Welcome, everybody, to the ASGE Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event on endoscopic therapy in pancreatic disease. My name is Michael Dellutri, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within a couple of business days on GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI Fellow moderators, Maham and Yasi, from the Center of Interventional Endoscopy. I will now hand over this presentation to them. Welcome, everyone. My name is Maham Hayat. I am an Advanced Fellow at the Center of Interventional Endoscopy, and I'm joined by Yasi. Hi, everyone. I'm Yasi. I'm the other Advanced Fellow at the Center of Interventional Endoscopy over at Orlando, and it's our pleasure to introduce our panelists for this evening. It's my honor to introduce Dr. Freeman, who is a world expert on this topic. He is the former Chief of Division of Gastroenterology and Hepatology at University of Minnesota. He has trained numerous advanced endoscopists. Many of those have gone on to be leaders in the field. He has led and participated in numerous courses for ASGE, and he was awarded the Master Endoscopist Award in 2012 by the committee. He also holds the honor of being the Master of ACG and Master of ASGE. He was the President of American Pancreatic Association in 2013, and then received their Lifetime Achievement Award in 2018. Dr. Freeman's main clinical and research interests involve pancreatic and biliary disorders, with a focus on interventional endoscopy. He has published over 30 textbook chapters and over 250 peer-reviewed articles, including several index papers and many multi-center studies. It's my honor to share this stage with him. And it's my honor to introduce Dr. Mustafa Arrain, who is a staff gastroenterologist at the Center of Interventional Endoscopy in Orlando. His areas of clinical and research interests include pancreatic, biliary disease, and therapeutic endoscopic procedures, including EUS and ERCP. He's also the Director of Pancreas Clinic at Abenhav Orlando. Next up is Dr. Mohammed Bilal, who is an advanced endoscopist at the Minneapolis VA Medical Center. And he's an Assistant Professor of Medicine at the University of Minnesota, and also Associate Program Director of the Gastroenterology Fellowship there. Dr. Bilal graduated his advanced endoscopy fellowship from the Beth Israel Deaconess Medical Center, affiliated with Harvard Medical School. He is passionate about medical education and endoscopic innovation, and he has published over 170 peer-reviewed manuscripts. He is recipient of several teaching and clinical awards, including the ASGE Diversity Research Award in 2018. He has mentored innumerable trainees, myself included. So thank you, Dr. Bilal, for being here with us today. And last but definitely not least, I have the pleasure of introducing Dr. Brooke Glessing, who is an advanced endoscopist at the University Hospital at Case Western Reserve University in Cleveland since 2014. She completed her general GI and advanced fellowship training at the University of Minnesota under the mentorship of Dr. Martin Freeman and Dr. Mustafa Arrain. She's currently the Associate Program Director of the Gastroenterology Fellowship Program and the Director of Endoscopy at Cleveland Medical Center. Okay. Well, welcome, everybody. It's a real honor and pleasure to be on this session with all of you. Really want to make this interactive. So what I'm going to do is present five cases that are all real, no composites, and just stop at the case presentation, and then we want to go around the room of the faculty and maybe pick one at a time. And I think we'll pick on the youngest first and most out of training and then move up to ask them what they would do. And then feel free to chime in on your, you know, online to ask any questions you have. We want to make this interactive. I'm going to show very little data. We'll allude to it where necessary, but this is not a lecture. This is a case presentation. So let's get started. Can you see my MRCP image here? Great. Okay. So this is an elderly woman with a refractory pancreatic tail leak after a splenectomy that had two prior failed attempts at PD stenting at a very advanced local practice. And I'm just going to show you the fluoro films from one of those and mention that the endoscopist who did this is extremely experienced and did mostly biliary work, and then ask you what you see and what would you do? First of all, what do you see on the MRCP? Anything about the pancreas configuration below? You want to chime in? What do you see here? Yeah. I mean, I think you can see on the MRI that the pancreatic duct is taking a loop. It's not going straight up. So I think it looks like it's taking like an answer loop. So I think it just sort of highlights the importance of reviewing an MRI or MRCP or high quality imaging prior to intervention, even both for biliary work, but I think for pancreatic work, I think it's really critical because you don't expect the regular pancreatic ductal anatomy that you would see in the vast majority of cases. Yeah, exactly. So what are we worried about here? Why do you think they failed twice? And this is a very experienced, skilled endoscopist. I'm just going to show you the first image. Yes, that would be helpful. Yeah. I mean, I think you can tell already that you just keep the MRI image in front of us in our back of our mind, that it's not following the direction of the pancreatic duct. So that we know on MRI. So there is two possibilities. One possibility is that it might have gone through the pancreatic duct and caused like a pancreatic ductal injury or perforation. And then now it's not actually in the pancreatic duct at all. And it's in a free space. But this could be deceiving because if I didn't have the MRI and I was trying this without looking at the MRI or after a good pre-procedure planning, this is exactly the path you would expect a main pancreatic duct to take in majority of the cases. Exactly. Spot on. You know, you've hit the nail on the head. Here's the next image. So it didn't go. So it looks like pushing a little harder. And then why do you think they didn't inject contrast first? Why not inject contrast first here in the pancreas? I mean, I think there's probably the concern for, you know, in someone who already has a pancreatic duct leak, plus also I think people are, there's obviously a hesitancy in injecting contrast in the pancreatic duct because of the concerns for post ERCP pancreatitis. Sure. So let me make my favorite point here. Which do you think is in about 10 multivariate analyses since Wang et al. in 2009 ACG, multivariable analysis is a higher risk for post ERCP pancreatitis, contrast injection or passing a guide wire deep into the pancreas? Yeah, I think you're probably alluding to the fact that it's passing the guide wire deep into the pancreas, especially repeated, repeated attempts of doing that. So I think that you'll probably go over it more, but I think when you embark on pancreatic ERCPs, you know, you're for pancreatic endotherapy, you have to do contrast injection. And sometimes that, you know, you obviously, there are strategies that to mitigate the amount of contrast you can put, but you really need to have a good day before you advance the wire forcefully, because that can cause a pancreatic ductal injury, which I think is probably what's happening in this case. Yeah. So, and by the way, just for the record, all I shared with the faculty was the first slide. I didn't share any of the other stuff or the outcomes. So this is unprompted, unprepared, intentionally. And very, very intimidating. What do you see now? So now, I think it's a balloon there, if I'm not wrong, in the duct, and above that, you can see that there is contrast extravasation. So what's that? So can you see my pointer? Yeah. Good. So here's the pancreatic duct, exactly like the MRCP. Like we saw on the MRI. What's this? I think this is contrast extravasating outside the path the glide wire took. Yep. Yep. And what's this? I think this is just contrast there. Yeah, that's extravasation. Yeah, extravasation of contrast. So basically, punched a hole in the pancreatic duct. And you know, one of the things I think that's really important in these situations is that, you know, I've kind of learned actually from Dr. Freeman over the last couple of years worth working with him closely is not using, you know, larger caliber guide wires because of this similar problem that if there is an answer loop and you're putting with a lot of pressure because, you know, you engage in the pancreatic duct when there is an answer loop. So you are in the duct versus the bile duct, you know, usually goes up straight versus in the answer loop or in a pancreatic duct, you're like, why is it not going? You feel like you're in the duct and you try to push through and it can actually cause a ductal injury, which is exactly what happened here. So in every multivariate analysis since 2009 Wang et al., which is about a 15 center Chinese study that was exquisitely done. It was like all the studies I published only frankly better. And they looked, they separated guide wire passage from contrast injection and guide wire passage, one or more guide wire passage deep into the pancreas is all it takes. So my approach to ESV is very different. Even for bile, I just did two intact papilla cases today. I put a little catheter in a small Kelvin, inject a tiny bit of contrast to see what duct it is. And if it's PD, I just go with it, but I'm going to show you how would you approach this? So what wire would you use? So this patient got pancreatitis, but