Welcome back, everyone. That was a fantastic kickoff to our course, beautiful live endoscopy, and we're thrilled that we get to start off our second session now, traveling to Hyderabad, India. I'd like to welcome my co-moderator for this session, Brett Peterson, future president of ASGE, and as well as Shayan Irani from Virginia Mason in Seattle, and Raj Shah from University of Colorado. So I think if we can take a head over to Hyderabad, where we have Nagi Reddy waiting for us. Good morning, San Diego, it's actually midnight at AIG Hyderabad, India. Welcome to this ERCP live course. I am Nageshwar Reddy, and along with me are my colleagues, Dr. Mohan Ramchandani, Dr. Asif, Dr. Pradeep, Dr. Santhosh, the chief anesthetist, Srinivas, and our technician, chief technician, Srinivas Reddy. For the next 45 minutes, we'll try and show you some exciting ERCP cases, and hopefully this should be a productive session. So, Amrita, thank you very much for giving us this opportunity. Hi. Thank you so much for staying up in midnight endoscopy. We're excited to see what you have for us. Thank you. It's just the middle of the day for them. Yeah, Raj has been here, he knows, yeah. Thank you. So what we'll do is we'll start with the first case. We can have, so this is a 72-year-old male patient who had recurrent abdominal pain, obstructive jaundice of two weeks duration. He had a deranged LFT. MRCP showed a gallbladder calculus, a bile duct calculus, dilated CBD. On the endoscopic ultrasound, there's a large CBD and a GB calculi. You can see the MRCP pictures here showing this CBD calculi. And of course, the learning objective in this case is the technique of ERCP to achieve selective CBD cancellation, tricks and tips of how CBD stones can be extracted. And if it's a difficult stone, as we go along, we might have to use laser and the technique of using this biliary retrotripsy or lasers. So we'll start with this case now. And what I'm going to do is for this case, I like to use a spindle comb for cannulation. Always biliary cannulations, except in few occasions, are with a biliary spindle comb. I use a hydrophilic angle guide wire. And the reason why I use this guide wire is obvious. If you can see here, my assistant is actually twisting the wire and see how it moves around. Because it gives that wide angle movement for us, it becomes very easy to divert this into the bile duct or the pancreatic duct. I always use a wire guided cannulation, not contrast guided because based on a lot of evidence that we have that this is better for cannulation and decreasing the PEP rates. But many times we use a combination, small amount of contrast along with the wire. So now I'll go in, look at the papilla here, and then we'll see what can be done in this case. So I'm down already deep into the second, third part of the duodenum. You can see a large diverticulum here. This is a connection between the second and third part. I get my scope up a little back to try and locate the papilla. I'm coming up here. And you can see there's a vertical ridge here, which actually leads to the papilla. And you can see the papilla up there. This is the papilla. And what I'm going to do is I'm going to look at the papilla carefully. I'm using Olympus Therapeutics Pro 4.2 channel along with a CleverCut splinter tool and a hydrophilic guide wire. I go close to the papilla. And then what I do is you see this technique. I'm going to lift my papilla up. And as I lift it up, as my assistant is flexing the splinter tool, I'm going to now push it a little in so that I get a downward to upward projection up. Now, this is the CBD. I'll just wait here. This is the CBD direction. It's very important to have a CBD or a pancreatic direction before you pass the wire. And now I'll ask my assistant to pass the wire. He's going to go by tactile sensation to see whether he's going to go in freely or not. And then I'm going to keep adjusting a leftward and rightward movement. Now, I'm not able to get in. Now, I'm just going to turn my scope a little more towards this side. And let's see if he can get in now. Now, if he can't, I'll inject a small amount of contrast to see if I can get in. Maggie, is there a prior pre-cut or prior sphincterotomy in this patient? No, this patient was a dying patient who just came to us. He came from another hospital. We don't know what was exactly done in that. But he came to us yesterday with his symptoms, and then we investigated him. Now, can you see the wire, Raj? It seems to have gone in. I'm finding it really difficult to get deep canalation with the sphincterotomy, but I'll just manipulate a little. If I can't get in very easily at this stage, I like to inject some contrast. Can you put some contrast in to see how it's going? Yeah. So, contrast is gone. The stone seems to be somewhere down there. And that may be the reason why we are finding it difficult to get. So, you have a few diverticuli here, Nagi, huh? Yeah, yeah. So, I'm not able to get my sphincterotomy very deep. Yeah, now