Thanks, Amrita. Thank you, audience. Thank you, ASGE. We'll try and stay on time with this talk as well. So, management of biliary obstruction. Stent cut or find a different route. These are my disclosures. And so, your approach to your bile duct depends on where your obstruction is. Is it distal, mid, or hilar? And we're going to try and avoid covering too much of the hilar cases in this talk. And I thought I'd break this down into scenarios or cases and see how we approach these. So, case one is an 87-year-old female patient with jaundice, vague abdominal discomfort, and all we have is an ultrasound showing a 12-millimeter bile duct. So, what next in this situation is a detailed history? What were the onset of these symptoms? Have these been fluctuating? Are they progressive? Is there an associated weight loss with this? Can you feel a gallbladder when you examine the patient? Then let's get some labs, know the bilirubin level, the renal function, and your coagulation parameters. And now, after this, you have to ask yourself, do we need further imaging? And if so, what? So, let's break this down into cross-sectional imaging, CT, and MRI. So, if you are worried about a mass, you may want to decide, let that creatinine guide you. Can you use contrast or not? Are you going to get a pancreas CT or just a CT abdomen? Or should you throw in a full staging CT scan to decide resectability and metastases? MRIs are usually not relied on by the surgeons to decide resectability, but they have their own role, especially in surgically altered anatomy, where you may not be able to see the distal bile duct with an EOS, and can provide a nice roadmap with high-low cases like Nagi showed. So, going back to this patient, she had symptoms for a few days. This was an acute change. And on history, she had actually had prior episodes similar to this in the past. She had no weight loss. She was postcholar cystectomy. Her bilirubin was 9, and she had some underlying renal insufficiency, but a normal INR. So, do we need more imaging in this situation? And I thought we could have done without further imaging, because the suspicion in this story was so high for stones. But, she did get an MRI, and there's some distal bile duct stones that you see over there, with a periampulary diverticulum. And this was her ERCP. So, you get down there, can see that diverticulum, but cannot see the fimbria of the papilla. So, you can use a forcep and try and evert that diverticulum, and ah-ha, there it shows up. Now, that kept wanting to rotate inside, so I just used the forcep holding that diverticulum, everted, and used a skinny catheter alongside the forcep and cannulated. And you can do that, get your guide wire in, and then it's alright to release that forcep and let that diverticulum turn you back in. Once you have wire access, now you can go ahead and cut. And again, being very careful to cut along the axis of the bile duct, and not into the diverticulum, allowing you to take out these stones. So, scenario two is a biliary obstruction with an obvious mass on imaging. So, your next steps in this situation, now you now know you're going to get the surgeons and the oncologists involved. So, have that multidisciplinary discussion. Get that pancreas protocol and staging CT before you do one CT and then have to ask for a second CT. And then you know at least you're going to start with an endoscopic ultrasound with tissue acquisition, and then you're going to have to figure out, do we need ERCP, and what if ERCP fails? So, we do a cytology in the room that's positive, and now we have to ask ourselves, do we even need an ERCP? Is this patient symptomatic? Is surgery going to be delayed for any reason? Does this look locally advanced in staging? What's the bilirubin level? Will the surgeon say, hey, decompress this bile duct even if they look resectable? And I put these two numbers out that number seven is used typically for hepatic resections, but the bilirubin can be as high as 14, 15 in a very healthy patient that the surgeon would be happy to take up front for surgery. And then, of course, if they're non-surgical candidates, then you have a lot more options. So, this patient gets an ERCP. There's a distal bile duct stricture, and gets a stent. All right, scenario three. You have biliary obstruction, but no obvious mass. You have a nice double duct sign, and so there is a differential for this. This could be papillary stenosis. This could be chronic pancreatitis, but the level of atrophy you have in the pancreas suggests that we might be dealing with something more ominous. So, do we need an ERCP in this situation? Let's go through those questions. There's no symptomatic obstruction in this patient. The bilirubin is four. Surgery would not be delayed. This looks resectable on cross-sectional imaging, but he was 94, and he and his family had not decided about surgery. So, the surgeons talked to me and said, go ahead, stent