not horrible. I'm going to preface this by saying, I have now seen and heard of three deaths from guide wire perforation with a guide wire, no contrast in young people with healthy pancreases, dead from severe pancreatitis. It's not trivial and it can lead to wicked pancreatitis. It's like a traumatic injury. So what wire would you use? Do you want to go around the room or do you want to stick with below? Let's stick with you for this case. We're going to pick on Brooke next. I think, I mean, like I said, I was sort of alluding to, I think that, you know, because you know, we had the luxury of already seeing the MRI. So you already know that this is a, there's a weird answer loop in there. It's going to be hard to traverse with a, with a, you know, a commonly used guide wire that a lot of people use 035 or 025. So I think for me, in this case, I would probably go with a smaller caliber guide wire, like an 018 guide wire, because it will be, it's unlikely to perforate because it's a smaller caliber and that would, and then use really start off as soon as you engage, do a little contrast and really just follow the direction of the pancreatic duct and follow the wire sometimes getting a little knuckle in there. And you know, if you do limit it, if you do reasonable amount of contrast and you effectively stent the pancreas, you will eliminate that risk. So it's, it's a lot of thinking in ERCP is based on the very old approach of cram and squirt, cram and squirt, and then guide wires came along and yeah, that's better using a guide wire, but hybrid technique is, is what we do. So I agree with you. Can I ask a question to the panel? Yeah. Has anyone had any experience with just a little bit of contrast injection in a patient that has a known ancillary loop? Do you feel like it sometimes opens up the answer loop a little bit and allows for their passage of your 018 wire? Yeah. I mean, but, but it's more than that. I'm going to show you a video of this actually in a minute. It shows you where the duct goes. Because it's so even with an 018, it may go straight out the side branch. So yes, it, it both, I agree with you. It not only shows you where the duct goes, this is an 018 wire through a 543 catheter. And there's only, there's two, there's Rogue Runner by Cook and there's Novigold by Boston Scientific. They're six of one. But what's important about it is the knuckle, okay? You want to knuckle the wire in the duct and the wire, I'm going to show you a video similar to this is the wire with the knuckle will always stay in the main duct. And this got wires gone out to the tail. This is like a sigmoid loop in a colonoscopy. Then watch this. What we're doing is reducing the loop in the pancreas just by pulling. So Dr. Freeman, actually there was a question also from one of the, one of the attendees who asked what techniques do you use to reduce the ancillary loop? So I think you were alluding to that. Here? Well, just back the scope up, but sometimes you can't reduce it. You know, it depends how firm the pancreas is, but here, and then what stent would you put in? I don't see Dr. Arane on here. Did he, is he sitting out? I'm here. Oh, you are. All right. You just had your video off, I guess. What stent would you use here? And I will say, I'll give you a hint. I have no conflict of interest in this. I'd go with a soft stent and given the size of the duct, probably a seven French and go with a seven, nine soft stent, like a Hobbs pancreatic stent. Yeah. Sure. Does it, I'm not sure size matters here, but length and, and what happens if you put a Zimmon stent, a seven French Zimmon in this duct? Yeah. The problem is this, this straightening is somewhat of a misnomer because once the stent is deployed, it's going to, the pancreas is going to try and go back to its own configuration. And at that point, that stent's going to get twisted and end up causing a significant amount of pain to the patient. Well, and injury. Injury. Yep. Right. And we've, we've all seen cases where it destroys the duct. This is a normal pancreas that got a leak out the tail from a splenectomy. And then this lady was in and out of the hospital for months before she, and she actually got referred to our surgeons to operate. And Dr. Freeman, I have a couple of questions for the panel and for you, for our fellows sake, like, you know, there's a lot of controversy about the pancreatic that, you know, duct leaks. I know in this person, obviously it's a different kind of etiology. Would you prefer putting the stent all the way into the body and tail if you can get, or do you think a short stent that lands just between the head and neck region is good? Just for what are your thoughts on that? Yeah. I mean, the main thing here is since this is such a refractory leak, our choice was a long soft stent, tend to like very short stents with a flange or long stents. But not in the median, you know, not in the median. And so I'll show you what we did. This is, this is stent I developed called, it's a Hobbs Freeman stent. And I, again, no conflict of interest. I've never even gotten taken out to dinner by Hobbs Medical. And then I found out 20 years later, they've sold a hundred thousand of them over the years. So then I went back and, hey, should I get a consulting agreement? Ah, you know, heck with it, too late now. So I only use these because I think they're better, not because I have any financial gain, because I think that's really important distinction. It's a polyurethane stent, and it follows the curves. The reason for the long one is so it doesn't fall out. And notice how it was exactly what Mustafa Erayn just said, it's a loose, see how it's reconfigured to be sort of the ancillary. If you put a stiff stent, even a four or five French stiff stent, it's going to straighten and injure the duct. So this is, I'll show you quick, because we want to get on to some other cases. But this is a little animation about standard genu, a standard wire will often go out the genu. And if you knuckle a little wire, and you can knuckle 21 wire, it's very hard to knuckle O2-5 wires, but you can in a normal pancreas. But for the ancilloop, just go with and knuckle the O1-8 wire. What we'll sometimes do is actually knuckle it outside the duct, and actually cannulate with the side of the wire and push it up the duct to make a knuckle, or you can bend the wire. Okay, so I want to show you a video. It's a very similar case with an O1-8 wire, and notice here, boom, right outside branch. And that's what happened, but the difference is, recognize it, if I'm training a fellow, and I think Brooke will remember this, if I see that wire going outside branch, I go ah, stop. Because if you push it, even with a little wire, you can make a damage. So here, what we're doing is working a similar situation where we felt it was important to straighten out the loop. And the only reason for the long stent is because this lady, you know, the ancilloop might be providing resistance, and she was leaking for months before she came. So this is not going to be a simple leak to close. Notice that we have a wire in the bile duct that helps you get into the pancreas, just like a pancreatic wire will help you get into the bile duct. And this is, see, the stent has soft, it's very soft, and it's got big side holes, okay. And this is just showing extreme ancilloop, you can go around, okay. And if you want to just do a short stent though, here's a very extreme loop, you're never going to get a wire to go around here, up here, and up there, and there's no reason to. So this is, this is placing a protective pancreatic stent, we're going to cut the biliary sphincter in a young woman with healthy pancreas and an ancilloop. So watch out if you do this. Be careful, NSAIDs are not going to prevent pancreatitis in this patient. And I've just mentioned we've taken care of 40 patients over 10 years with necrotizing posterior CB pancreatitis, and almost all of them got NSAIDs, no PD stent. That's just saying from my bias, and there's a study coming out soon which should address that, but that's all I can say. Short, and this is a short flanged stent. What if you put a short unflanged stent in this patient? What will happen to it? Short, straight, it'll fall out. And does a stent that falls out right away do any good? No, no, it actually is the same as poking a guide wire. And then the other thing that really high risk patients we put in PD stent, we double wire put in a PD stent before we cut any sphincters, because then you don't have any doubt you're going to be able to drain the pancreas. But anyway, let's move on to a different case, okay? We've got 724. I'm going to try to get through at least three of these cases. But that's my main, I'm going to go fast through the next ones, because that's the one where we do things so differently. Go ahead. Sorry, Dr. Freeman, I think there's just a few questions in the Q&A that maybe we can quickly address for the last question. Sure. So someone had wanted to know whether for the stents, does it matter for pigtail versus straight? For long stents, we always use single pigtail because they tend to migrate into the duct. And if anybody's had experience fishing stents out of pancreases, especially normal pancreases, can be very tricky. Short stents tend to put straight ones in because short with a pigtail has a lot of weight in the duodenum, and even with an inner flange will tend to fall out prematurely. It all depends, you know, who you're doing it and how critical the stent is. You know, there's grades of risk. We like to be binary, high risk, low risk. But if somebody's really