here. Choosing stent lengths for suprahylar strictures, we just talked about that. So I'm assuming that that's not what you're referring to. You want to know when you're working in the common duct how you choose stent length. And there, the stent should be just a little bit longer than the location of the proximal end of the stricture, because the stent absolutely has to span the stricture. However, if the stent is much longer than that, you're getting nothing out of that added length. Because remember that with Foswe's law from your physics class, that the longer the stent is, the higher the resistance to flow. So you're gonna get lower resistance to flow for the same stent diameter by choosing the shortest stent that's gonna get the job done. And there's always this concern that longer stents migrate less than shorter stents. And that was long ago in studies proven to be incorrect. So choose the shortest stent that spans the entire stricture maybe give yourself an extra centimeter or something like that. And that's your right stent length. All right. One more question before I move on. No questions at this time. I do wanna remind our audience to please use the chat or Q&A feature at the bottom of your screen for any questions for Dr. Martin. Thanks Ellie. All right, I'm gonna keep going. Remember we talked about the wire spinning method with a hydrophilic angled guide wire. Now I must mention that not all catheters are created equal when it comes to allowing you to spin the inner lumen diameter for the guide wire actually has to be large enough to allow it to spin freely. So balloon catheters tend to be a little bit better for this than a standard cannula or a sphincter tone just so you know. Now to stent the gallbladder you usually want a double pigtail stent. The last thing that you want is a straight stent in migrating into the gallbladder that's gonna cause problems. So have a pigtail curl on the proximal end so that it stays in the gallbladder and doesn't out migrate, but also a pigtail on the distal end so that it doesn't in migrate into the gallbladder. Most of the time for transistic stenting of the gallbladder you want a seven French stent and the most useful lengths are 10 and 12 centimeter lengths sometimes though, for whatever reason, we may wanna get a stent all the way out to the fundus of the gallbladder. And in patients with larger long gallbladders you may need a 20 centimeter, a seven French 20 centimeter. That's not made as a biliary stent but it's made as a ureteral stent. So you can use a seven French 20 centimeter double pigtail ureteral stent as a gallbladder stent as well. Ureteral stents tend to be lubricated with a hydrophilic lubricant that can sometimes make them slide in a little more easily especially if you are placing two gallbladder stents that can be useful. So here's a case of an 80 year old woman with a recurrent prior episodes of acute cholecystitis. And so she does have underlying pancreatic adenocarcinoma with liver and lung mets. She's on hospice care. Somebody had put in a plastic biliary stent common bile duct stent over seven months ago. And I think in the hospice setting, it was forgotten about. She came in jaundiced and also with a history for recent multiple episodes of cholecystitis due to a known gallbladder stone. So they're asking us to place a permanent metallic stent for this elderly lady with metastatic pancreas cancer but also to stent her gallbladder to prevent future recurrent episodes of acute cholecystitis because she's not a surgical candidate. So here you can see her gallbladder. She has a plastic stent in the bile duct. Here is a liver metastasis on a CT. Here is the stone in the neck of the gallbladder that's been problematic. And we are then asked to place a metal common duct stent. I am going to choose a bare metal stent in this situation because I do not want to occlude her cystic duct with a covered metal stent and risk causing cholecystitis when she's already had that. So I've just navigated an angled 035 hydrophilic guide wire into the gallbladder. And we are then placing a balloon dilator up there, four millimeter balloon dilator. And we are going to inflate that and perform a dilation. As you can see, sometimes dilating a cystic duct that you think was hard for you to get your catheter through gently with a four millimeter balloon. You don't necessarily inflate it to burst pressure. And then here goes one transcystic gallbladder stent. We have a study going on where there appears to be some at least marginal benefit in terms of durable patency. If you place two gallbladder stents side by side. So where it is possible, that tends to be our practice. We do tend to place two if there's enough space to do that. And just to show you, here's one stent already in. We're going in with a second one. And sometimes it helps to have a rat tooth to help you make little adjustments in the position of your stent. If you want them to lie a certain way. I think I just wanted a certain cosmetic appearance to what the stents look like here. So that was one case. I had another case last week with a 68 year old with acute cholecystitis and a CT showing gallbladder wall thickening and air in the gallbladder suggestive of emphysematous cholecystitis. And for medical reasons, the surgeons didn't want to touch him and asked us to place stents into the gallbladder. This unfortunately was, this is the papillary orifice inside a diverticulum. It took me a little while to get access, but ultimately I did. Here's that 018H 45 degree angled hydrophilic wire. And I'm spinning it and darting it and looping it to try to get through the valves of Hyster that are throughout the cystic duct. And you'll know that you are successful in successfully in the gallbladder once that wire shoots out into the gallbladder and curls itself there. And you can usually follow it right in with your catheter. That'll tend to straighten the