I'm deep inside, okay? So, now I'm deep inside. So, what I'll do is I'll inject contrast. So, my policy is to go very high inside and then inject the contrast. So, inject contrast. I'm using a partly diluted contrast, very deep inside, and there's nothing there. So, as I come down, the important thing is I want to look at the size of the stone. I also want to look at... Can you... You can see the... Yeah, that's an important point you raised about injecting contrast high, because injecting low sometimes you can force these stones into the intrahepatic, so into the cystic ducts. Exactly. So, you have to fish them out. Yeah, now inject contrast. So, now I'm trying to inject and see where exactly the stone is and what is the size of the stone. Yeah, now I'm trying to see the stone. Can you see that? Yes. So, we'll measure... So, we'll measure the stone. The lower end of the seabed is actually two stones, I think. They look like one small and one larger one. We'll freeze the picture and measure the stone here. Can you measure the stone? It looks to me a little bigger, slightly bigger than the scope. So, we'll have to now make some critical decisions about spintrotomy versus spintroplasty versus laser and so on. So, what is the size I'm seeing there now on that? It's... 10.8. 10.8. So, still it's below 12, and the lower one is smaller. So, I come back to do the spintrotomy. If you can see the endoscopy picture now. Can you show the endoscopy picture also in addition? Yeah, you can see the endoscopy picture now clearly? Yes. So, I'm going to now do the spintrotomy. I'm using a clever cut spintrotome, which is a little safer. I've already decided that in this patient, I'm going to do a spintroplasty after spintrotomy. I believe that this stone, stones less than 12 millimeters usually can come up. Only thing is the challenge I'll have in this case is I'll have to push the stone up into the bile duct before I actually do anything. So, here actually, I'm going to use a pulse, slow pulse cut, a combination of coagulation versus cutting current, and then come back with the spintrotome, open the spintrotome, and just flex the spintrotome. Now, I'm going to cut. Nagi, any considerations about the length or orientation of your spintrotomy when it's on the rim of a diverticulum? Yeah, so this is a good point. One has to be careful that one is not actually cutting towards the diverticulum because then the layers there are less in number, the chance of perforation would increase. But in general, what we find is that if you have a bulky papilla like this, it's not much of a concern, and I'm fairly confident that I can cut to at least half the papilla before I think of a spintroplasty. It's okay, you feel? I can cut a little more if you want. It's a big papilla. Nagi, do you base the size of the spintrotomy on the size of the stone, or do you try to do a complete spintrotomy in all these patients to reduce the risk of spintrotomy restenosis? Yeah, so I think it's always best to do a complete spintrotomy so that the stenosis doesn't occur because sometimes I've seen this Mickey Mouse spintrotomy resulting in restenosis. But in this case, we're doing half a spintrotomy because I want to do a balloon spintroplasty because even if we do a complete spintrotomy, I don't think we're going to get this stone out unless we do a good balloon spintroplasty. Okay, so now what I'm going to do is I'm trying to see if we can shift this stone up. So, Amrita, can you see this stone down there in the fluoroscopy? I have to shift it up so that it doesn't... Now you can't see because the contrast has flown through, but we'll give some contrast out there. Yeah, now give some contrast. We'll have to shift it up a little, otherwise it'll come in the balloon space. Looks like you have a few there, actually, these stones. And your concern about it coming in the space of the balloon is perforation of the duct? Exactly, yeah. Yeah, that's what concerns me. So I think I've done four spintroplasties, significant spintrotomy. I'll put in a balloon now. What I'm using is a TRE, Boston Scientific balloon, which goes... It's normally used for pyloric balloon dilatation, but in this case, we're using it. There are also specific balloons now available for spintroplasty, which are currently available, but what we traditionally use is this TRE balloon, which we use for pylorus aerosubergus and so on. We're going to use that. Again, I'll have to push the stones up a little more now, as you can see. Yeah, TRE. I'm going to use this TRE balloon. Nagi, your distal end of your wire, are you concerned that's a little bit far? Yeah, Shayan, we'll do that. We'll bring it back a little. We'll get it out a little more down. And you're seeing some contrast fill your diverticulum there, yeah? Yes, yes, exactly. You can see the contrast fill in diverticulum. So now what I'm going to do is to push the stones up a little further. I'm going to blow the balloon up a little and use this partially blown balloon to push