high risk, like an ampulectomy, young person with a healthy pancreas and small ducts and a leak or SOD or whatever, I want to, you know, a flange, a short flange stent or very long, unflanged pigtail. So short, straight or long, single pigtail. That's what I do. Let's move on to the next case because we could spend the whole time, and we're, you know, I want to get to some other issues. Okay. Great. Let's maybe address the questions at the end. Yeah. They're good questions. That's a very good question. Okay. There's another real case I've had to prove. We have a huge chronic pancreatitis program at the University of Minnesota. And we're lucky to dovetail into that. It's because islet autotransplant was invented here. So, this is a 17-year-old woman that I saw eight years ago. She's 25 now. Eight years ago. She's had pancreatitis since age six. She has PRSS1 mutation. This is the first mutation described by David Whitcomb, R122H. It's autosomal dominant. We've taken care of about 200 patients now with PRSS1. Just saw a new patient Monday with PRSS1. No interval pain, but feels very well, varsity athlete. And 17-year-old, which you know is not an easy time to be an adolescent woman. Identical twin, believe it or not, had a PUSTO H6, and actually having problems. Three large stone clusters in diffusely dilated MPD. Here's big one, medium one, and smaller one in the tail. And this was actually referred to us from Mayo's pediatric GI group for consideration of TPIAT, total pancreatectomy islet autotransplant, which is magic for progressive hereditary disease if all else fails. So what are we going to do here quickly? ERCP, SWAL, surgery, drainage, like guidelines recommend, or just treat her medically? Anybody? So we're going to pick on Brooke next. Of all the cases, this was the one that I didn't want to be picked on. No, but for real. So yeah, this is a great, this is an actually, this is a great case. And I think that, you know, in the audience, when you're hearing this, you might look at this case and say, it's a 17-year-old, she's been having eight years of recurrent acute pancreatitis, and, you know, her duct looks terrible. She has multiple areas of, you know, obstruction with stones and a dilated duct. And we should just, you know, look at the guidelines and we should just recommend surgery because, you know, she has this autosomal dominant hereditary pancreatitis. And I think this is a really good case to just pause and really look at your patient. So she's 17 years old. She is on track to graduate as she should, meaning that she's been able to make it to the majority of her education. She's a varsity athlete, as Dr. Freeman was saying. She's actually been doing really well and surviving really well with this chronic, with her pancreatitis. And when you look at her imaging, she has what looks like a potentially really treatable problem. And so she would be someone that I think would be a great candidate. I mean, all of these, maybe not medical, but all of these options are not necessarily wrong, I would say. And I think this is a great case to really have a multidisciplinary approach and to make sure that that patient feels like she is, she's educated in what options are available and what the benefits and what the risks of each of these approaches would be. But looking at her case, she is one that I think would be reasonable to offer her ductal clearance to see if she would improve with ductal clearance and if her pain, these pain attacks could actually be relieved. Because in between attacks, it sounds like she's completely fine. She doesn't have residual pain. She is not malnourished. She's eating. And so this is a patient that I think would be great for ERCP and maybe some, you know, pancreatoscopy with EHL therapy. Amazing. Yeah, of course. You know, it's very thoughtful. We have a group, we meet every week at the U, Mustafa will remember, Burke will remember. There's about 15 people online now. And so she was presented and we went over everything I saw her and we gave her all the options and decided to do exactly that. So I'm going to show you her video. I'm going to remind you, this is eight years ago. And back then, we still started with S-wall. We've kind of moved on from to exactly what Brooke said now as frontline, but we did S-wall on the biggest stone and you'll see that it didn't make a whole ton of difference. It smudged up that big stone, but it doesn't get rid of it. So I'm just going to show you just for the sake of time, our approach with a big duct like this is big pancreatic sphincterotomy. Balloon dilate. Again, back then we tried mechanical lithotripsy, which we'd actually reported many years ago, but don't waste much time with that because you're going to break, the lithotripsy baskets break on these stones and we've gotten them stuck. So this was eight years ago, after digital spy had just come out. And this is what we call turning snowballs into snowflakes, in Minnesota, at least. And it's sped up, but we're able to break up every stone in that, you know, it's unlike S-wall where you target one stone, and it's general anesthesia separate, we just keep going through the stones till we get to the, as far as we can get. And then, then clear them, usually, generally prefer basket because with chronic pink, you often push stones into a side branch with balloon. But here we're kind of getting, we got pretty much all of the stones out as you can see, so we thought, but it's like, it's like pest control. One session doesn't do it. And then here I did use rigid stents because I didn't want them to fall out. I used four French or five French, not seven in this situation. So, and that was eight years ago. I think she did. So, she did so well that she never followed up with us. And what the way we tracked her down recently was her twin sister, identical twin, I mean this is like a randomized controlled trial of two, who had a pusto at age six came in quite ill. She has a stone that they left behind the pusto, you can see her collapsed atrophic pancreas with a big stone right in the very ampullary area that they don't get to with a pusto and blew out a pseudocyst. So, we put an NJ in her center home for two weeks, let this settle down and we went and did spy EHL. Now she's doing much better. So, we tracked down the patient I just showed you and said, hey, we haven't seen you in eight years. She came in, she's now a personal trainer, has no pain at all, is doing great. But we said we need to get a CT on you. Which I don't normally do, but to see if you've grown any more stones. Sure enough, she had a big stone in the head, and we did a spy but it was in way off in a side branch so nothing to do. The point of this is, don't be formulaic. Why, what's wrong with doing drainage surgery in this patient. In a PRSS one who's 17 years old. As if you ACG guidelines by Whitcomb, Gardner and everything. So they say, it's better than, better than endoscopy. Because you're, if you do end up going to a total pancreatectomy or completion pancreatectomy, your yield will be lower so you've burned bridges in terms of islet yield. Exactly. And, you know, we just, we have a, we don't do, we don't operate on genes here. We don't operate on PRSS one, I've got one, we've got two PRSS ones that we're trying to figure out what to do with. We're doing too well to do TPIT. You know, because if they're really doing badly especially stricturing disease. And they do, you know, that's the way to go. But, and the reason is exactly what Dr. Raines said. Drainage operations fail. Eventually in most patients, and TPIT that was invented, you've done over 800 cases, there's a huge study NIH funded that Melina Bellin, our PI has got funded and completed and they're analyzing, she and Guru are doing the principal data analysis. Surgery impairs yield, ERCP does not affect yield. Look at the authors on this multi-center study. Joel Munzer, you know, these are my son Abu Elijah, she's a leading pediatric pancreatologist, etc, etc. Chronic pain, don't start treatment, your center can't finish, send them to a place that can take it from A to Z. That doesn't mean they need to do islet auto transplant, because there's very few centers to do that. But, you know, if you're going to do endoscopic therapy, make sure you're one of the centers like, who are the panelists here, Brooke, Bilal, or Rain, that can take this from A to Z endoscopically, and then decide early if, but don't take on endoscopically impossible cases. We don't treat patients with massive, for any number of reasons, it's not going to work to do endoscopically, we go right to surgery or palliative care, and integrate long term management, see beyond, this is a game of chess, not a game of 21, or go fish. All right. Recurring acute pain. Sure, before we do that a couple of questions actually I think we're answering those. Would this patient benefit from pancreatectomy due to high risk for pancreatic cancer with PRSS1? This was early before the case was presented. I think that's a good question. The data for, and the experience for cancer in PRSS1 is dependent, it shows that there's the dependence on smoking, so patients who don't smoke, their risk is significantly lower than the ones who do. Secondly, it's a young person, you have time on your hands. And as Dr. Freeman sort of demonstrated over the course of time this patient has done quite well. So you, you would definitely want to try endotherapy in a situation like this, before you go to surgery. In this regard, I think that an important fact is that the composition of the stones is not the same as alcoholic smoking pancreatitis