So, I have the honor of introducing the moderators for Session 2, but first of all, it's been a fantastic, amazing course so far. Thank you to all the faculty in Session 1, the proceduralists, the moderators, all the cases and discussion were amazing, so we really appreciate you. So I have the pleasure, again, of introducing the moderators for Session 2. So we have Dr. Todd Barron from UNC School of Medicine, Chapel Hill, North Carolina, Dr. Brooke Glessing from University Hospitals Case Medical Center in Cleveland, Ohio, Dr. Jennifer Phan from USC Keck School of Medicine in Los Angeles, California, and now we will go to the first case of Session 2. Natalie, can you hear me? Can you see me yet? We can hear you. I don't think we can see your screen yet, but we can hear you. Okay. So this is Mohammad Hassan from CIE Orlando, and I will do the first case. Let me present the case. I don't see the slide, but this is a 76-year-old gentleman who had a liver transplant almost 30 years ago. We don't have all those details, but he had intermittent abdominal pain, underwent MRCP. That showed multiple large stones in the baldeck, and the baldeck was completely filled with the stones. That's how they described it. With regard to LFTs, just fluctuating LFTs, though barely alkaline phosphatase being pretty normal. And I did not have the MRCP images, though I had the reports, and also didn't know the whole nine years of the anatomy with regard to liver transplant. So I just did an EUS right before we started the ERCP, and yes, there are a lot of stones, and there are large stones. One of the largest stones was close to three centimeters. So I just put the ERCP scope down there right now. I'm at the GE Junction. I think we can switch to Ando image and fluoro image. So I'm right at the GE Junction right now. The way I usually say is, like, once you get into the GE Junction, I'll spend just a minute how to pass the scope. You are looking at the opposite wall where the gastric folds are. So keeping in mind, it's a side view scope, so I don't want to see the full lumen right now, which is right there. So I will slowly advance the scope while looking at the opposite wall gastric folds. And that will take me towards the antrum. That was my first stop, what I call right below the GE Junction. Take a look at the anatomy. Once I'm close to the pylorus, obviously, let it go into sunset position, get through the pylorus. Into the duodenal bulb, I stop, make another stop. And again, to take a look at where the lumen is going so I can advance and guide my scope towards the lumen while looking at the side wall. So just gently advancing the scope, using a little bit inflation, I can see that's where my lumen is. And I see the papilla. It's a pretty protuberant. So once I'm into the second part, small wheel away from me, just shortening the scope and trying to get into the position. So he looks like he had a really not very long bulb, first and second part of the duodenum. So I got there very easily and quickly as soon as I got through the duodenal apex. So it's a little bit, if you look at the papilla, if you look at the fluoroscope, the scope is in a good position. Papilla is quite bulging. Go ahead and give me the sphincter tone. So I'm using a clever cut sphincter tone with a visiglide wire. Usually the way I do is, the way I teach my fellows is to take a look at the papilla, take a look at the orifice, take a look where the papilla meets the duodenal wall, how many folds are. And here in Orlando, we call it talking to the papilla. And once you talk to the papilla and that papilla starts talking back to you, usually the cannulation becomes a little bit easier. So here I see the orifice is right here. There is a bulge right there. And the papilla meets the duodenal wall right there. So right into the central part of the last fold where the papilla meets the duodenal wall, if I have an imaginary line from the orifice all the way to that area, so that would be axis of my bile duct cannulation. Here I'm having a little bit trouble with keeping that scope in a position, the way I kind of stabilize myself is usually I like not to lock the wheels, but I did lock in this scenario. So I can stabilize my scope, the wheels of the scope are facing towards my chest, and my wrist is a little bit twisted to the right, or my shoulders to the right, so I can stabilize myself. So now I cannulate with the wire tip, let's go ahead and do that, to engage the papilla. And right there after engaged, then I can either use my wheels, or again in this case I'm having a little bit trouble, so a little bit trouble kind of stabilizing the scope, so I may even have to go into a little bit long position, which is