We will now go to Dr. Mustafa Aray from Center for Interventional Endoscopy and he will demonstrate a pancreatoscopy for pancreatic duct stones. Dr. Aray, you are live on. Hi, thank you and welcome everyone. So this is Mustafa from CIE as well. So we have a patient who is a 62-year-old male who presented with acute pancreatitis about three months ago to one of our referring hospitals. At that time, a CT scan showed a 7-millimeter stone in the duct, the pancreatic duct around the neck of the pancreas. He was referred for ERCP but his symptoms resolved and at that point he elected not to have any intervention done after a discussion about the pros and cons of intervention. Then he was seen by me in clinic and we talked about things, the potential need for multiple procedures for removing the stone. And since he was doing well clinically, we decided not to do any procedures. A month later, he called back and wanted to be seen again and at that point reported having more symptoms, pain, discomfort. And we again talked about ERCP, S-wall surgery, the fact that the stone is small to start with ERCP and see how it goes. So he presents today for attempted ERCP with potential EHL to clear the duct. Now if you can go to the next slide, you can see on the CT scan there is a stone in the neck area of the pancreas with upstream duct dilation. And on the floor image, if you can see the floor image, you can actually see the stone that's to the right of the spine. I don't know if you can point it out with the mouse. Right there, yeah. I can see it. Right there. So the goal here is, I did an EOS just before the procedure and you can see the upstream dilation. You can see inflammation in the pancreas. The small, the downstream duct towards the head of the pancreas is small. And to my sort of evaluation, I don't see any signs of divisum. So logically, it makes sense to start with a sort of a ventral pancreatic duct dilation going from there. Dr. Arain, this is Brooke from UH. Do you routinely do an EOS prior to your ERCPs for pancreatic ductal therapy? It depends on the environment. I think in our environment where it's easily accessible, we will do it in case there is a concern for the downstream duct or if there's a concern for any stricture or mass. I would say I don't do it all the time, but more often than not, I do it. Yeah, and these cases that you mentioned, first of all, Mustafa, hi, Todd. The way you're facing your patient looks like they're probably supine. Is that right or no? No, the patient's prone. You're facing toward the head. Are they prone? So you have your monitors, because you're not looking across, so your monitors are in a different position. Because when you do them supine, of course, exactly your position, as long as you have your monitors toward the head of the patient, you're not in an awkward position. But also to your point of often the downstream duct is small, such that a lot of times, even if I want to do pancreatoscopy, sometimes what I'll do is put a seven French stand beyond the stone, let the duct dilate up a little bit around it so that you can get your pancreatoscope. Otherwise, do you feel like you have to dilate the downstream duct to get the scope in or? Yeah. No, I totally agree with you, Todd. I think, firstly, good to hear your voice. I agree with you. If there isn't room, I wouldn't push it too hard. I would put a stent in. And what's changed in my current position here is our ability to do SWAL is perhaps the best that I've had to date. We have a urologist who we work with very closely who finds having those stents in as a good strategy for him to do SWAL. And in him, before I bring him back, since we've already done one procedure with the ERCP and we have a stent, and I would actually then send him for SWAL and then bring him back so that potentially we may not even need to do pancreatoscopy. But I agree with you that if it's small, put in a stent and come back. Yeah. So we'll get started here. In these ones, you know, obviously your goal is the PD, but I actually don't mind getting into the bile duct because I like to do a biliary sphinctrotomy and have a nice big orifice to work with. So we'll see. The biliary orifice looks slightly higher up, but I'll try PD first. But if it doesn't work out and we go into the bile duct, that's okay too. You ever find that doing a biliary sphinctrotomy makes it more difficult to get in the pancreas later or no? So that's what my usual practice was to avoid doing a biliary. And I found that if sometimes you're having a hard time getting into the PD, putting in a, doing a biliary sphinctrotomy may actually make it easier. Yeah. I agree with you. Yeah. A hundred percent. Yeah. Yeah. That's true. So injection please. Keep injecting. And here's another challenge. Oh, there you go. I think we may have our answer for what we're going to do today. Keep injecting. You have an answer for your answer? Yep. There we go. So here's... Beautifully done though, Dr. Rain. Oh, thank you. What wire are you using? Yeah. So for the audience, and I know you're going to tell them anyway, is this is an ansolupe ANSA, and that makes your life a whole lot difficult, more difficult because the wire is going to make a circle and getting anything beyond that, sometimes it can be very difficult. Yeah. And the question becomes, how far should you even put your wire? I mean, at this point, I'm tempted to actually do a cut. Look at it though. It looks like it's going, he said, I don't think he has the visa, but I see it's going across. Towards the minor. Yeah. Yeah. So you're going to have more of a straight shot, I think, going through the minor. Yeah. Which I did look at and it's there. I'll show it to you in a second. At this point, I'm tempted to still cut him and put a stent in, in case the minor doesn't work out. And then you could try the minor. Yeah. Dr. Irain, do you have any tips on kind of traversing this ansolupe? Well, I think the first