cystic duct out. Here it is way out in the gallbladder. Now we've switched out to a thicker wire, an 035 wire, and then ultimately we end up putting in. This cystic duct was only large enough for one gallbladder stent, but it certainly did a nice job. We just performed a sphincterotomy, got into that gallbladder as you saw in the fluoro, and then here we are inserting the stent. And one of the most gratifying things is when you start seeing the pus draining out of the gallbladder and know that you just did a really, really good thing for this patient. So there you go. Makes the day worthwhile, doesn't it? Okay. I just wanted to show you a couple of things about biliary RFA. We use this for treatment of certain bile duct malignancies that are not amenable to surgical resection. Here's a 65-year-old woman with multiple medical problems who had an ampullary high-grade dysplastic adenoma, and she had a successful endoscopic ampulectomy, but she had some sub-centimeter length of intraductally extending ampullary adenomas. So the referring endoscopist asked if I could use an RFA probe to do this. This is a 10 French device, and I just wanted to share with you the settings that I prefer. I have an Irby Bio electrosurgical generator. I use soft COAG. I set it on seven watts, effect eight. Remember, this is bipolar device, so there's no ground pad. I step on the pedal for 90 seconds. Some people like two minutes. I use 90 seconds. I wait about three minutes before I withdraw the probe, thinking that that may reduce the risk of bleeding somewhat, and our entire group of ERCPists leaves a stent behind after this. So this has a couple of electrodes. The burn goes just a couple of millimeters deep, and as you can see, a little bit of an indentation where that intraductal tumor is as I inject there, and this is the probe. So I try to make sure that the electrodes are in the area where that tumor is, and step on the pedal for 90 seconds. It goes in over a guide wire, and at the end, over the same wire, place a stent. So it's actually really simple to do it. This is the device. There's one of the electrodes going in, and the second electrode, I think you can see that. And then perform your treatments for 90 seconds, and then here goes the plastic stent being inserted, and then the patient comes back to have that retrieved in a couple of weeks, okay? So that's it with the cases. I just wanted to show you where I work. This is what we call the downtown campus of Mayo Clinic. This is mostly outpatient work in this area, and the endoscopy unit that I work in is right here on the second floor. My office is up here on the ninth floor. So this is what the Rochester Methodist Hospital or Mayo Clinic campus looks like. This is the medical school complex that is directly attached and across this park here. So this is the medical school, and this is the medical center. And all of that complex that you think of as outpatient Mayo Clinic is over here, but our big inpatient hospital's called St. Mary's Campus. It's about a half a mile between the two. There's a shuttle that runs back and forth constantly between the two, and all of us work at both locations because obviously here, I would tend to see inpatient presentations for ERCP, whereas over here, I would tend to see the outpatient presentations. When I walk in in the morning, this is the lobby that I see as I walk into work. As you can see, it's still dark outside because this is early in the morning, probably around six o'clock or so, but there are still people walking around, getting ready for work or getting ready to be seen, and when it's time to check in, this is where they go. I walk up two flights to get to the endoscopy area, and one of the fun things when you walk in the door, everybody who works there, their picture is up on the wall, everybody from the anesthetist to the nurses to the physicians, anesthesiologists, secretaries, et cetera, because we're all one big team. I walk down the hall. This is recovery over here, and my workroom is right across the hall. There's Dave, who's one of the anesthetists that I work with, our Pyxis machine, where we keep the medications we use frequently, Dave's gas machine and equipment. This is our C-arm fluoro machine, along with the control trolley that the radiology tech uses for our team. These are the reference monitor for fluoro and endoscopy that we use. Everything is on booms. We have a microscope in the room for the cytotechnologist. Here is a workstation for the nurse that's doing the documenting. Most of our stock is kept behind this door in a core area that opens to all six endoscopy rooms. This is where we can prepare specimens and so forth, and we keep a limited number of devices in a cabinet in the room so that we don't have to go into the core necessarily to get them, and this is recovery right across the hall. So that is where I work. So what to do is where the rubber meets the road. Stenting is substantially more complex than common duct ERCP. Planning, particularly obtaining good cross-sectional imaging beforehand, then reviewing those images and establishing a drainage gain plan before ERCP is absolutely imperative. Know the different types of stents that are available, their advantages and their disadvantages. Understand what can and what needs to be drained and what does not or what cannot or what shouldn't, like atrophic lobe or necrotic tumor, and why, and be able to explain this to the referring providers. And then finally, use targeted guidewire and navigation technique and plan to drain whatever you will pacify, okay? Let's enjoy a couple of minutes that we have left for questions and answers or any discussion that you would like, and I thank you very much for your active participation. Ellie, any questions for us? Thank you, Dr. Martin. That was a fantastic presentation. Audience, I don't have any questions right now coming in. We'd love to hear any more