So, we're going to start the video session now, and I would like to invite up Richard Kwan from University of Michigan. While he's getting set up, we do have one or two questions regarding the pancreatitis talk. Raj, if you have an asymptomatic patient with PD dilation, but it is progressively becoming more dilated over time, and you're visibly seeing an increase in atrophy of the pancreas, do you think this needs to be intervened upon? Any worries about underlying IPMN or anything like that? If they're asymptomatic, then we usually will do endoscopic ultrasound, and if that's negative, say it's four or five millimeters or so, we generally wouldn't pursue ERCP pancreatoscopy, but we'll often do a surveillance imaging in six to 12 months, MRCP. If it does look like it's increasing in diameter, still remaining asymptomatic, I'd consider pancreatoscopy in that patient to exclude IPMN. Great. Thank you. Hey, Rich. All right. Excellent. I'd like to thank Dr. Sethi and the course directors for inviting me to participate in this case conference. So, I have two cases, right, two, that I'll be presenting today. All right. So, I have no disclosures. All right. This patient is that of a 67-year-old female who underwent a laparoscopic cholecystectomy at an outside hospital one week ago, and she was admitted for biliary colic and cholelithiasis. The operative report reports that the surgery was notable for dense adhesions of the colon and the omentum to the gallbladder, and that the anatomy was, quote, unquote, distorted. The patient was discharged without any incident, and then came back one week later with abdominal pain and jaundice. At that point, the biliary was noted to be nearly eight, and the light pace was normal. The outside MRI, which we did not have the report of at the time, described choledocal lithiasis, ascites, and a fluid collection in the gallbladder fossa. So, at this point, what would we all be thinking? Dr. Shah? These are the findings, right? Yeah. You're giving me the answer, right? Huh? You gave me the answer. Bowel and duct stones, maybe a bile leak, a subtotal cholecystectomy is possible. Yep. Transsection of the duct is another possibility. Right. So, the running diagnosis at their hospital was that this was a possible bile leak. So, they went on to an ERCP, but were unsuccessful in cannulating. They did attempt an IR-guided PTC, which also failed, citing decompressed intrapartic bile ducts. And so, they placed a drain into the gallbladder fossa. This patient was subsequently transferred to our hospital. So, here, once they arrived at our hospital, the patient denied any fevers or chills or abdominal pain. The labs were notable for a normal white blood cell count. The LFTs were essentially normal, with just a mildly elevated AST and T-belly. A right upper quadrant ultrasound described a periopatic fluid collection that was 9 by 5 by 9 centimeters, and that with an adjacent drain placed by the outside hospital. At this point, the patient went on to MRCP, because we did not—or an MRI and MRCP, since we didn't have their images. And this is what it looks like. I'll have the panel comment, if they would like to. We're definitely seeing left duct disruption. It's interesting they couldn't do a PTC on this patient. Yeah. Oops. The obstructions at the hilum. All right, so that's the money shot. The obstructions at the hilum? Yeah. So what they noted, what we noted, was that there was intrapartic biliary dilation. There's clearly a dropout of the CHD, and then a chain of stones. At that point, by the time we got this MRI done, we're able to get the images from the outside hospital. Again, to remind you, the findings were a colodocal, athiasis, ascites, and fluid in the gallbladder fossa. So there are your stones there. This is the ascites. The fluid collection starts here, but it's mostly in another cut. So we took the patient to ERCP. This is the scout film. So what you'll note is the drain here and the cholecystectomy clips here. There's no pneumobilia that we could appreciate. So that fluid collection was there despite this drain? No. Well, it's a great question. Yes, it was there, here, despite the drain. The thing that did improve was the ascites. So that was not a concern for biliary peritonitis. There was a more confined collection near the gallbladder fossa. That was the working diagnosis at that point. So they went on to ERCP. We were able to get into the bile duct, and we got a wire. And it kept going straight for the surgical clips. So we were worried, well, either that we were in the cystic duct over and over again, or that there could be something worse. Contrast injection, because we were looking for the common bile duct, just shows a duct that goes through straight to the clips with multiple filling defects. After several minutes of trying to identify a common bile duct and praying that this was the cystic duct, we were unsuccessful. So we went on to cholangioscopy. I will have our expert team of cholangioscopists comment on this video. Rich, can you pause there for a second? I'm sorry? So can you pause the video for a second? So what was the bile output from the drain at this