the stones. Very important point. Stones have to be pushed further up a little. Stop, stop. So with this partially balloon, I'm going to push the stones up a little further, okay? Yeah. And still I have to do a little more of that. Yeah. So no, stop, stop. And now I'm going to inflate the balloon and I'll have to go 15 millimetres because this is 11 millimetres stone. Yeah. So what we're doing is filling up this CRE balloon to 15, so that it blows up to 15 millimetres in size. And then do it very slowly. The principles are very important here. Keep it in the centre and blow it up very carefully, stage-wise, till you reach the 15. And then afterwards, how long you keep it is controversial. In fact, we have an Asian consensus which suggests for 30 to 60 seconds, but you can see now, already I've broken the waste. The stone is above the balloon. Can you see that, Shan? Yes, good view. Beautiful view, yeah. Yeah. So you can see just above, the stone is just above. And 15, we'll go to 15. That's important. And you can actually measure the stone approximately in relation to the balloon also. We're most excited about that bigger one in the gallbladder. So I think we'll have to leave it to some of our colleagues to go and take it out. So you can see, I think here is going to be an important debate. Maybe you can discuss it later in your discussion. Whether at this stage, one would think of using just a large balloon and a basket or a balloon to extract this, or go for a single-operated cholangioscope and laser. In general, my rule is, if you have a stone size, which is less than the bile duct size, the ratio of less than one, and the lower end of the CBD is less than, more than 50% of the proximal part, then I prefer to do a direct extraction rather than going for a cholangioscope to prevent the cost. So now we are going to deflate the balloon. Yeah, deflate the balloon. Slowly, slowly. Some amount of bleed is expected to occur. I want to emphasize for the audience too, that Dr. Reddy did this pretty quickly, but the idea was he partially inflated the balloon to try to push up the downstream stones to above the area where the balloon was going to be dilated, just to reduce the risk of any trauma to the bile duct by impacting the stone there. So that's the initial thing he was doing prior to the balloon dilation. So we have a fairly good opening here. And then what I'll do is to put in a standard balloon. Of course, there's a debate whether you should use a balloon or a basket and so on, but to make it quicker, I'm going to use a balloon. Although some people would use a basket with mechanical compatibility at this stage because the stone is large. Again, the panel could discuss that, but just because we have only about two minutes to finish this case, I'm going in for a balloon. So do you make the choice, Nagi, based on the consistency of the stone, the shape of the stone, the CT images? Yeah, that's a good point. So generally I base it on the stone. If it's a square stone, they're more difficult to get out than round stone. And I use a basket in those cases. And if the stone is showing them calcification, again, they're more difficult to get out. So I tend to use a basket in those cases. If the stone is very small, then of course a balloon is okay, but because you can't catch it with a basket. Now, what I'm going to do is I'm going to... Now, the technique is very important here. I'm pulling my balloon down and you can see the stone coming down along with the balloon. At this point of time, what I'm going to do is I'm going to hold my balloon catheter with the left hand, pull it down as far as possible. Don't pull it back into the scope. Screening, please. And then I'll use this moment where I push my scope down and turn to the right so that I'm in the axis of the CBD. So you won't see the actual stone coming out, but I'll be in the axis of the CBD and you can see the stone now. You can see the last stone coming out. Okay? So that's a technique. Yeah, this is a 15 balloon. Yeah, this is a 15 balloon. I'll deflate it once. And what is very important is as I finish the case, I always do an occlusion cholangiogram to show you that all the stones are out. Of course, our lab surgeon will be delighted with the other one in the gallbladder, but now we are going to inflate it now, and then I'm going to pull the balloon back just to be sure that nothing else is there. And you can see a large opening, so I'm sure anything that's there is going to come out subsequently. Okay? That may be the biggest gallbladder I've ever seen. That was a beautiful demonstration. Do you have any concerns about bleeding after that violation? No, no, no. No, no. What you see is a few millimeters, a few RBCs there. They'll spontaneously stop. Nothing else to be done in this patient. So should we move to the next case where Mohan, my colleague, is ready? Thank you. Thank you. Well done, Nagi. Thank you. Thank you. We'll move to Mohan. Mohan? Can you hear us now? Yes. Yes. Okay, great. So