tips that you would like to offer us, Dr. Martin, for our... I think, you know, the bottom line is planning. If you have a common bile duct stone or say a common bile duct stricture, you can look at an image and pretty much know what you need to do. With a stone, you need to do a sphincterotomy, go in and remove it from the common duct. You have a pancreatic head carcinoma and the entire upstream biliary tree is pre-stenotically dilated. You can look at one cut on the CT and decide what you need to do. But complex hilar strictures are a very different animal. The other thing is the gallbladder, you know, is also an upstream bile duct and one that can be very difficult to get into. One tip that I can give you is when you are going to attempt to get gallbladder access, go ahead and opacify the common duct and at least get some contrast into the intrahepatics. Look very hard for the cystic duct insertion at the common bile duct. It's not always easy to see and sometimes it is hiding behind the column of contrast in your common duct. What you can do is you can take, if you have a C-arm fluoroscopy machine, you can rotate that C-arm and you can also tilt that C-arm and try to see if rotation or tilting of the C-arm allows you to separate the cystic duct that's opacified from the common duct that's opacified so that the common duct is no longer obscuring the cystic duct. If you have a C-arm, it's there for a reason. It's there so that you can rotate or tilt it so that overlapping or superimposed structures can be separated. Okay, that's a clue. If you don't have a C-arm, you can turn the patient. Turn the patient and see if you can effect the same thing that you're trying to do by rotating the C-arm. Another clue is that I frequently find that the cystic duct insertion, at least in the position that we perform ERCP tends to be medially oriented. So if you orient the tip of your catheter medially in the distal common bile duct and then dart and spin your wire, you will have a much greater chance of getting into the cystic duct by pointing the tip of your catheter towards the medial side of the distal common bile duct rather than laterally, medially rather than laterally. Remember that the cystic duct is like the veins in your leg. It has multiple valves called the valves of Hyster. And those valves are going to make it difficult for your guide wire to go straight through the cystic duct into the gallbladder. This is why you need an angled wire and you need a hydrophilic wire that's very slippery and you need to spin it. If you spin it, sooner or later as it's spinning, that angled tip is going to get past a valve and you're going to basically be able to screw that wire up the cystic duct through those valves. And once you're in the gallbladder, you're home free. Another clue, follow that wire up with the catheter that that guide wire is in. Because if you advance that catheter over the guide wire into the gallbladder, that loopy cystic duct will frequently straighten out and it's going to make your stent placement a lot easier. Deploying double pigtail stents is extremely different from deploying straight stents. You really need to allow the upstream pigtail to curl first. And what you do to do that is you ask your assistant to slowly back up the guide wire. And as the guide wire starts to enter the proximal tip of the proximal pigtail, the pigtail is going to naturally start to curl. And then once that guide wire gets all the way back to the very beginning of the proximal pigtail, that proximal pigtail will curl 100%. Then you very slowly withdraw the guide wire even more, making sure that you leave a little bit of distance between the tip of your scope and the papilla so that as you withdraw the guide wire from the distal pigtail, that pigtail will curl. What you don't want to do is push that distal pigtail up the duct and cause an inward migration. By keeping some distance between the papilla and the pigtail, you will prevent that. The other thing that you can do to release that pigtail to help you not have the distal end migrate up the common duct is to just deflect the catheter laterally away from the papilla as your guide wire is about to pull out. Then it will just collapse off your stent pusher and off the wire, and that pigtail, I guarantee you, will curl very nicely in the duodenal sweep. Any questions you see there, Allie? Nope, Dr. Martin. Those were very important tips. We appreciate that coming from our experts. I think that is going to, looking to make sure we have no more questions, audience. I think that's going to wrap us up. Thank you again, Dr. Martin, for a fantastic presentation discussion. And in closing, thank you all for your participation in tonight's presentation. Before you log off, we would really appreciate your feedback on tonight's event by going to the networking lounge and completing our evaluation. This concludes our presentation, and we hope this information is useful to you and your practice. As a reminder, you can access a recording of this webinar by logging on to GILeap by going to learn.asge.org. You do not have to be an ASG member to access this content as our goal is to provide information and education from our Thursday webinar topics as an open source resource to assist gastroenterologists globally in improving their practices. Our next webinar will be next Thursday, March 25th, at 7 p.m. Central Standard Time by Dr. Field Willingham, Video GIE's Editor-in-Chief. Please plan to attend. Thank you again, and have a good night. Thank you, Dr. Martin. Thank you very much, Ellie and ASGE team. It's absolutely a pleasure, and I thank the audience for your participation. Have a great night. You too.

endoscopic retrograde cholangiopancreatography

ERCP

hyaluronic strictures

gallbladder stenting

cross-sectional imaging

stent insertion

biliary radiofrequency ablation

hydrophilic guide wires

balloon dilation

stent migration