that presents at the age of 50. These tend to be more sort of amenable to endoscopic therapy. So I would say that we should, we should err on the side of trying them, rather than just sending them straight for surgery. Very good point. We don't operate on genes here. We never offer TPIT to prevent cancer as the only reason. It is an added benefit if they need it because they're miserable and intractable and failing. But there's a huge part, my clinic now, I have two full days of clinic, three days of procedures, two days of clinic, you know, I'm going the opposite direction. I gave up all leadership, but I just do that now. And I have a clinic full of TPIT patients with long-term issues. You know, it's trading one set of problems for another. It's totally worth it in about 90% of patients are 80 to 90. But if you can, you know, we don't offer it to people just to prevent cancer. What Dr. Raines said is very true. Smokers, the original 40, 50% risk is European smokers with PRSS1 and also probably drinkers. And it's different. Let's move on. I want to get- Dr. Freeman, just one point to add on this or a question for you or Dr. Ryan, Dr. Glessing is that, you know, this would not be an approach in every patient, right? Because if this patient's anatomy based on the CT scan, the ductal anatomy also seemed favorable to respond to pancreatic endotherapy versus similar patient had like, you know, multiple strictures, then your approach might've been different. So it's not that take home is that everybody will get, right? No, no. And I'm so glad you brought that out. This is sort of unique. You don't see this in alcoholics where they have one huge duct filled with stones and no strictures. It's very unusual for alcohol, but it's not uncommon for PRSS1 and other hereditary pancreatitis, different disease. That's why I'm so disappointed that the guidelines in the ACG by real world experts in pancreatology didn't differentiate age, etiology, and morphology. Stricturing disease, you can waste endless amounts of effort and patient suffering by dilating and stenting strictures in PRSS1 disease, especially kids with stricturing progressive disease. So that's a very good point. So it's, and you need to do that with every patient with chronic pancregardus etiology. Let's get this one in. I want to get this one in. I'm going to, do you want to end on a good, I think we have time to get through all these cases because they're all very different points and very different issues, but you've already heard some great comments from the panel. So 56-year-old female, recurrent acute pancreatitis, US and SMR, secretin MR suggests mildly dilated dorsal duct with the visum and the Santorini seal. And the patient has pretty obvious chronic pain. And I'm going to show you a similar MRCP, but in the video, I'm going to show you this patient's CRCP. I mean, MRCP, sorry. But it's very similar. Looks like this. So classic. Well, let's pick on Dr. Rain. So you can see, I don't know if I can do a pointer, but you can see the pancreatic duct as it comes from the tail towards the neck and the head, instead of coming down towards the bile duct, takes a turn upwards on the left side. And that's classical pancreas devisum. And on the secretin enhanced image, you can actually see that the duct distends and you can see a few more side branches than before, as well as additional filling towards the head, which would be the Santorini seal as it sort of exits into the duodenum. So that's the snake's head. But even pre-secretin, the duct looks prominent. And with secretin, it really enhances. So we've got all the features of chronic pancreatitis here. Visible side branches, irregular duct, right? So if you read the endoscopy literature, chronic pain patients don't respond to devisum therapy. Do you agree with that? No. But also clinical, we already showed you a patient with recurrent acute pain clinically, who has no interval pain, who's got extreme calcific disease. And we know that imaging and symptoms do not correlate. Yeah. So this patient has some baseline pain, but recurrent acute. And most patients with these kind of recurrent acute, if you really dig at least half of them have low grade chronic symptoms. So what do you do here? What should we do for this lady? I know what I do now, which I'm going to end with. Yeah, so... I have a randomized trial. But what do you do? You know, you see this patient at Center for Interventional Endoscopy in Orlando, which is world class, by the way. I've been there, seen all their work, learned stuff from them. Yeah. So because the trial is still ongoing, I tell them that they can go to Atlanta for the trial, being the nearest center. Oh my God, that's a long way. Yes. And so more often than not, the response is, no, what can you do for us? And in that case, we offer them ERCP. Okay, so I'm going to show the video now of this patient. And this is, I've actually a log, I've done, I did my 176 minor papillotomy today, second to last case. And I'm going to, there's a little moral of that. I was going to try to squeeze that case in, but didn't have time. So here's, it looks very similar, got dilated irregular duct, Santorini seal. And here it is, it's in a diverticulum. That's very, that's actually common with Santorini seals. They're, it's like an innie and an outie, they're, it's inside a diverticulum. So what do we do? Should we start probing around in there? Any, any clues? How would you approach this? So if you just can't get close, the question is, can you bring it closer to you? So is there a way to, if the scope can't be manipulated, can we potentially consider either secretin, which may not necessarily make a difference, or just go with a very small, like 543 camera and see if we can at least engage it. But I've actually, after so many of these, I've gone directly to what, one thing comes with, with older age. First of all, I use a scope dock to hold the scope so I don't get tired. So I did six cases today, no fellow. And one of them was monster. But I've gone for expeditious. So let me show you what we just went right to. Always, if you can't see the orifice, spray methylene blue and then give secretin. And look where it is, not at all where I thought it would be. And notice how it's gone from an innie to an outie. This whole thing was collapsed. And this is in the diverticulum. It went from an innie to an outie. It's sticking out at you. And I'm doing something here you just shouldn't do. So, but I kind of knew where I was gonna go. So this thing is turned into, from a collapsed punctured water balloon to a bulging grape. So how are we gonna access this? So I'm trying to find the orifice by seeing where the methylene blue is clearing. Oops, sorry about that. How are we gonna access this? Because I'm poking around with a guide where I'm not finding it. Yeah, I downsized to a cannula. Oh, sorry, I shouldn't be doing that. Well, yeah, I did. I started with that. Couldn't find it, couldn't get into it. So this is actually very common in Santorini seals. And I'll show you what we did. And I went to this very quickly. So, you know, I'm probing around with the wire. I tried a 543, tried a O18 wire, but I didn't spend much time. But this is now a bulging sac. How do you treat bulging sacs? You can do a needle knife, yeah. Yeah. Pre-cut, yeah. Right, now watch, because we know that's a sac in there, okay? And this is why I give secretin, both to turn it from an innie to an outie, but also opens up the duct. Look at that. It's like lit from the inside. That's the inside of the Santorini seal that we're exposing. And then this is the O18 wire. And you'll see how we make a knuckle there on the left screen and pass the knuckle out to the tail. And then use soft stents. Could use a hard stent here because the patient's got some chronic pain, but, you know, I just think these drain better. And then I think you do put a long stent in, a 411, and then a locking. This is a Genin SoftFlex stent. See how soft it is? And that's to lock the 411 in place. This has two inner flanges, two outer flanges, very compressible, soft. It won't injure. And you can see the side-by-side stent. So, if this, we have a pretty good idea that this works for patients with recurrent acute or chronic pain in Santorini seals. Two, it helps. But do we know, and, you know, in other patients with device and recurrent pancreatitis, do we know whether it helps? Is it effective? No. And what we do know is posterior speed pancreatitis is common. It was minor papilla instrumentation, and it can be devastating if you poke and fail. Okay. I want to show you, forget acute necrotizing pancreatitis. I want to show you long-term damage. I have a clinic full of chronic pancreatitics caused by ERCB, where they had, and this is a patient we're still taking care of, Devesim, normal dorsal duct, think had a normal EUS other than Devesim, and one minor attack of pancreatitis after a cholecystectomy. A really expert endoscopist went after this with minor papillotomy, and then a rigid stent, and then she kept coming back with stent occlusion and kept up, you know, digging a hole with more papillotomies, bigger stents, and then ended up, look at her duct, went from a pencil-thin duct to a huge duct with a very long stricture, and then came, and then I offered her, this is somebody who actually said, she's in her 50s, executive, flies all over, and said, you know, you should probably have drainage operation, because, you know, she absolutely refused. You see Greg Bielman several times, wouldn't do it. So we treated her with multiple soft stents to dilate up the stricture, and