thank you very much for giving us this opportunity to do a live demo to one of the prestigious courses at BDW. And this is our case, the second case. A 45-year-old male who was presented to us with jaundice, and he had weight loss since last one month. There is a high bilirubin of 7.5 with high alkaline phosphatase. The tumor marker, C19-9, is quite high. MRCP has revealed a mass in the head of the pancreas with distal CBD stricture. Since we wanted to see the receptability, the PET scan was done, which has shown a mass which is 3.5 centimeters in size and has intense FDG uptake, but there are no distance metastases. We went ahead and did EUS-guided pine needle aspiration cytology, which has clearly shown that it's adenocarcinoma. This is the MRCP picture showing dilated CBD and also the dilated pancreatic duct. The CT scan along with the PET scan, which was done, and you can clearly see on the image that the pancreatic head mass is abutting the superior mesenteric vein there on the right side. The left side, the superior mesenteric artery is free, but superior mesenteric vein is closely abutting the mass. This is, from our definition, is a borderline receptable case and will go for neoadjuvant chemotherapy and radiotherapy. That's why we are doing ERCP to do preoperative biliary drainage. In this case, we'll be learning about the selective CBD cannulation already. Dr. Reddy has shown his technique. We'll also be learning about how to place the stent here, the choice of stent we can discuss. We prefer to put fully covered stent in such situations. We'll also discuss about the role of sphincrotomy, whether we have to do it or not, and the role of additional plastic stent if the fully covered metal stent is placed. For the want of time, I have put my scope facing right to the ampulla. As you can see here, this is the ampulla. The first thing which I do is, I try to see the intra-duodenal portion of the bile duct. You can see from the pancreatic or the biliary orifice, it's traveling like this towards this. I made an imaginary line in my mind where I have to go. I'll give some Bascopan and then start cannulating by this sphincrotome. This is a clever cut from the Olympus we used. Then I will, first of all, engage the tip of the sphincrotome to the superior margin there, and I will aim at 11 o'clock position there. Then my technician, Srinivas, will bend the sphincrotome there, and I'm trying to align to the bile duct there. You can see now the bile has gone into the bile duct. We'll push the sphincrotome there like this and inject some contrast to delineate the anatomy of the bile duct. You can see now. Thanks to the large volume, we do it here at AIG and our expert technician. I just guided the sphincrotome, and the wire manipulation was done by my technician who used an angled pteromobile, which is a very good wire to initially cannulate. In our institute, we use hydrophilic short wires, which allows us to do torquing. Once we do a selective cannulation, we exchange the wire with the long wires. We do not use the short system here. We are used to the long wires. Once we do this, then the plan is to select the type of stent. As we have defined in our presentation, this is a borderline resectable case, and we are going to do a fully covered stent. Now, the question is whether to do a sphincrotome or not. Literature-wise, there are randomized controlled trials, a high-quality trial with 200 patients from Japan, I think. They showed that there is no additional benefit of doing a sphincrotome, but in our experience, we have seen that once you are putting a fully covered stent, this is the study which I was talking about, 200 patients in both the arms, and adverse events were more common in ES group, maybe the equivalent. The conclusion of this study was the endoscopic sphincrotome before metal stent placement does not affect the incidence of adverse events, the metal stent potency, or the patient survival time. That is the literature, but our experience with the fully covered stent says that if you do a short sphincrotome, you may have additional benefit of preventing the pancreatitis because logically it may block the pancreatic orifice because once the flange is open, they may block the pancreatic orifice. I'm doing the sphincrotome there using the same setting that Dr. Reddy used, the pulse cut slow, but I'm not going to do a big sphincrotome because here my aim is not to remove a big stone but to facilitate passage of the metal stand and keep it away from the pancreatic ductal opening. Any any tips for our audience Mohan on the sphincterotomy as far as how much of how what length of the cutting wire that you use that you prefer and also how much of the cutting wire you have in the duct? Exactly so here you can see we are using a stand which has the sphincterotome which has got a protective wire over there so that is clever cut but every sphincterotome does not have that so it covers 50 percent of the wire and the sphincterotome starts the wire