okay, but before you touch the papilla, just try to get into the best scope position. So I think this may be even better here. Can you show me the floor, please? I think it's a little bit long position, but it's a very stable position right now. So let me try from here, if that doesn't work, we can always go into the short scope position. So I'll engage it with the wire tip, and then just using my scope a little bit to maneuver it. Hi, this is Jennifer Fan from Keck. So this is a beautiful primer on how to do elegant ERCP here. So often do you find that if you have to cannulate long, after you can get your devices in, it's easier to maintain a short position once you can anchor your devices in, like a balloon or something like that, to get into a more stable short position. And then on your EUS, did you see stones above the anastomosis? You said this is a post-op. So there were so many stones, honestly, I couldn't even tell where the anastomosis was. Anastomosis was? Yeah. So when we do a, like, cholangiogram, go ahead and move a little bit. So if you look at the position, you see that... Go ahead and gently go in there. Yeah, that's a good point that you make, because most of these... Really, really full of stones. Most of these transplant patients, if they get stones, are above an anastomotic stricture that you have to deal with first before you can get the stones out. Yeah, especially these duct-to-ducts, when they get really fibrotic with anastomosis, you may not even be able to tackle the stones on the initial ERCP. You may need dilation, stenting to even get the instruments necessary to actually make meaningful progress on the stones above it. So we're trying... I think we are in a good position there, a little bit stable position. I'm just gently trying to see if I can engage it better. Let me in a little bit. Let me in. So Enrique was moving the wire very gently. And I think we are in the right position into the bile duct. But you will see in a little bit how many stones are really there. Are you able to move further or no? Okay. Try that. Keep going. Beautiful. And I think here, we're starting to see a lot more living donor transplants. And this is where we see anatomy being very creative here. And some of the ones that we're seeing, at least at USC where we're doing quite a few, is a very kind of S-shaped curve of the duct to duct anastomosis, especially in living donors. And we may not see a true stricture at the anastomosis, but there's enough space that's kind of at the S-shaped curve that we get similar pathology. Yeah. So do you guys see the floral right now? Wow. Yeah. Are you guys able to see the floral right now, right? Yeah, yeah, yeah, yeah. So you can imagine how many stones are there and how big they are. So let's see what we are even able to do with these stones today. And right now, I think what I'm going to do is we are in the right position. We're in a good position, even though it's a little bit long. And you just have to be careful while doing a sphincrotomy. But if you look at the direction of my sphincrotomy or my plan of sphincrotomy is right, you see the first fold and in the direction where I said like the papilla meets the duodenal wall towards the center of that last fold. That is the direction of my sphincrotomy. So here I will go for sphincrotomy. And if there is a big diverticulum there, I usually try not to do full sphincrotomy because there is a little bit risk of bleed because right where the papilla meets the diverticular wall, usually there is a vessel there. And if we're planning to do a sphincroplasty, you don't need to do a complete sphincrotomy to begin with. And you can do a dilation. But for sphincroplasty, which I'm planning to do to some extent, I'm going to see how much success I have on that because there are so many stones there, but I'll at least demonstrate how I do it. Go ahead and push the... I think this is a good enough sphincrotomy. What we're going to do is we're going to try to come into the short scope position while trying maintaining the access. It is a very short duodenum. So I am rotating my scope to the right, gently pulling that scope back, gently pulling that back. You can see on the fluoro. And right here, its scope wants to fall back. So I'm going to move my small wheel away from me. And if it doesn't get into the short scope position proper one where I want it, I still have a little bit crookedness there. So I'm going to try to go back in there and try one more time and see if I can straighten it. If not, then I can just go in a longer scope position and do that. And when I'm shortening it, you can see that it wants to fall back. So I think let's just stay here right now in long