she did great for about a year or two, and then come back and redo it all over again, and each time she'd come back and said, what about surgery? But she's mostly stent-free and doing okay now, but not so with this guy, who had less of an indication, this is an outside, a famous endoscopist in a different part of the country, did a minor papillotomy, and a seven French stent in this little duct, and then he developed chronic pain. Look at his MRSV now. We tried, and he came out to see us in Minnesota. We tried endotherapy. That didn't help. I sent her, she lived out in the East Coast, sent him to Hopkins, where they worked on him endoscopically, because he lives out there, and that didn't help. He ended up with a total pancreatectomy with islet auto-transplant, and he actually did surprisingly well, but you can destroy pancreases, and divisum is, I have a bunch of patients who've had trans-pancreatic pre-cuts now, for biliary access, for biliary RCPs, young patients with only pancreas same story, pancreas wrecked and miserable. So just a word of caution. So plug for the SHARP trial. So I just want to tell you this quick anecdote. How are we doing on time? Because we got, yeah, we got time. We're going to get through all five cases, and we're going to go around the horn and get the audience questions. I had a patient signed up for my randomization number 12, because I really, I believe in this study, because I don't know if we help patients with divisum, after doing about 300 of them over my career. Randomized a patient today, a 60-year-old who had two years of recurring acute pancreatitis and divisum on two MRCPs, had three CT scans, had two EUSs at a practice in town, came to see us, got him to sign up for the study, went in and the first step of the randomized trial is expert EUS. So if Sean Mallory goes in, guess what he had? He had side branch IPMN in the ventral duct, duct, with a focal suspicious looking area. So it was pseudo-divisum. And I went in to try to, and he FNA'd it, but he wanted me to brain it. So I went in, I could not find the ventral duct, even though he said the patient didn't have divisum. And Sean Mallory wrote the book on that, right? You guys who trained with him. And so I went in the minor papilla was gaping, spewing mucin out and blood from his FNB, did a big minor papillotomy, put a three French stent in because mucin plugs up stents, right? We don't put stent, be careful about putting stents in IPMN because they plug up. So I put a three French in after clearing out his dorsal duct and he had a bleed, like a refractory bleed. And actually it's something I've never done before he used a little, what do they call it? A little pinching artery device they use. Co-act grasper. Yeah, co-act grasper. Yeah. Because they don't want to put a clip on and they didn't want to burn it. So the moral of the story is be careful before you leap and don't, you know, this guy, so he's going to end up with a whipple. So the bleeding was from the minor? Minor papillotomy, they bleed, man. Yeah, yeah, they bleed. They bleed. And I did epi injection, epi injection and a little bleeding vessel just, and it just wouldn't stop. So I've never used the co-act grasper before in a sphincterotomy, but I got Nabil Azim, his wizard colleague who started his training with Dr. Irani and UCSF to FaceTime me on how to use the co-act grasper and did a network. He went and he did great. I kept him for four hours, checked the lipase, felt great, made him stay for four hours and sent him home. So Dr. Freeman and Dr. Irani, we're just, while we're on this topic, I have a question that in my practice, I don't use any fully covered metal stents in the pancreatic duct. So we've recently seen more and more studies coming out of Europe and other parts of the world where they've used a fully covered metal stents to treat these strictures. I know you mentioned putting multiple pancreatic stents. So just wondering what the panel's thoughts are on that and where we're heading with that. What do you guys think? So I do not use them for benign chronic panc. I have used metal stents uncovered twice in cancer patients. One of them during training with Dr. Freeman and one subsequently. The only time I would do a metal stent is in that kind of situation, but I'm not convinced that we have the right stents to not cause harm to the ducts yet. But we'll see how the field evolves to see if there's any role. But currently that's my practice-based experience. Couldn't agree more. I think they wreck side branches. We don't have the right stent. Pancreatic strictures are not... What I've gone to is not even using seven French stents, just multiple four or five French stents because you get a stack of logs. Chipmunks can run through a stack of logs, right? The problem with a big stent like a Jolin, which we did for a while, is they're fine until they plug up or migrate and then they occlude the duct. And the beauty of multiple small stents is they allow side branch drainage and they don't need to stay... So on that note, I'm going to move on to another case because I want to get through these. Disconnected pancreatic duct syndrome. Dr. Rain, very steeped in that. Dr. Rain helped us jumpstart our necrotizing pancreatitis program. When were you... Remind me when you were a fellow. I know Brooke finished 10 years ago. When did you finish training? Before then. 2009 to 2010. Yeah, that's right when we were jumps... That's when our neck pain program took off. So one of the things that Dr. Rain is superbly expert at is the long-term issues. Not just how do you get through the neck pain phase, but three to five years later, they come back with more problems. And what... How does the disconnected pancreatic duct syndrome... Do you want to rotate back to Lal or should we keep you on the... Can I stick with you, Dr. Rain, since you're such an expert on this? And I want to hear your wisdom. Happy to. What are the ways that disconnected duct syndrome... Because every paper that you read, practically, except finally a really great one from the Dutch Pancreatitis Study Group focuses on recurrent fluid collections. Yeah. How else do they... So chronologically, if we take it from the beginning, if the patient has a percutaneous drain, then they can present or they can have a persistent fistula or drainage output from their drain because that disconnected duct has an outflow through the drain. If they don't have a drain, then they can have a recurrent collection or a pseudocyst, which is a true pseudocyst because it's pancreatic juices and it contain cavity. And then the other one that can happen later on over time is recurrent pancreatitis, recurrent acute pancreatitis of the disconnected portion. And that can happen, especially as that disconnected duct, which is leaking scars down, and then you have a disconnected pancreas with the obstructed duct. And over time, that duct can become distended and be associated with pancreatitis. And so you can have recurrent acute pancreatitis, and that can progress to chronic pain, chronic pancreatitis as well. So those are the main manifestations of disconnected pancreatic duct syndrome. And- Yeah, and it can be really challenging to treat. Exactly. And that's why you sign up to treat these patients endoscopically. It's really important to follow them long-term. Yeah. So let me show you this case. This is a 34-year-old male, history of familial adenomatous polyposis, who'd had a total procto-colectomy. And then I'm not sure what the mechanism was. I don't think it was post-endoscopic ampulectomy. I'm not sure, but he got treated. This is all at Mayo. He was a med student, actually, and got treated expertly, as you can imagine, at Mayo with endoscopic transluminal drainage necrosectomy. This was about seven, eight years ago. And then he's tootling along, but he developed exactly what Dr. Raines said, recurrent acute and chronic pancreatitis in the remaining tail. And once again, he was actually, Mark Topazian was taking care of him, who's a wonderful pancreas expert endoscopist at Mayo, who's now, I think, doing volunteer work in Africa, but referred to the University of Minnesota for possible distal pancreatectomy with islet auto-transplant, because they had, at that point, didn't have a program. They had given up their program at Mayo. So, and I'm gonna show you his, MRCB showed an isolated, mildly dilated, remnant tail of pancreas. And he really didn't have any significant remaining head or body. So, any thoughts? Should we move down the line, Brooke and Bilal? I've got one more case, which I'm gonna pick on Brooke for, but I wanna get through this. So, I think, like you said, I mean, this person has a dilated, remnant tail of the pancreas, and we know that the person has disconnected duct syndrome. So, I think that usually bridging, in this case, is challenging. And at some point, I do want to have a discussion about that from the panel, because I know there's controversy about that, but I think that, in this case, it's harder. So, then the- Wait till you see the MRCP. Okay, all right, let's see. Let's see the MRI, and then, yes. So, I think- Okay, so, just for that, so you wanna show us, what do you see here? Yeah, I don't, you have to move the cursor, Dr. Freeman, but you can see there's the dilated tail of the pancreas, where Dr. Freeman is pointing to, and then there's an absolute disconnect over there. Well, I mean, there's nothing here. Yeah. So, is bridging possible? So, bridging, to me, in this case, I think it would be a futile effort to try an ERCP. There's nothing, yeah, there's nothing here. Yeah, to try