starts around eight millimeter beyond the tip so this eight millimeter is inside and fully and half of the sphincterotome wire which is bare wire is inside and then I use this much of length and use my knobs to direct and you can see here once I'm cutting I'm pulling the shaft of the scope so that it directs me towards the apex of the cut so this is how we use and then once I have done the adequate sphincterotomy I will exchange the sphincterotome with the stent which I am planning to put so here I'm six centimeters so the gallbladder is intact so I'll try to put as short a stent possible. Mohan can you get us a good fluoroscopic view of the exact length of that stricture and the cystic duct take off and then we'll ask you the obvious question about the cystic duct soon don't worry. Wow very good so we'll do that and you can see the length of the stricture is 27 millimeters can you can you measure it again please yeah from here down yeah from here yes and you can see no no you have to do from the upper margin of the duodenal air slightly less so it's around three centimeter and the cystic duct take off yeah from here yes to the here yes so it's around six centimeter so the cystic duct take off from the ampulla is six centimeter the stent length the stricture length is three centimeter. So many many of us don't have that slick ability to to measure during the procedure are there other tricks you might use to help our physicians in figuring out length of stent? So by rough estimate we use four centimeter to six centimeter always in the in the lower CBD and for the higher stricture we use eight to ten centimeter but if you want to measure it you have other measures also by by measuring the the amount of lengths say for example I'm going to the top of the stricture here and then I come out till I I'll keep my finger over here and I'll keep on coming out until I get the accessory completely out so this is the length which has been traveled by the stricture I can measure here so so other options are like that but here since we have this technology where we can have a fluoroscopic evaluation of the length we we don't do all this because it's slightly cumbersome but yet it can still be done if these if these softwares are not available in your fluoroscopy machines. So the length of the radio peg tip of the wire would be a useful ruler to pull down to there if you don't have an accurate measurement by withdrawing your catheter. Yeah that can also be a possibility. So I'm using a six centimeter stent as I saw the cystic duct take off is at six centimeter and I'll see the stent will shorten once I go into that and you can see the the marker which is the yellow marker here that is I'll keep around one centimeter outside the ampulla and now I will start deploying and keep pulling the stent down. So Mohandas patient has an intact gallbladder and at least where you're starting off right now the top end of the stent is going to be probably close to that cystic. Close to yeah so I'll keep on pulling it down you can see now I'm pulling I'm readjusting the length because and you can see now I am totally wait wait so I'm adjusting it I know because the stent gets shortened and see that my scope I am pushing it down and rotating to the right if somebody can show my hand please see that so this this is the so I torque my wrist like this and push the stent down so that I can adjust last minute and you can see now the stent has come right below the cystic duct opening and I will now close yeah release this and keeping the yellow marker there yeah and then you will have some yeah please so now we'll release the lock and it will still shorten Mohan was there a reason you chose a covered stent and not an uncovered stent or a partially covered stent? So the reason for this is that we are planning surgery in this though uncovered short stents have been shown and not to cause any issues while doing the surgery but in our institute we have the policy of putting a fully covered stent once the patient is going for surgery so that it doesn't pose any challenge for Whipple's PD however the study has clearly shown the metal stents are superior but in these malignant strictures because of less tumor infiltration and easy removability in operable patients we use fully covered stents. Can you comment on a lower insertion of the cystic duct and at which point you'd be averse to the covered stent or choose either a bare or even a plastic? Yeah so that's a good point so if the stent is the cystic duct insertion is so low that we do not have a stent say for example the shortest stent available is four centimeter so if the cystic duct is below three centimeter from the peripepillary orifice because one centimeter we leave we remove we keep it in the duodenum in such situation it is inevitable to be below the cystic duct takeoff in such situation we use plastic stent or even uncovered very short stents otherwise we use fully covered stents. And is there any decision making based on cystic duct