scope position. And I will probably shorten it later because I got to put an IMAX through that, so it would be better if I can do that in the short scope position. But let's go ahead and exchange and do a sphinctroplasty. For sphinctroplasty bone, I think there has been evidence that you can dilate it even up to 20. I usually end up doing up to 15 at most, at times maybe 16 1⁄2, but that's good enough. After that, if I need to make the stones, a stone is still bigger, I need to make it smaller, I will use a mechanical lithotripsy or I'll use a laser or EHL. So for the sphinctroplasty, we'll take a 12 to 15 CRE balloon. I will go ahead and exchange that. In this scope position, my scope is very stable. It's not going to fall back. I'm resting on the greater curvature. That's the benefit of being in long scope position. But at the same time, there could be sometimes issues with passing the accessory or ease of passing those accessories. Your point about the sphincterotomy and for the audience, there haven't been prospective randomized trials, but there's been pretty good large retrospective studies showing that if you do a full sphincterotomy and large balloon diameter dilation, there's a higher risk of bleeding, not a higher risk of perforation, but a higher risk of bleeding. So as you pointed out, if you know going in, you're likely to do the large diameter. As you mentioned, you only have to do a small sphincterotomy. The idea that if you think that it's a higher risk of pancreatitis, you're directing the dilation and the tear away from the pancreatic orifice toward the biliary orifice. Having said that, a lot of studies from Asia have done primary large diameter balloon sphincteroplasty without sphincterotomy. I'm not saying to do that. I'm just saying that, you know, it may not be unsafe or may not be a higher risk. But in this case, it also looks like the degree of narrowing is really at the very bottom. Not, you know, that maybe opening it up is going to help them in the long run for not getting more stone formation, you know. Yeah. So other, Todd, thank you for all those comments. And I know there was a meta-analysis you did before as well about the sphincteroplasty and like about the sphincterotomy, no sphincterotomy for sphincteroplasty. Without sphincterotomy, if you do a sphincteroplasty, there may be some scenarios where you may have to opt for that, but a high risk of pancreatitis, post ERCP pancreatitis with that. And but less risk of bleeding with that. Here, I'll go ahead and demonstrate the way I do the sphincteroplasty. This is a five and a half centimeter long balloon. And working channel of the scope is 4.2 millimeter. So I don't want the stone to be entrapped between the balloon and bileduct wall, especially if it's a really hard stone. Then either it can rupture your balloon or it can cause damage to the bileduct wall. So what I do is, I think you already noticed that I already shortened the scope to get a better access to the papilla. So what I do is majority of my balloon is still into the scope. What I will do is I'll pass one centimeter off the balloon into the duct. And I'm going to ask Enrique to inflate it to 0.5. What that does is that's gonna inflate just a very little bit, but it would be enough inflation that when I push that through that orifice, it will push the stone up. But here, we may not honestly have much space. The duct is really full of stones, and I'm already having a little bit trouble getting that balloon in. So he's gonna deflate, and then I'm just gonna push that a little bit further, just that's it. Little further in, and see if I am able to maneuver that in a little bit. Okay, floor up. But what I was trying to say is like when you inflate that little bit, what that would do is that will push the stone up. It would not get entrapped within the balloon and the biodeck wall. That little bit inflation is not gonna cause any damage to your scope channel or the balloon itself because the working channel is 4.8 millimeter. So I think in a little bit, oh, let's go ahead and inflate. At inflating that, and look at that, how the inside of that balloon is. And also, when you inflate it slowly and little bit, it does not pull you in the way the dilating balloons always try to pull you in. Doesn't matter where you are, esophagus or intestine, wherever you are dilating, the balloon tends to pull you in when you inflate. But if you inflate it slowly, it would not pull you in. It will make a waste and sit there. Other thing to be careful about is, push the wire in. Make sure your wire is nicely in there. And also, the balloon, dilating balloon, is in long axis of the biodeck. And it's not crooked or it's not bent right