to bridge. It's where the head and body used to be. But I think it's, now, in terms of like, I think over the last few years, since EUS therapy has advanced significantly, and this is a dilated pancreatic duct, so it's favorable, I think, for an EUS-guided intervention. I don't think that surgery is completely unreasonable in these patients, also, but I think that in this case, if you, these are young patients, so you might have, he's got FAP, so you might have a lot of other future surgeries that the person's gonna need, so whatever you can avoid in these patients. We have a lot of veterans that I see who have FAP, and they get so many problems during the course of their life. Obviously, this is unrelated to, maybe it related to ampelectomy, but unrelated to the primary disease process. So I think this would be a reasonable case to discuss EUS-guided intervention, to do EUS-guided pancreatic gastrostomy, to do that, because the duct seems very favorable. In expert hands, you can even sometimes do it in a relatively challenging duct, but I think this is a decent-sized, generous duct. The only caution, I think you already sort of took it upon, is that when we're doing EUS interventions for biliary disease, that's usually like a one-and-done, because we're either doing it for a metastatic disease, or we're doing it for a patient, like a colorectal adenostomy, or we're doing a rendezvous, and then once we have successfully completed, but in these patients, I mean, 34, so it's really important that you have a long-term plan to follow this patient, and you're not just doing an endoscopy. So I would not intervene upon it until I've had a multidisciplinary discussion with the surgeons, you know, with radiologists, because you could have complications that can go down wrong. So this is not a procedure that would just be like, I'll do it on the fly, you know, make sure I have high-risk consent for the patient, maybe even consider, you know, admission in some situations, depending upon that. And then I think I would consider EUS-guided pancreatic orchestrasomy. Definitely one of the most high-risk procedures I think we do in interventional EUS. Yes, what do you think, Rahr? No, I absolutely agree with what Bilal said. I don't really have much more to say, but I do want to point out, which is really obvious, is that there is no fluid collection, which I know that a lot of times when we're talking about disconnected pancreatic duct syndrome, a lot of times we're hoping for a large fluid collection that we can maybe leave a destination stent in as far as like cystic gastrostomy. And so in this case, Bridgie's not an option, destination stent therapy for cyst drainage isn't an option. I think, you know, having that pancreatic gastrostomy kind of in your tool set is really important for treating this. Oh, that's great. So we, you know, this patient was referred directly to Greg Bielman, who, you guys all, hopefully all three of you, you have sensitive, in my mind, the most amazing benign pancreatic surgeon I've ever encountered. And one of the reasons I moved to the U is he has done the most TPIATs in the world now. I think he surpassed David Sutherland, who invented it, but also is a brilliant, he can do whipples, fries, we do a lot of fries at the U actually. So we're not, it's not all about endoscopic therapy, but so, you know, this is very reasonable to do DISSEL, but mind you, he has basically, he has no colon, he has no, if he had a distal with islets, he would have no pancreas. There's no head of pancreas left, basically. So you'd have no, and you don't, the spleen always comes out with a distal. It's very risky and been abandoned to do spleen-preserving distals. So he's got, he would have no spleen, no pancreas, and no colon. He's 30 years old, has three kids, by the way, at least one of whom has FAP, and he's a med student, so he's a pretty smart guy. He said, no way I want surgery, if you can do anything to avoid more surgery. So he was one of our index, and it was a bit of a good luck, because we have a different way of doing that, like everything. And most of our theme is smaller is better, not bigger is better. So, by the way, just showing fellows can have a big impact. This is Umar Hayat, who trained, he was a fellow here, but trained him in advanced endoscopy in his faculty at university. It's University Case Western, right? That's how you refer to it? Correct. And he had poster of the year or whatever, distinguished, distinct. So I'm gonna just play this for you. There's no sound, Dr. Freeman, is there supposed to be sound? Oh, you can't? So okay, well, then I'll just narrow it. I'm hearing it, but obviously you're not. So too bad, because Umar has a very nice voice. But anyway, I've presented that to you. I'm going to show you how we developed this technique for this guy, and it was sort of a combination of me and Sean Mallory. Sean actually invented the U.S. rendezvous, just to brag a little bit. And in 1999 did the first one, when there barely was a U.S. And very innovative, brilliant. But I'm sort of the stint guy, and so we kind of collaborated on this, how to do it. Let me just play this. Okay, so okay, so it's a seven millimeter PD. We use a very small needle, 22 gauge needle, and then an 018 wire. And the idea being, it's all cell dinger technique. Look at the distance of tissue you're going through. Do not want to drill a hole with a needle knife or a, and look how small this segment of duct is. Notice we're pointing towards the tail, not the head. In a rendezvous, you're pointing towards the head, but here, pointing towards the tail. Very short segment of duct. I don't have much choice where to enter it. And he's knuckling up the 018 wire using an angioplasty balloon, which Boston Scientific makes them, it's called a Sterling balloon. It's 150 centimeters long, it's just long enough to go through a ERCP scope or an E.U.S. scope. Then we put in a backwards three French stent, and again, has to be a Roadrunner wire, not a Novigold, because Novigold shear in the 22 needle, we figured all this stuff the hard way. This is an Advanix Boston Scientific three French stent, because they have a smaller pigtail and I think a better material than the Cooke-Zimmon stents. And we're putting the pigtail first, you see how the pigtail is hooking there? And that acts like fingers hanging onto a cliff. I don't climb mountains, but hanging on for dear life. And that pigtail forms. And when we first started doing this, we tried putting two in, but what we did is wait. It actually wouldn't stay overnight, he went back to the hotel, stubborn guy. Did fine, came back a couple of weeks later. We re-dilated, put a second one in, and the idea is it's like a seton to keep the fistula open. And that was, well, when was Umar? I had a three-year fellow. Long time ago, right? I don't know. How long has he been with you guys? Like two years? Two years maybe ago he was with you? Graduated two years ago? Yeah, so, but this, we did this three years ago. And he's now, I see him every year. He's doing fine. The stents are still, you see how the stents have curled in the duct? There are two of them, so they act like a seton. They don't need to remain patent, you don't change them. I actually have done a bunch of duodenoscopies to screen for more neoplasia in, you know, FAP. And he's doing great. That's beginner's luck. We've done a bunch, we've done 15 of these, Umar reported on eight, I think, was published. And, you know, the last one we did, we've gone to this post-whipple, it's a great technique post-whipple, but there we do through and through stents, where we actually go through the stomach, through the pancreas, into the jejunum. But of course, the last one we tried, who came to us after a whipple at Mayo, had a complication. You have to make sure the pancreas is adherent to the stomach. So, and that's more common after necrotizing pancreatitis than it is recurrent acute pain after a whipple is very tricky. And we've had a couple of leaks after that. Any thoughts? Dr. Arain, you've done a bunch of these. To prevent the leaks, you mean? Well, how do you predict if the stomach is not adherent to the pancreas, you're in trouble? One of the things I've sort of noticed just with experience is that the longer the procedure goes on, the higher the chance of a leak, and if you've punctured multiple times, it's, and also, as you said, the non-necrotizing pancreatitis post-operative. I don't have any good sort of ideas for how to prevent it, other than to say that oftentimes, fortunately, the leaks can be self-contained and the patient's maybe in the hospital for a few days, but they don't necessarily need drainage. Well, we had one, you know, the patient who had the lap whipple at Mayo developed recurrent pancreatitis. We just, like fools, we went directly to pancreatic gastrostomy, and it took 20 minutes. Oh, VRCP, yeah. And then we sent her home. Mistake number one. And she came back with pancreatitis, and CT showed the stomach had separated from the, and the stent had dislodged, even though it was way through and through. So that's a good question, Dr. Freeman, and Dr. Arain, Dr. Glessing, is that I think that for the audience, when do we choose pancreatitis, like I said, we talked about this case specifically, but what is your algorithm of sort of determining EUS guided approach versus surgical approach versus ERCP in these patients? Can I just make a quick comment on that, because we've done so many of these, and I may have perspectives. I want to get in one more case, which is necrotizing pancreatitis, because we have to talk about