proximity to the stricture? I'm not sure about it yeah so the cystic duct opening proximity to the stricture you meant to say? Yes sometimes if the cystic duct is right at the top of the stricture I'm concerned in my practice about a covered metal as opposed to a bare metal. So I think Brett's point is that the more space you have in the bile duct where the cystic duct opens you're a lot safer with a covered stent where you won't close off the orifice of the cystic duct. I think that can still be a another point to select uncovered stent absolutely right that if this if the cystic duct is too close to stricture we do not have the space for the stent to open I think that that also is a point where we can use uncovered stent. Okay Mon thank you Mon I think we should shift to the last case we have just another 10-12 minutes for this case so we have to we have one more case to go and we try and quickly finish this. This was a female patient 58 years old with obstructive jaundice abnormal LFT showing an obstructive nature. CCT and MRCP showed a locally advanced hyalar mass with vascular encasement and bilateral HPRD. She had an elevated CA99 and a previous ERCP showed a breast cytology positive. If you can see the imaging very clearly now there is a definite mass lesion in the hyalar area. The left hepatic duct seems to be okay but the infiltration right hepatic right posterior is clearly seen so it's either 2 or 3a. So what we're doing is we are going to look at managing hyalar strictures in this short period we have. Of course we're going to insert a self-expanding metal stent. Panel could discuss about plastic with the stent and the technique of how bilateral stent could be put in. So I'm waiting for you I've already gone inside now did a deep canalation and we've gone into the left hepatic duct. If you can see the fluoroscopy breath you can see the fluoroscopy picture there. Yes. We are deep into the left hepatic we need some contrast there to define the anatomy of the left hepatic duct and then yeah can you inject and you can see that we've gone into the loop and you can see a stricture there somewhere very high up for the segment 3 and 2 I can see very clearly. I come down and I'm going to inject some more contrast to define this anatomy. So I've got about 30 to 40 percent of the liver now covered with this but I require to get 50 percent. We always do an MRCP before hyalar stricture management because that gives the anatomy. If I can get my guide wire into the right hepatic ductal system either posterior or anterior then I'll be covering about 50 percent of the duct. So what I'm doing is I'm keeping the guide wire in place reintroducing the sphincter term and try to see if my assistant can help me selectively go into the right hepatic ductal system. The MRCP report was type 2 but I think it's type 3 to me so I'll have to see if I can get selectively into that right ductal system. Okay now let's see if we can do that. No we are in the left still. So what I'll do the trick here is I get my sphincter term up there my assistant is manipulating the guide wire which is an angle guide wire to try and see if we can get into the right system. So I'll go up further with my sphincter term to the expected area of bifurcation. We can magnify. Now you can see that we're in the right ductal. Can you see that Brett? Yes it's a nice view. A nice demonstration of cannulating without filling the contrast first. So you're guaranteed to drain whatever you've contaminated. That's a very important point. You can see that we intentionally didn't put in any contrast mainly because we are not sure when once it's going you can put in contrast. So now we'll put a yeah so we'll now we have a good anatomy here. To me it looks like type 3a. Type 3a. What I'm going to do quickly is we have about 10 minutes now. I'm going to do a radio frequency ablation of both right and left and then follow it up by putting two metal stents. Now why RFA? I know RFA is not used so much in the United States but our experience has been good and based on this randomized study which was published about a few years back from a Chinese group and subsequent another study also came showing very clearly that if you do a radio frequency ablation and then put in stent in high-dose fixture you not only prolong survival but you probably also prolong stent patency. Okay so we have now lift. So we have two wires now one in the left hepatic duct in segment probably three and then we also have one in the right anterior duct. The right posterior probably just communicating with that. Are you getting the anatomy clear there Shan or Amrita? Just for the audience's clarification segments two and three on the left side and yeah yeah five six six seven eight on the right. Yeah so I'm passing the RFA catheter here and just to show you this RFA catheter. Can you see the catheter passing through? Can you have the big picture of endoscopy then you can see the catheter. Yeah you can see this RFA catheter. This is the