at the papillary orifice. It should be long axis in the axis of the biodeck where you can see that it's coming like straight from the biodeck into the duodenum. So slowly keep going up on that. Where are we? Okay, go to one. And this doesn't look to be an anastomotic problem, obviously, yeah. Yeah, I don't think so. It's the whole duct is, there may be anastomosis right where the scope is traversing over the biodeck. There may be anastomosis there, but this is, I think most of it is, I will have to, I don't honestly see the anastomosis itself. Yeah, it's just so dilated above where it is. Yeah. Yep, okay. Yeah, kind of to the point of what Todd was saying is that the problem is just really trans-papillary there and beautiful kind of flora image of the waist and it being broken with your dilation. Yeah, yeah, yeah. Okay, okay. So we will go ahead and dilate to, where are we? Well, we'll try to dilate it to 15. And then after that, I think we'll remove the balloon. And I don't know if they wanna go to the next room. And then what I'll do is I'll set up our IMAX in the meanwhile, and we can come back. Is that okay? Yes. That's great. Great start. So the question here is, you know, when you're doing a big balloon sphincteroplasty and your plan is to do kind of introductal lithotripsy, how does, what is your experience with creating such a big downstream orifice and then trying to adequately submerge and then do effective lithotripsy? As long as this is, in this case, if whatever we do, I don't think we're gonna be able to take all those stones out today after looking at those the way they are. So I dilated enough, enough in a sense, like I'm able to remove the bigger pieces out of that duct, but I don't need to go too massively on the dilation there. So that's how usually my approach is, and if I'm not able to remove those stones, which unlikely is gonna be, which is unlikely today. So I will just then put the stents in there and bring the patient back. But here, after dilation, and also the duration of dilation, minute and a half, two minutes. Some people even do up to five minutes. The reason for that is to decrease the risk of post ERCP pancreatitis. If you dilate it aggressively all at once, what that causes is causes quite a bit of trauma and edema around the pancreatic orifice. The idea behind that is if you are dilating, it slowly dissipates the edema and doesn't let it develop around the pancreatic orifice, so less risk of post ERCP pancreatitis. So approach is- Thank you, Dr. Hassan. Go ahead. Thank you, Dr. Hassan. We'll switch to another room and we'll come back to you in a few minutes. Sounds good, thank you. Dr. Hassan, we are back with you. Look at that biome. Oh, I'm back on? Can you see me, hear me? Yes, we can. So this is a IMAX. There are two sizes of the IMAX. One is a bigger, which is the outer diameter is 3.9 millimeter. That would translate into 11.7 French. And there is a one smaller one, which is 3.1 millimeter. And the Spyglass itself is 3.6. So they have two sizes of those. And Spyglass is in the middle and two IMAXs on both sides. The difference is the pixels of IMAX are 160,000 as compared to 49,000 for Spyglass. Also, the other thing that I like about the IMAX, the bigger one, which is 3.9 millimeter, has a working channel of two millimeter. You literally can put a pediatric biopsy forceps through that, which is 1.8 millimeter. But the length of the pediatric biopsy forceps is a problem. It's the same length as the IMAX scope. So it's not gonna get to the end. But they have a bigger biopsy, which goes through it. And it's 1.6 millimeter diameter. I think it jaws open up to 4.5 millimeter. So it gives you quite a big of a bite. For me personally, the way I do is, unless I have to go into one of the intrahepatic ducts or into the cystic duct, I usually try to cannulate the bile duct without wire with the Spyscope or IMAX. I don't use the wire-guided cannulation. That's majority of the time. Not always, majority of the time, unless the papilla happens to be in the diverticulum. Other thing what I do is, it's not possible with the IMAX. It's just some issues with the, or some political issues, I should say, of attaching the scope to the IMAX scope to the duodenoscope. I usually keep my wheels, these wheels towards my chest and the Spyscope or IMAX wheels, for me, are at 90 angle. But with this handle, it's not possible. The reason for that is, after I have cannulated the bile duct, I bring my left hand right here and I control my wheels, if, I don't know, you can see that. I control my wheels with my left hand and right hand both, but mostly use right hand for accessories while the scope wheels are facing towards my chest. What that