that. And Dr. Arain may remember, this may ring a bell. Anyway, you can tell, we go over these with John Mallory, because he's done all of them, and Guru is grooming into it. Our other guys have done rendezvous, which is different, you know, but this is a unique thing. And if the stomach is not near the pancreas, and they haven't had necrotizing pancreatitis, and especially if they have varices in between, we pretty much don't offer them that. We use, you know, you have to be really, really careful. What I don't do, what we don't do, is take a needle knife or a cistodome and burn a hole to get access, because that's actually how Jacques Dubier described it, and he's a world class innovator. I showed him this case, and he said he would never do it in this patient. So, you know, you have to just, I think you avoid it by choosing your patients appropriately. We decline a lot. All right, I want to show you one more case. Especially risky if, you know, we don't like to burn a hole with a needle knife or cistodome. We use the Seldinger technique with tiny wire, tiny catheter, angioplasty balloon, because we've had some failed drainages, and the patients have gotten away with it. The two biggest complications we had are post-whipple, where the pancreas wasn't adherent, and they leaked. One needed PERC drainage. Anyway. Can I add one point to that? Sure. So, for disconnected duct, I agree with everything you've said. There was one patient where nothing would go, even the smaller wires, and I ended up using a $6,000 cistodome, using a six French Axios as my axis, and it worked out beautifully. I'm not suggesting- But how big was the duct? The duct was about five millimeters. It was small. Yeah, but it was fibrotic. Fibrotic gland. Yeah, it just wouldn't, it was adherent to the stomach, and ironically, I had actually done a pancreatic gastrostomy, but the stent fell out, the three French, and the guy came back with recurrent pancreatitis. So, not advocating for that, but perhaps with smaller co-treated devices in the right setting, we may be able to in the future. And they're, you know, smaller and smaller devices, and they're being worked on, right? So like access, hot access EOS needles, and all the exciting stuff is interventional EOS. I mean, we do some exciting ERSP stuff, at least I think it's exciting. And then to that point, post-WIPL, I would always start with a endoscopic sort of ERSP approach, and then to answer your question, well- Well, and you know what? We ended up, after the horrible complication, but you got through it just fine with PERC drainage. We went back, and even I could get up her efferent limb and cannulate the pancreatic duct, which generally, if they're stenotic, the sad part is we've totally dilated up her pancreatic anastomosis, and she's doing better, no acute pancreatitis, but she has chronic pain, and is, you know, doing okay, but not great. And it's not ready for completion, pancreatectomy, islet auto-transplant. So it's a very tricky visit. I want to show this case because we're running out of time, and it's this real case, a 58-year-old, 20 days post-severe biliary pancreatitis, had a biliary stent, you know, had, and, but went 20 days after presentation with fever, shock, respiratory renal failure, trifecta, triple organ failure, airlifted to the U for management, and this is the CT. Can you see it? Yes. Yes. Okay. What do you see? Who should we pick on now? Dr., how about Blal or Blessing? Yeah. I mean, I think that we can all see a large collection with gas that is gas-filled, and just with the known clinical history, we can tell this is, you know, this is necrotizing pancreatitis with a walled-off necrotic collection. Now, when you see gas, for everyone that's attending or on the line, there, it means one of two things. It is either representing, you know, infection and gas-forming organisms, or it is potentially a fissilization into the lumen, and in this particular clinical case where they are coming in with fever, shock, you know, respiratory and renal failure, this is something that you do not go to sleep on. This is something that if you get consulted on, you are calling in your advanced, you know, advanced pancreatic biliary attending, because this is an emergency. This is a true emergency, and this needs to be addressed in one way or another, and so I don't know if Dr. Blal has to talk about management. Sure. Great. And what are the one ways or the, what is the one way or the other, aside from supportive care? It's only 20 days. Isn't early intervention a bad idea? So, as we know, intervention can be surgical. It can be with our colleagues, with a percutaneous catheter drainage management, or endoscopic through direct endoscopic drainage, and, you know, conventional teaching was that we had to wait an average of four weeks before we were able to safely proceed with any sort of endoscopic drainage procedure, and what we now know through some really great research and a recently published article is that, you know, we're kind of moving that spectrum now as far as what's considered an appropriate time for intervention, and we now know that early intervention before that, quote, four-week mark, you know, after the sentinel event of pancreatitis may actually be safe. In this particular case, just looking at how extensive it is and how deep that necrosis goes down into that left gutter, this might be a really great case to consider a multigated approach and maybe consider both an endoscopic drainage access point and then even maybe a percutaneous for potential, you know, just kind of thinking ahead for how we're going to manage this patient might be an appropriate case to consider sinus tract endoscopy as well. Fantastic. It's like, you know, the amazing thing is I, these guys didn't, we didn't talk about these cases in advance. The only disappointment is we've had no major disagreement, because Dr. Arrain, you may remember this case. So we did all of the above, not we, Dr. Arrain did when he was on faculty at the U many moons ago. So this would be 10 years ago or something, I don't know. So LAMS, LAMS alone, LAMS plus double pigtail, singular dual drainage, percutaneous for a second or not at all in what road. So but maybe just because of time, let's go through it. And this is what Dr. Arane did at night. Do you remember this case, Dr. Arane? Yes, because I had to call the radiologist. Right, this is how you know he's a great, not just a great endoscopist, but a great physician and person too, because he really felt compelled. So he did emergently a transgastric LAMS and a double pigtail transduodenal LAMS, because this collection, it's really the whole pancreas was gone and it went way down into the pelvis. Did another LAMS double pigtail. This was right shortly after LAMS came in. We were privileged to be one of the first places to get access to them. But he also made the radiologist come in, in the middle of the night. How did you do that? I told him, yeah, I called him and he said, I'll have to come in the middle of the night. And I said, I'm already here in the middle of the night. If I can come in, you can come in too. And he was actually one of our, I remember, Jason was an excellent radiologist. And he- He's still here, Jason Wong. I'll show you a picture of him in a bit. So what route, because we get this, you see, you guys see this all the time. They come in from outside hospitals with a, what route do you want to go? Anterior, posterior, transperitoneal or retroperitoneal? Does it make a difference? Comments? Because we need to direct them. We don't need to at the U because we've done so many of these together and they were all on the same page. But most places you need to tell your- You want to go retroperitoneal so that you have a conduit for necrosectomy down the line. Right. Also, because if you go transperitoneal, those patients prone, right? So not to be confused, spines in the back. So this is Jason. This is this patient, middle of the night, left posterior retroperitoneal because the retroperitoneum is a closed space. It doesn't disseminate all the evidence. Go transperitoneal, you'll spread this stuff all over. Get peritonitis or you can't use the track. And then he did dual drains. Then you have a choice. And I will say, I'll just make this quick because I think we're running out of time. And then we want to at least have a couple of audience questions. We did a lot of sinus tract endoscopy back in the day for these kinds of cases because you can't just change catheters and drain them. I don't know how they do that in Seattle, but it doesn't work here. It's got the necrosis out. We did a lot of this. It's laborious. Dr. Rain was terrific at it, but we're now very lucky to have a surgeon who's very brilliant at doing video-assisted retroperitoneal debridement. Because he can do in one session what it takes us like three or four sinus tract sessions. So what we're doing, large bore catheter, he takes that sinus tract, makes a five centimeter incision, puts actually a laparoscope in, and he has all the devices. And he's very smart about doesn't do, if it's a really circuitous collection, he won't stick it in there and perforate things. It has to be big like this. And we've done combined where he does the big stuff and we put a little flexible scope and do the little stuff. But that's just, that's dependent on your local expertise. If you don't have a VARD expert, do it. If you try to do this as a solo, you're like this guy here. If you try to manage this without help, this is our neck paint team. And this Dave Martin's our new VARD expert, but this is critical