point? The bile was coming out of the drain. The bile duct output from the drain? It was just biliary fluid. At a large volume, like a liter a day? The percutaneous drain. Yes. It was not quite a liter, but it was significant. So we got straight into what we considered the bile duct, and then ran into this. This extrinsic compression, like a surgical clip? Can you actually see it? You could actually see the, well, we thought we could actually see the surgical clip. How can you distinguish between that you're being in the cystic duct itself versus being in the common bile duct? That's a great question. From our standpoint, we had saw stem to stern up to here, so we knew we were in the bile duct. We were very careful to check. So we tried and prayed that we would somehow be able to massage something through. You saw 15 seconds of video. It actually went on for a little longer. And then when we pulled back, we see a chain of stones here that needed to be cleared. So you were able to selectively cannulate with a, what size wire was that? It was this. This, I believe, was a long jag. So when I do spi, I use a long jag. Typically, I would cannulate with a long jag. But this was a long jag. So we were able to selectively cannulate with a long jag. Typically, I would cannulate with a hydrophilic short wire, though. These stones are downstream of that. Yeah. This was in, if you remember the MRI, there was like a chain of stones. So I'm just showing you that. And then, well, we had to get something out of it. So and also had to clear the duct. So we cleared all these little bit of lithotripsy and then cleared the duct. Always so satisfying to see that. All right. So let's just move on. So obviously, we weren't able to provide an endoscopic therapy for this patient. The patient did end up going to the operating room where she had an extensive lysis of adhesions. As you recall, the previous operative report described dense adhesions of the colon and the amentum to the gallbladder. And then the surgeon performed a Roux-en-Y hepatic augergynostomy requiring two anastomoses because the common hepatic duct was pretty destroyed to the intrahepatic bile ducts. It's been two years and the patient is currently still doing well and asymptomatic. So Rich, what was the exact site of the bile leak? Was it from the intrahepatics or at that site of the transection? It was just above the site of the transection. And so that's an important point where the liver function tests weren't markedly elevated because this patient's decompressing their bile. So they don't need to raise their liver function tests too much to suspect that. Right. And then the other point of interest for that first was that there was no intrahepatic biliary dilation on the initial imaging because they were just pouring it straight into their belly. So Cheyenne, would EOS hepatic gastrostomy be an option in this case? So looking at that MRI, which is where it's super useful, I think the concern was both ducts were cut off. So you'll achieve left-sided drainage, but you'll fail that right side. So you'll need a combination therapy. So I would not do a hepatic gastrostomy without talking to the surgeons. And in a person like this, definitive surgery is the right thing to do. Excellent. OK. All right. So we'll go on to our second case. It was a really beautiful sort of demonstration of how a spy can clearly clear up the situation, not spending a lot of time with fluoroscopy to try to understand what's happening. All right. So the second, I couldn't come up with a cute title for the first one. The second one is entitled Margaritaville. I, again, have no disclosures. All right. So this patient is a 57-year-old female who's a longstanding alcoholic. She had her first bout of pancreatitis two months prior to admission, or two months prior to being seen in GI clinics, sorry about that, after another hospitalization, which was after Jimmy Buffett concert, for abdominal pain and shortness of breath for roughly two weeks. She also describes a 15-pound weight loss at the time. Her past medical history was significant only for spinal stenosis and a history of a C-section. She smokes a pack per day and has been binge drinking since, quote, forever, which is her term, though she has been sober since her last admission. On physical exam, she's talking in full sentences. She has mild abdominal pain, and her lungs are generally clear. Her outside CT was notable for a right pleural effusion. She underwent a thoracentesis, the results of which I did not have, but were described as having a markedly elevated amylase. You could see just a cut here showing a pretty sizable right-sided fluid collection. I'll show you just her scans, her coronal scans. I'll have the panel comment on the effusion and any other findings. So it's a large effusion, which is why you started as a gastroenterologist describing breath sounds, which was interesting. And what prompted whoever was looking after this patient to check an amylase? The history of prior pancreatitis? Yep. You mean in the fluid itself? Correct. That's exactly right. They tend to be left-sided, but this is right-sided. Which is also