does is, that stabilizes your scope position. It doesn't fall back because the scope hugs around the duodenal apex. So that's how I do it. First thing what I'm gonna do is, we're gonna go ahead and cannulate. This is gonna be a little bit problematic because I have not been able to, I tried to remove the smaller stone with the balloon or a basket. Honestly, it wouldn't even budge. And so now I'm gonna go in with the IMAX. What I'll do is, I make it like I'll use the wheel and I can lock those gently. I will make it like in a way that it becomes kind of a same trajectory as a sphincter tone. The stone right here, I'm gonna show you the pixels of this, the imaging on the side of it. And it's, honestly, I have done quite a few of these IMAX cases. This case is not doing the justice, the way the image shows up. But look at the wall, if you can see that. And if I can clean it up. So wall, like images are quality is phenomenal. And when you compare it with a regular endoscope, it's just gives you pretty much similar quality of image there. So right now I cannulated, my stone is right here. And we all know that how difficult sometimes it could be when that we are evaluating the very distal part of the bile duct. So the way I do is if I have to evaluate that somehow with the colangioscope, SpiScope or IMAX, what I will do is I'll just move my shoulders in and out. So that just gives me one centimeter movement of the scope in and out of the very distal bile duct and I'm able to examine very distal area. What I'm gonna do is this stone, I don't even have a space to really open a basket around it. So I'm gonna start working on this with the laser from right here. Our goal initially was like if, I think Dr. Arane just, he didn't use the EHL. Our goal was to one of us uses EHL, other uses laser. So I have a laser here and I will go ahead and use that, put the laser down. If you guys, I can show you that before you go to the other side and then you guys, if I have to move, that's fine. So a couple of things, I mean the imaging. Oh, go ahead. No, go ahead, John. The imaging quality here is fantastic. So I know you kind of alluded that we're not seeing how good it is with the stone case, but can you speak a little bit more about how do you utilize this in the setting of clangocarcinoma, PSC clangocarcinoma, what you've seen in terms of your experience with using the IMAX and being able to tell with your visual inspection the differences and how to visualize kind of malignancy versus benign disease using this? Yeah, so a really good question. With this quality of images, can we differentiate that between different pathology? I don't think obviously we have that much data, or at least, but in my personal experience, you can see the neovascularization really, really well. You can see these sclerotic type of areas very well where you can see the fibrosis, whitish area, whitish fibrosis, and mucosa itself, that also becomes very, very clear with this imaging. So I think if we set up a study to differentiate different type of these lesions from normal to abnormal, we should be, I think we should be able to achieve this. They don't have any NBI capability on this scope, but overall imaging is really great. So I'm having trouble getting this laser through the last part. So what I'm gonna do is, if I will unlock those wheels a little bit, see if that's gonna help me, because I locked the wheels on the IMAX scope, but if that doesn't help, then what I'll do is I will completely remove this scope outside and get the laser, see the laser in the duodenum before I push that further in. So I'm still having the same trouble, even though I unlocked the wheels, which is okay. And other problem which can happen with the laser is, laser is so tiny, I'm just gonna move this to the back and then see if I can get that out. So laser is so tiny and this working channel is so big, sometimes it can just hung up on one side and just get folded on top of it. So I think I'm okay, I can see the laser right now. So I got the probe out, so I leave that probe out a little bit before I recanalate that. Yeah, and the benefit here for the audience is with the laser, it's a very flexible tip, but once you either burn out the laser tip or if it gets damaged, all we have to do is kind of bring out the laser and cut out an inch or so or centimeter or so of that laser tip, and then you have a brand new, almost a brand new set of probes in order to use. And so going through a really long, tough case like this, I personally prefer laser because typically I would only use one laser probe for the whole entire case and just clip along the way. So yeah, that's a great point. And other thing is you really don't need a