radio frequency temperature control catheter that we have here. You can see the four stainless steel electrodes that are going in. I place it exactly at the fixture site on the left side which is yeah which is there. It's exactly it gives a 2.5 centimeter RFA burn injury and yeah if you can concentrate on the generator there you'll see the generator which is yeah can you focus on the generator. So this is the temperature control. I'm more interested in temperature which is 72 73 75 between 75 to 80. The wattage varies you can see. So if you put the wattage at even 10 it goes to zero and then varies. So wattage is not important. The timing of course is two minutes. So you can see it's fluctuating now between 70 to 75 which is what we want. Slow cooking barbecuing the tissue so that you get good effect on this. That's a nice fast two minute barbecue. And this catheter doesn't have any type of cooling system you don't have to worry about. Yeah exactly so this doesn't have a cooling system but the most important thing about this catheter two things you can see the temperature is being constantly checked and also you see the impedance on the right upper part which is 40 to 43. If the impedance goes very high above 100 the machine automatically shuts off. So this is an intelligent machine which gives you temperature controlled ablation at that point of time. Because if we don't have this impedance you can go very high up without knowing just charring the tissue which doesn't have any meaning. So RFA has to be done in a proper way with temperature control. Okay. Nagi do you find that the initial treatment is your best option with RFA because the stricture is still tight so you have good contact and it's harder after. Yeah. I think Chan that's an extremely good point. What we find is that for RFA you should not pre-send the patient or put in direct the strictures because if we do that RFA is not very effective because you have to have the tissue hugging against the catheter. So the first time you do it's more effective. That's the reason why we don't do repeated RFAs. We just do one RFA and then put on metal stand. So okay now we have finished the two minutes on this side. On the right side I'll do only one minute. The reason is we found that on the right side if you do a very strong RFA right hepatic artery is very close and you have hemobilia suckling after that. So right side only one minute but we do actually same 10 watts temperature control. I think the lack of a temperature controlled catheter in the past is what's given us reticence about using RFA at the hylum because of depth of injury and with the temperature control that adds an element of safety that should reassure us to use it more frequently. Yeah I think that you're absolutely right. Till now we didn't have good temperature control. We've been using this for some time now this machine and we is now a part of protocol in our institute to highlight you must do this but unless you have a temperature control machine and impedance intelligent machine you are I think RFA is not adequate or sometimes it's too deep so you get into complications you know. And would you change the distal duct structure? No no no temperature is always around 75 usually between 70 to 70 between 80 so it's usually 75. Yeah this is the right structure. I'm finding the right structure very tight so after doing the RFA I'm going to balloon dilate the right side because the stent may be difficult to pass through unless I balloon dilate it. So I do it after RFA. So whatever you want to do you do it after RFA because RFA softens the tissue and then balloon dilation becomes very easy. So we are doing this RFA for a minute here shorter time and then I'll balloon dilate using a tightened balloon to six millimeter so that the structure opens up it's easier to put the second stent. As we're doing this to discuss the type of double stenting that we're doing there are two ways of doing it. One can put one stent beside another stent so it's stent after stent or a stent in stent which is what is often done in Asian countries the white stent. But I'm going to do the stent by the side of the stent. Yeah this is okay now wait a minute we can switch off now. The RFA right side is over. Balloon dilation is important on this side because it's very tight. Switch off and we're going to do a balloon. Would you say that given this important precision of the temperature control that really all of RFA should be done with some degree of that using devices that allow for temperature control? Yeah Amrita I think I absolutely agree that you must do RFA only with temperature control because if you look at the RFA that is done by hepatomas or by what the urologists use for like tumors it's always temperature controlled with an impedance being continuously shown. So you have to have low impedance good temperature control for good RFA otherwise just blindly doing it you don't get good controls. By putting a tight balloon to dilate this segment because I