him till he makes up his mind. And this is what we see as expected. An ulcerated mass consistent with an ampullary cancer. Now, you could argue you may not need an EOS in this situation, although you can see nice intraductal extension on EOS, because this is not something you will take out with an endoscope just looking at it endoscopically. So, don't do a papillectomy on this. ERCP can be tricky in these situations, and so I used a little bit of secretin, which helped me identify the pancreatic orifice, got a stent in, and you can see how far that biliary orifice is from the pancreatic duct. So, he went on to get an ERCP and a fully covered short metal stent. All right, scenario four. So, you have biliary obstruction again in the distal duct. You have a bilirubin of 18, and this patient looks resectable on a pancreas CT, but you cannot cannulate. So, you've already had your conversation with the surgeon figuring out your options. It means initially they'll want percutaneous drains because they don't know you, but as they get to know you, they may start getting more comfortable with EOS biliary access if needed. So, when is that needed? When you cannot cannulate, with some tricky or infiltrated ampullas where the cancer gets into it, you have a duodenal obstruction or you have surgically altered anatomy. And so, let's just break down biliary obstruction when you're going to need EOS. You can use EOS to access the bile duct itself where you're going to perform a rendezvous, so grab your wire and get in the traditional way. You're going to try and place a downstream stent, and this one is my least favorite. You're going to try and make an anastomosis to the small bowel with typically a lumen-opposing stent so you can get back to the entrance. Or you're going to create a new anastomosis, and is that going to be in the extrahepatic bile duct? Is it going to be in the intrahepatic bile duct, typically the left side or a left hepatic gastrostomy? Or can you do something temporary like a quick gallbladder stent, especially if the gallbladder is very distended and you know that there is patency of the cystic duct? I'm not going to be able to go through all these videos of EOS biliary options and anastomosis, but let's start with at least a rendezvous where you know your scope under fluoroscopy should be pointing in the direction you want the wire to go. And you can see the tip of the scope is pointing in the direction of the hilum, which is where we want the wire to go. Now you want to use as large a needle as you can comfortably into the bile duct, and then use a slightly smaller diameter wire, like a 0.025 inch guide wire, with preferably an angle tip which allows you to rotate through strictures if need be. And so you saw there we grabbed the wire, get into the bile duct, and were able to deploy the stent. And by we I mean this was courtesy Muin's video that he shared with me. So there are other ways to place stents, and this is a downstream stent that you can place. And it looks very nifty and cool that you're behaving like a radiologist, where you get a nice cholangiogram, you see a nice distal bile duct stricture, and you feed a guide wire down through the left intrahepatic duct, through the stricture, into the duodenum. And another trick with any kind of EOS biliary access or rendezvous, you want to place as much wire as possible, gives you the comfort in case you pull some of it back. So here contrast is being injected in the duodenum. You dilate the tract, and this is the part I don't like about this procedure, because if you place a downstream stent after this, you've left a small little dilated tract in that left intrahepatic duct that has the potential to leak or bleed. So we'll skip over some of these videos and get to this slide about EOS upfront versus ERCP. And just one line on this, there is no consensus to say that even if you're an expert, you should be starting with EOS upfront. Bile leaks can be challenging with your EOS rendezvous and anastomoses. And another risk is the risk of bleeding, and that one is a little bit trickier, because bleeding into the peritoneum can sometimes go unrecognized. There's a learning curve to these procedures. The more you do, and as seen in these three studies, the better you get. So in conclusion, get a detailed history and physical. Understand your labs before you get in. So know that INR, so you're not stopping in the middle of the procedure. Understand the role of imaging, CT versus MRI. Have a multidisciplinary discussion before you go in and outline all your plans. EOS-guided biliary access or drainage is still challenging, which limits its dissemination, but it's rare in expert hands to have to do a percutaneous drain these days. There's clearly a learning curve. Be prepared for adverse events, but manage them well. Thank you. Thank you, Cheyenne. That was excellent.

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