unusual. The biliary tree might be a little dilated. Maybe not. The spinal stenosis looks pretty good, Rich. And the PD was somewhat decompressed, I thought. You'll see that. Let me see if I can get back to the other slide. So the thing that was noted was the huge right-sided effusion. And then you can see that there's more fluid here. And then what you may have seen as the screen was flashing back and forth is that there's a fluid collection within the body of the pancreas. So this patient then went on to endoscopic ultrasound and ERCP. We did the EOS looking for chronic pancreatitis, for one. And then also to see if there was, because of the slightly dilated PD in the body and tail, whether there was a mass obstructing the bile duct that could have led to all these complications. This is linear echo endosynography. So what you'll see here is that the PD in the neck is decompressed and essentially normal looking. Then you get this fluid collection with some debris in it that measured roughly two centimeters in size. And then this is all to demonstrate that the pancreatic duct upstream of this was not markedly dilated. So your concern is the duct is broken at both the tail end and the head end? And that area is the area of disruption? So what we were worried, well, we think this confirms. And actually, let me pause this for a sec. Let me try to pause it. Yes, we were concerned that there was a duct disruption here. And the question was, was there any obstruction at this site that would have led to upstream dilation? But we didn't see any. There was, as you recall, a suggestion of that on the prior imaging. So what we noticed, though, the fun part of this exam is that if you follow this and talk to the right, then you can actually see the anechoic fluid collection continue. And as I'm doing this, I'm actually pulling back up higher into the stomach, and then even into the chest, make a right turn at the heart. And now I'm fully in the chest. And this is the top of that fluid collection. So how tempted were you to put interstents into the pleura? Oh, it was very, very, very, very, very, very tempted. The tech actually stood in front of the medicine cabinet to prevent me from finding something. All right, so this is just the video again. This time I have an arrow, just in case you didn't see it the first time. So again, there's the fluid collection here in the body. The duct upstream, again, you'll note, was not dilated. And now we're just following the fluid collection back, again, making a right turn at the heart, and then ending up in the right chest. So we're dying here. What did you do for this patient? Right, so we went on to ERCP. So what you see here is a massive disruption here. We stopped injecting at this point because we didn't want to have it track much further. We placed a stent that bridged this disruption and then sent the patient home. The patient came back at two months. Her shortness of breath had resolved. Her pain had resolved. And she was still not drinking, though she was still smoking. Follow-up ERCP shows that the disruption is completely healed and her chest CT is completely clean. And so she was doing really well. I saw her in clinic and congratulate her on her amazing recovery. I counseled her to stop smoking and drinking. I kid you not, she came to clinic with a Jimmy Buffett t-shirt and smiled at me. And she was sober and did quite well. But Jimmy Buffett came in to concert in Detroit a year later. And I'll show you her case next year. Did she have a pack of cigarettes at all? I'll show you her follow-up case next year, if invited. So Richard, if you had not been able to get the wire across the disruption, what would your options have been then? Yeah, so at that point, usually what I would do at that point is get it as close to the disruption as possible and cross my fingers and hope that it is enough of a diversion to move forward. I probably would give it a second try to see if that stent has had some partial benefit, whether I can then establish the tract across the disruption. And then the worst case scenario would have been, obviously, to send them to surgery or do something more creative. I guess the other question is, and we deal with this often with pseudocysts or Waldorf necrosis, is duct disruption and leaving, for example, draining the collection and leaving a double pigtail and indefinitely, if there were a position at which you could get into that collection and drain that, would that be an option too? It would have been, the big fluid collection was in the chest, which would have been a bit of a challenge. The fluid collection that was at the level of the pancreas and just north of it, or just caudal to it, would have been a little small. At that point, I kind of would hope that it would enlarge and allow a metal stent or an axios or something. This might be the rare situation where you could consider a transpapillary pigtail stent into where that ductal disruption was if you couldn't get something transgastrically in this situation. So ideally, bridge the leak. But if you can't bridge the leak and really your only option is a tiny collection there, a