care surgery, interventional radiology. That's Jason who you called in. And this is our endoscopic team. And I just want to show you the last slide and then we'll take whatever questions we have time for. But we wrote an editorial on, for gastroenterology in 2019, with the evidence for endoscopic over minimally invasive surgery is growing, but one size doesn't fit all. Nick is a phenomenal surgeon at IU. This is by the way, the other Martin Freeman. Anybody recognize him? The real one. He's the Hobbit in Lord of the Rings, British actor. So not quite the same. All right, end of show. We have time for any questions. So I addressed a few while we were chatting so that, because we're going to get cut off in two minutes. I don't know, Maham or Yasi, have you guys fielded any? Yes. I think the ones on there are probably unanswered. So Dr. Rehn, I let you filter out a few just given time. I think maybe like a 30 second response, Dr. Freeman. What is the learning curve of pancreatic endoscopic therapy? It's still all going on for me. And I started it in 1988 when my then chief, I said, well, you know, I'm this fancy biliary endoscopist, but every, you know, I can't build the practice of once you do stuff in the pancreas, that's never going to work. Yeah. But it was a great, it was a great advice. I'm still learning. I think great mentorship early on is humongous because that sets the sort of scene for you to be able to grow and feel confident. But we can continue to learn and learn from our mistakes. But we don't want to just keep learning from our mistakes. It's okay to learn from other people's mistakes. So, but it's a process. The other one was, do all PD stones need to be addressed? Chronic pain, recurrent pancreatitis, et cetera. That's a good question. What PD stones can we maybe leave alone? Most of them, especially if they're asymptomatic, no reason to intervene if they have no symptoms. Yeah, and I'll tell you in Florida, Central Florida retirement sort of hub of the country, we see a lot of elderly patients asymptomatic, incidental chronic pain with stones. And we just leave them alone. I just tell them you're doing fine. If they have enzyme, exocrine pancreatic insufficiency, obviously we start enzymes, but if they're pain-free, then you leave them alone. And secondly, to my knowledge, there is nothing to support going after stones to prevent diabetes. That's a question that comes up, but I have never done endotherapy or any therapy for that matter to reduce the risk of the patient developing diabetes down the line. Any thoughts, Brooke? I think- And Bilal, both. No, I think you're 100% right. I mean, we see a lot of veterans with similar thing. You know, they have history and they have these asymptomatic pancreatic ductal stones. Sometimes I get a stat consult from some other small VA and I explain them the difference between that and bile duct stones. So I think it's really important. And I think just adding upon your question about I think learning pancreatic endotherapy as someone who's still early in my career, I mean, I'll tell you every single pancreatic endotherapy case I did in the first year, I reviewed all these cases with Dr. Freeman, you know, because like I think Dr. Arai said, it's okay to learn from other people's mistakes and not have to make- I've made a lot of them. You not have to make your own mistakes because this is the pancreatic endotherapy, I think from Biliri endotherapy is completely different. And it really, you have to review the cases, a lot of planning and preparedness, I think, not just like put them on the schedule, never looked at the scan until the patient shows up. I think you're gonna set up yourself for success if you do pre-pre-procedure planning. And it's very risky. We didn't even get into complications, but I think hopefully data, the first case brought them out. Go ahead, another question. I think, Bert, any comments? No, I was just gonna, I wasn't gonna add very much. I was just gonna say, I know we're running out of time, but just for any of anyone that's still on, this is like hashtag pancreas goals. And I really, I'm hoping that these cases have really kind of sparked your interest and excitement into like the world of pancreatology. But everything, all these videos that Dr. Freeman showed, these are, they are so elegant and they were so well done. And he made very, very difficult and challenging cases look very effortlessly, but they are very, very difficult. And so I just wanted to kind of share that this is, we are all still learning. We're also learning from each other. This is why it's so exciting to be on a panel with all these experts, because we're continually learning from each other. And as I think was highlighted during this hour and a half is that we're still learning and we're still learning what we can do better and what we have done that we thought was great 10 years ago and now we've completely pivoted to a different way in thinking and in therapy, so. Oh, that's great. I'm just going to throw in what a great panel. Really enjoyed it. Sorry that Yasi and Maham, you didn't get a chance to say anything, but really envy you getting to work with Dr. Irain and his colleagues down there. Great. I think one of the questions- But thanks for everybody for joining and do you have another- Yeah, I think it's a really important question. I think it's a thumbs up all the time and then we can finish up is probably, if you see imaging showing hemorrhagic component in an infected walled off necrosis, do you still offer endoscopic drainage? Well, probably. What do you think? Why don't you answer that? I think that's a great question. It is a very good question. I will say that I have, again, learned from my mistake because there was a patient who came over at my previous institution and there was a concern for bleeding. And I said, it doesn't matter, this collection needs to be drained and I drained it. And the next day I'm sitting in clinic and they tell me that she's hemodynamically unstable and she's bleeding and she's got melanoma. And so we sent her to IR for CTA and to radiology, CTA and from there straight on to IR for coiling. I think it's incumbent upon us if there is a concern for bleeding to do a CT angiogram for a pseudaneurysm. And if they find one that they can treat, then great. Sometimes, and this happened to us last week, there was definite bleeding. You can see that there's blood in the cavity, the patient's stable. And so there's no rush to intervene. And it's probably better to then just sit tight, let the collection do its thing. And if your arm is really, if you're really pushed into a corner to intervene, then intervene. But happy to hear other comments on that too. So that's exactly right. And the rule for necrosis is if it's infected and they have organ failure, it's urgent. If it's infected and, just reviewing a paper from near you in Orlando that showed that, do you to breathe right away or do you wait? And they randomized patients to immediate debridement or waiting and found you shorten hospital stay. When, what was fascinating is exactly 3% of their patients had organ failure. So, sure, they were maybe infected necrosis, but if they have organ failure, that's when you need to rush in. If they, organ failure that's persistent organ failure that doesn't stabilize. But if they don't have organ failure, you know, and that's why when you read papers and look at this, it's organ failure that matters. And Guru's paper on early intervention, almost all those patients had refractory organ failure. And that's why we went in early and you get away with it when you need to do it. But it's those sterile necrosis were easily manageable infected necrosis that you get burned on and with bleeding too. So, I agree totally with what they say, but I'm sure they're going to cut us off soon. Do you have any more brilliant? These are very good questions from the audience. No, I think it's approaching my bedtime. So, it's probably good to just say. Ah! Well, you're in Florida. What is it? 936 there? 936, yeah. Well, at least you don't have to put your kids to bed anymore, right? No, that's true. Yeah, so. Well, it's been a pleasure, everyone. Thank you so much. Yeah, thanks so much for inviting us. Really appreciate it. You've just, you've probably forgotten what it's like having me talking in your ear all those years. No, no, it's great. Thank you all. Thank you, everybody. Thank you. Yeah, and thanks Dr. Bilal and Dr. Glessing. And thanks to our moderators. They're really wonderful. And thanks to the ASGE for making this possible. It's wonderful. All right. Okay, bye-bye. Thank you again to all of our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure, check out our upcoming ASGE educational events. Registration is open. Visit the ASGE website for the complete lineup of 2023 ASGE events and to register. Our next end-to-hangout session will be esophageal motility. Registration will be open soon. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASGE membership for fellows is only $25 a year. If you haven't joined yet, please contact our membership team or go to our website and make sure to sign up. Thank you again to our faculty and moderators for this excellent presentation. And thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a wonderful night.

ASGE Endo Hangouts

endoscopic therapy

pancreatic disease

Michael Dellutri

expert physicians

refractory pancreatic tail leak

hereditary pancreatitis

recurrent acute pancreatitis

Santorini seal

ERCP

pancreatic duct drainage

multidisciplinary treatment approach

endoscopic therapy efficacy