fluid medium for laser to work, which is not the case with the EHL. All for laser, you really have to be able to touch the stone and for EHL, obviously you wanna stay a little bit away from that. So we got the laser in. I'm not at really the best angle to touch it. I'm gonna move the, no, I think I got it. So right here, we'll go ahead and I'm gonna clean it a little bit. Are you ready with the laser? Yes, okay. See what it does. Okay. So these are gonna be, guys, really, really hard stone. So it's not gonna be easy. This will take a whole day, I guess, if I want to finish this. And I have literally seven more cases after this. So I don't think I plan to spend that much time. Yeah. One trick, by the way, on the EHL, you know how it'll tell you that you're out of shots and you have to change the fiber? So I went to a course that'll go unnamed, but if you turn the machine off and turn it back on, you can get a lot more fires. And you do that several times until it really, really is burned out completely. So you might be able to save yourself a fiber that way. No, great point. You can get a little bit more juice out of it than what it says. And also, I am like literally digging a hole in there right now. You see that? Yep. So I will keep going in that with the hope that it will keep breaking. Yeah. By the way, I've had a couple people do the same. When you put a hole in it, you can put a guide wire right through the stone and inflate a dilating balloon and break it from the inside out. You can implode it. And my laser is really now deep in there, by the way. So if I pull it back, the stone is coming with it. So I will keep working on it. This is working actually. Yeah. Yeah. And I think there's studies out of Texas that you can really just put the laser onto the biliary epithelium for seconds and it's not going to perforate through the biliary epithelium, which is really nice about laser, right? It's quite safe and you have this targeted visual light that tells you exactly where you're going. And so here again, as you're seeing, it's perfect cratering kind of right into the core of the stone. And it works really well to kind of then blast it open kind of in the center. And the laser is also asking, what did you get me into in this chaos? All right. Thanks, Dr. Hassan. As you're working on this, we'll switch to another room and come back to you in a few minutes. Sounds good. Thank you. Dr. Hassan, we are back with you. Oh, can you see me? Yes, we can. And do you see the fluoro and IMAX view yet or no? Yes. We've done quite a bit of work. Okay. So, fluoro on please. So you see that there's a lot of small pieces there. Actually, I had to switch from laser to EHL. Laser wasn't doing a lot of job. And so I switched it to EHL and that honestly worked better. And here we'll put a little bit contrast fluoro please. Okay. And you can see that we have now more space to work with at least. And I will go, this is my second EHL probe by the way. And it's working nicely. I'm able to go quite in there and I am controlling the EHL while Enrique, my tech, he's controlling the water. So because they're going back and forth sometimes could be a little bit more of a hassle. So I'm adjusting the scope a little bit. Water please. Okay. Yeah, it looks like you've at least been able to bore a path for easy stent placement kind of across. Yeah. In this case, what I want to do is I'm going to just use this probe till it dies. And then I'm going to do a double pig tail stent in there. So here, look at it. Okay. So why the double pig? I think there are two schools of thought of no pigs in the duct versus pigs in the left, et cetera. So why are you picking a double pig here? So my goal is going to be the way I think is like if I put a straight stent, it may fall out or the upper end of the stent may not be above the stone and it may slip down. So if it's a pig tail inside, I'm able to put that pig tail above the stone and it kind of hangs there and stent doesn't fall out and you provide a drainage because it really is very necessary that we provide a drainage after this much work on there. And here you see a lot of pieces. Enrique is trying to deceive the probe. So what he did is a probe died and he unplugged it and put it back on and I'm able to use a bit more. We have noticed that we can do it only once. After that, it realizes that we're trying to deceive it. Yeah. And your proximal duct has a lot of capacity there because it's so dilated from these large stones. So it's going to easily accommodate a pig tail stent in there nicely. But he turns off and on and off and on the EHL generator to kind of deceive it to a longer lifespan. Water. So any other thoughts, anybody? And this