transpapillary pigtail is not unreasonable there. Would you actually go into the disruption itself? Yeah. I don't like to do that because you're committing that to a disrupted gland. But if you truly have no other options and you have massive either ascites or pleural effusions, you can control the leak by then diverting the flow right from there, both from the tail and the downstream head. Yeah, we had entertained that as well. I personally have had some bad experiences with those stents getting infected, leading to even more trouble. It's a combination, though, I think, of that stenting and percutaneous drain. A combined approach to try to reduce that risk. Yeah, I'm sure she would have had a chest tube in her future. So, OK. Thank you. Thank you. If you want to, we can go over some questions. Yeah. OK, great. I have two minutes, or three minutes to do this. So. That's a higher obstruction management at AIG. Oh, let's skip this case. Let's just do how not to do a coledoco duodenostomy. How about that? So this was a patient with a gastric outlet obstruction. And let's just go straight into the video. So what you're seeing over here is a 12 millimeter, or sorry, 13 millimeter bile duct. So early on, I saw everything. I had a luminoposing stent. And I said, I can put a luminoposing stent into anything. So here is the video of how you not put in a luminoposing stent with a direct puncture into what you thought was a 13 millimeter bile duct. But you start seeing the flanges deploy, oops, right outside the bile duct. And I recognized that. So I said, OK, let me pass a wire down into the bile duct. I have access. Let me reconstrain the stent, which is not reconstrainable. And let me push a little bit harder and see if I can get the stent to go into the bile duct. And so I said, OK, maybe it'll follow the path of the wire, which it looked like it did. And I said, what do I have to lose here? Let's deploy the stent. I'm deploying it, pulling it back. I do not like the shape of this stent. But I had no other choice but to release it over here. And then it's not pleasant when you see blood come out of a luminoposing stent from the bile duct. So at this time, you can see on EOS, what I had done was I'd actually double punctured the bile duct and deployed the stent between the portal vein, bile duct, and out through the duodenum. That's a big oops. So I didn't give up on this patient. I cannulated through the hole in the duodenum into the bile duct. You can see the air cholangiogram. And I can see my tome directing my wire downstream with the stricture over here. And then I got it to go up as well. Now, there's no point deploying the stent downstream. You're going to block that bile duct. So I passed a wire. And you can see some of these passages are going outside the bile duct. But you have to be patient and get your wire upstream. You want to drain the liver, not the downstream bile duct through the duodenum. And so with fair patience, I was able to then negotiate what I should have chosen for the very first time, a tubular stent into this narrow bile duct. You can see how skinny that bile duct was. It was closer to 10 to 11 millimeters than the 13 millimeters I'd appreciated on EOS. So the patient did well. There was no big fluid collection. Needed antibiotics for a couple of days and was discharged in three days. Do I have 50 seconds to show how to dislodge an edge? Yes, yeah. I like to show dislodging things. OK, so this was a patient who had an edge. So a gastrogastric anastomosis with a lumen-opposing stent to find this nice little duodenal stricture, which mercifully for the patient was benign. But then immediately on fluoroscopy, you can see my lumen-opposing stent has dislodged into the stomach. And I said, oops. OK, so pulling back, there's peritoneum. There's some blood in the peritoneum. That's the excluded stomach. But you don't have to panic at this point. You have wire access in the stent. So I used a 1T therapeutic scope. And you don't have to waste a new stent. You can just constrain the stent into the channel of a 1T scope and use that as your delivery system. So I used that to pull the excluded stomach back. And both under fluoroscopy and ignoring that blood, don't look at the blood. Under fluoroscopy, deployed it into the gastric pouch where you can see it over there. And then once you release it, you can re-establish that connection. All right, I'll stop. That was great. And just for the audience, you might not be familiar with EDGE. That's gaining access in a RU-I gastric bypass to the excluded stomach in order to be able to perform ERCP. Those were great and humbling cases. And I think important that we keep that in mind, that when we're going to start to use LAMs for these type of interventions, we do need to know all about salvage techniques, keep our cool, but also make sure that we do get our colleagues involved if we don't think we can solve the problem. That is the end of our morning sessions. Thank you all for your attention and for joining us. We will resume here at 1 o'clock.

laparoscopic cholecystectomy

choledocholithiasis

ascites

ERCP

Roux-en-Y hepaticojejunostomy

pancreatitis