felt it was very tight and after the RFA it smoothens out a little and it's easier to dilate before I just put in the same. So another two or three minutes will take to finish. Yeah so I'm going up up so sometimes these axes are rigid so you have to move your scope up and down. The balloon is through now. Yeah balloon is through and I'm going to dilate it here. We'll dilate to six. Yeah it makes it easier. Okay good. Yeah so that's good. That's good to know. Yeah so we'll go first the stenting. When you do the stenting the first stent should be on the left side always because the left angle sometimes is difficult to negotiate the left side. So we'll remove the dilated balloon now and we'll start. The other thing we always do when you're doing a double stenting. Yeah so this is a study which actually looked at plastic versus metal stenting. I think this is another interesting topic that one could explore in the panel that whether you should do plastic. Some people strongly believe that we should do plastic stenting for ILADD not metal because many of these patients are coming back with after chemotherapy surveying for five years six years whether that's that's another I think opinion that we'll have to discuss. So Nagi that's an important point as survival is improving we're seeing our challenges with especially a Y configuration stent. Now if you have a truly double barrel stent that comes out through the papilla then you can cannulate each stent but even then you can get granulation into these stents and pop between one stent and another. And then that does leave the option of getting in with a hepatic or gastrostomy if you needed access in the future. So always leaving the left as a good option is good. Yeah so that's that's right you're right absolutely. I'm actually trying to find a long enough stent so that it comes out of the papilla so that I can go in. I'm using a 10 centimeter stent I'm not sure if it's going to be but if it's not going to be long enough I'm going to in fact telescope another stent inside. So I'm going now into the left side you this is the nitty stent that I'm using which goes on the long guide which is easier to manipulate. So I'm just going up there I think we are through now. Yeah so we are through and hopefully the the outer one is coming out. Yeah so now I'm in and I'm just looking at the lower marker. Yeah lower marker is seen there. Can I see the lower? Yeah yeah now we're going to the other important thing is the camera should focus here on my hand. So what we're doing is that as we are we haven't released the first stent but even before releasing the first stent I'm actually getting the second stent down there up to the wire here keeping it ready because you should not waste too much time. Just get the camera. See both the stents are in place. As soon as I release the first stent I'm going to quickly withdraw it and go to the second set. Okay so now we're going to withdraw the first stent and I'm looking at the lower end of the stent because I want it out there. Now can you see the endoscopy picture and the glossary picture? Yes. Wait pull it out. So you can see the yellow marker there that gives us a guide. I'm pulling it. I'm watching that carefully. This is not really considerable so be careful. Okay so this is now I'm going to quickly pull out this whole stent along the guide wire. The other guide wire is in place on the right side and then I don't waste too much time in pushing the second stent through and hopefully it should go through because we have dilated the segment after RFA and you can see the second stent here and this is now into the bile duct and here the friction is a little there but I think we should be able to get it through. So I'm using my scope actually the up and down knob and my body movement left and right. You can come outside and show this. You can see this well. So yeah the stiches pass through the stiches. Now I'm using a left and right movement to get closer and now the stent is very deep inside. I'm just getting yeah now okay. So now you got a long stent on the right. Yeah long stent on the right but we'll pull it back a little as we come out so that yeah okay now you can see yeah okay pull pull pull yeah take completely okay so it's going to yeah so both the stents are released now yeah and you can see now both the stents are released endoscopy can be large so you can see how their place endoscopy picture can be large. You can see the place outside so easy to re-intervene if you want because as I said now we're seeing patients who had RFA and who had the chemotherapy coming back to us after four or five years. We sometimes have to go in and clean this stent or put in other stent also. Nagi that was absolutely beautiful demonstration. We've unfortunately run out of time but we thank you so much for these great cases that you've given us and keeping your unit open. Thank you.

biliary strictures

management techniques

ERCP

stone extraction

SEMS

sphincterotomy

RFA

stent potency