one, I don't know if you can see my hands, but I am controlling, I'm keeping my hands not on really on a duodenoscope wheels. I am controlling the wheels of the IMAX. If it's a spy scope with my left hand and the right hand, I'm using either wheels or accessories or just adjusting the scope, duodenoscope position. And here I really don't need the wheels of the duodenoscope to work with. And you can see a lot of small pieces, but don't be deceived by these pieces, which they look small. There's always one big piece sitting somewhere, which is going to be trouble for you. So I try, what I do is I'll use it as a, like until it dies on us. And then after that, I'll stop and put a double pig tail stent. And then you're using your EHL here, right in the center of all these small stones, kind of getting the popcorn effect is what they call it in urology when they're trying to break stones, right? A central kind of lithotriptor core, and then just popcorning the shockwave across the small stones. And then, yeah, I'm having a little bit hard time really listening, but I think I heard that I'm staying in the small stones in the middle. Can you hear me? Yes, we can hear you. Okay. So yeah, I'm staying, trying to stay in the center, even though the small stones are coming in my way, but what I'm doing is I, there is a one big stone. You can see that right above that. And actually we may be quite high up there. And I think the stones are mobile now. And this is one bigger one. One thing I will do is I'll put a contrast in a little bit again to get an idea about the boundary and the sizes of the stones. And because I need a contrast also to make sure that the pigtail goes above the other bigger stone. And. So I think the question people always ask is how long can you, do you do your lithotripsy for? Yeah. So, you know, I've done it where it's a time limit where I stop, because I think they're, the introductal stenting is very effective at decreasing stone burden for the next ERCP. So how long do you typically go, or where's your stop point here when you have such significant stone burden? Anybody has an answer on that for me really, as long as the probe is working, I'm not tired and I don't have more cases. Or I see any damage there, which I think, which makes me stop. Done. Okay. What is your settings right now that you're using for lithotripsy? We have a question about that from the audience. So I have a EHL pulses at 30. I had a high power on that just because of the stone itself. It was quite hard stone. But you can, if you decrease your pulses, because there are a certain number of pulses in each probe, and you can maybe use it for a longer period of time. But we're using the highest, which is 30 EHL pulses, and power is high. So that's what I'm using. And we actually have lost this probe as well, so I'm going to take that out. What I would do right now is I can either put the wire through this IMAX. Let's try that. Let's do that, because sometimes we have to use the cholangioscope to get a wire into the right place as well. So what I'll do is I'll use this IMAX and get the wire through it and see if I'm able to get that across above the stone while using this. So sometimes if we need to go into one of the intrahepatics and having a hard time getting a wire in there, or even for that matter having a really hard time getting into the cystic duct, but we need to do a transpapillary drainage of the gallbladder for any reason, we may have to use a cholangioscope to guide the wire in there. So you can see the wire right there. I'll still use a fluoro because I don't see above that. So I think it's going nicely in there. Let's see if I can go. Can you control the wire? And let me push the spy scope. Yeah, so I think one indication for cholangioscopy is, here you're using for other things, but cholangioscopy is for selected access, right? So we talked about this, if you're having trouble going into the cystic duct, if you have a highly stricture and it's tough to get into the duct that you need to drain, cholangioscopy is really good for this. And then we have one question about using a thallium laser instead of EHL and big stones. And so I think commercially we have chromium lasers available, and that's what we use kind of in our institution, but definitely a role here. The laser may not be as effective into boring kind of into large, really tough stones, as well as the EHL, but has a really long half-life. And that's what we've talked about this case prior. Dr. Hassan, is your plan to stent right away? Or are you going to attempt at any kind of distal stone removal of the fragments? So right now, I am just going to go ahead and put a stent in there. I did remove pieces earlier before you guys came back, so I think I'm okay. I did a good enough of a sphinctrotomy, and I'm planning to put a stent there anyway, so I'm not much worried about those small pieces underneath. And floor, please. So I will just go ahead and just simply put a stent in there. Fantastic. Thank you so much for walking us through that. Great case. Yeah, very well done. Thank you. Okay, go ahead. So wire keeps coming back, so I think what I'm going to do is I may take the spy scope out, and look at that. There's another huge stone there. So as soon as I move the spy scope back, and it worked, and now we have a wire in a good position. So Enrique will push the wire for me, and I'm going to make sure all the wheels are unlocked on my spy scope. It was locked just to stabilize the position, but not fully locked all the way. So Enrique is pushing that wire. I'm pulling it back, and they have a 7 French 7 7 double pigtail stent ready for me. So that's my goal is going to be to put that in. So but whenever I'm putting a double pigtail stent in there, I want to make sure the stiff part of the wire, hard part of the wire is above the area where I want this upper tail to end. So if it is only a soft wire, part of the wire, which is the first 5 centimeter of the wire, then tail may start forming below the stone or your desired area where you want to keep that tail. So right now we're just unhooking that. I don't know if you can see that my hands, I have kind of opened the cap to put the IMAX there. That helps maneuvering easier instead of a closed cap. Also, it is big enough that it doesn't let any air leak through that cap. So right now we're just exchanging the wire through the cap, and then we're going to put the stent. You're welcome to stay for the stent, or we can have a discussion until I get the stent in. Dr. Hassan, this is Natalie. Any thought of the benefit of putting multiple stents in to help continue to grind up the stones, or you think just one stent in this situation and then bring it back and then kind of manage the other ones later? I think maybe multiple stents may have a little bit better role, especially if you can get those on both sides of the bigger stone. But I think I'm not planning to do that. Right now I'm just going to put one in there and try to get that around that stone. But there may be some validity that it might provide more provide more mechanical trauma to the stone and help you break it easier next time. And are you planning on discharging this patient with antibiotics? Do you think just the periprocedural are fine? I think I will give him a few days of antibiotics. He was there for so long, used so much water, and even though liver is much bigger of a compartment as compared to pancreas. Pancreas, when you do a EHL, you really have to be very, very careful how much water you are putting in. It's a small, very contained organ, and you can easily perforate the side branch with the hydrostatic pressure. So you have to be really, really careful in that regard. But here we have up more space, really. We have a more area to fill that. So in this one, but still did use a lot of water, and I'm going to keep him on antibiotics for four or five days. So we have one other thing. If you have time, I just push the wire in, push the wire in, push the wire in. So I want to show you that that's what was happening. The wire was trying to come down, and that soft part of the wire and tail started forming. So I asked Enrique to push it further above the stone. Now what I can do is, Enrique, keep the floor on. So the soft part of the wire comes in the stand, and now it is inside the stand. The tail is above the stone. I'm not worried about it falling back, and only thing really right now, Enrique, I don't need to move too much. I just need to push that and that's going to deploy. So sometimes we start moving back when we have to let that tail go, and what I do is form the inner tail first, and then bring the soft part of the wire into the and with that you just got in that position just push with your catheter that stent out of the scope and form on. So you don't have to even move from your place. Thank you so much. We'll let you get back to your other cases, but we do have one final question from the audience. Is IMAX FDA approved in the U.S.? So I don't know if you want to comment on that. Yes, it is. We have used it actually. I was lucky enough to do the first case of IMAX as soon as it got approved. Fantastic. Great demonstration. Great case, Dr. Azzam. Thank you so much. Thank you. Thank you. Thank you for your patience.

ERCP procedure

bile duct stones

EUS

ERCP scope

sphincterotomy

laser lithotripsy

double pigtail stent

IMAX scope