one is if you don't need to, don't try too hard. The second would be to either switch out to an angled wire or a 018 wire, which will knuckle itself and allow you to perhaps go around. I think I've used glide wires, which are obviously completely hydrophilic and you usually get it to go all the way around the corner and out to the tail. But difficulty, of course, is getting anything to follow. Now, sometimes you can actually get a five French stent to go all the way around and out and it sometimes straightens that out a little bit for your next ERCP. But I think, you know, I think going through the minor is going to be probably the way to go in this case. Yeah. So what I'll do is I'll do a little cut here and put in a, perhaps a 4-2, very short pancreatic stent, and then we'll try the minor. So a bit of both. Do you guys routinely do a biliary sphincterotomy in these patients? I don't. Okay. I don't either. I don't. I don't need to. Yeah. The only time I get a little bit, I wouldn't say worried, is some of these patients, this one I'm not talking about, have a concomitant distal bile duct stricture because of their chronic pancreatitis. And I've had some people where I do a lot of endotherapy and stenting and then I don't and they actually come back with biliary obstruction because there's enough compression from what you're doing on the pancreas side with the bile duct stricture that it kind of pushes them over. And I'd wished I'd actually had done a biliary set at the same time. But that's only, like I said, if they have a, you know, either suspected or known distal bile duct stricture. Yeah. That's really helpful with the EUS. Yeah. And helpful to see via the EUS, right? It's a plan for that and kind of open up the orifice prophylactically if you're going to stunt the CBD anyways. Right. Or I suppose quality MRCP as well could be helpful. And then LFT. Yeah. I have to say, my EUS, on the CT, I was wondering about an answer, but I couldn't tell. On EUS, I definitely couldn't tell. And then I was thinking, should we have got an MR, but, you know, we were going to do this regardless. I figured we'll see it. So I'll do a little cut here. My approach with these is to see my wire as it goes in and not have too much cutting wire inside. And then the thought is to go towards one. Sometimes it's not really in your control, but as I angle this way, it's more towards one instead of 11. And just little taps to see if we can open it up a bit. Yeah. I think your point about not putting in too much cutting wire is really important because in my early days of being very inexperienced, I was aggressive and you can get a really bad stenosis because you're in contact with the ductal epithelium and you can really stenose the pancreatic orifice that way. Yeah. So at this point, we may not have done a super big cut, but I'm going to take that and just go ahead and do the PD stent. The tricky part is, you know, maintaining wire while you do this. And so we'll see how it works out, but hopefully we can exchange. Hopefully we can maintain our wire and there you go. Yeah. Yeah. Nice. And so for that, for again, for those of you in the audience, once you see the barber pole, if you will, you have a little bit more wire, you're losing a little bit there, but you're a little more stable when you have the, can see the markers on. That was a really good demonstration though of being really cautious when you're doing a wire exchange, especially in an ancillary loop. I think at one point we did not have live fluoro and the wire got a little bit away from us, but nice salvage. Thank you. I'm going with a soft four French, two centimeter stent because we really just, it's not therapeutic in nature. It's really just to, yeah. Yeah. I think if you're going to go into the minor, keeping that short out of your way is kind of a good idea. So that's a great, great plan. And then we'll use the tome for sure, yeah. So then when you do PD stone work, are you more EHL dependent or laser? What has been your experience in terms of the most effective way to break these kind of white stones that they're there? My, I, you know, we've used both, I, for my first line still is EHL. And if the stone is refractory to EHL, I may switch to laser. And then somewhere in between, we may do S wall. The thing about laser is I found some stones interestingly that don't break with laser and then you'd go to EHL and they break up. So I can't tell with the density situation, but my preference is always to start with EHL personally. I don't know how the panel feels. Yeah. I mean, we don't have laser here, so we do all EHL. We've had good success with it, but I know the, the literature would suggest that laser can be more beneficial in some cases. By the way, do you, do you think that he could have both or the patient could have both an ancillary loop and an incomplete divism? Right. It could very well be that. Yeah. Especially with the filling of the duct the way it did. Yeah. Yeah. Cause it really does look like it's dorsal dominant. So I have my stent, it's a soft stent coming out slowly, but now I'll go live. But essentially there's one internal flange and two external flanges and I'm just gently advancing it. Is that a Hobbs stent? That's a Hobbs stent. Yeah. Four French two centimeter. I can see the tip of my tome. I can see my two flanges. So I pulled back my tome just to free it off the stent. I'll put some forward pressure with the tome there and I'm just going to gently pull my wire back and that's our stent deployed. Now these stents, if when they're used for prophylaxis, they're notorious for the four two Hobbs does not fall out very often. So getting an x-ray we've, you know, basically may or may not be helpful. You're almost like, want to make sure you do an endoscopy for removal if needed. At this point, I think we'll switch back to Dr. Hassan and we'll come back to me. I'll try and line up in front of the minor here. Okay. Fantastic. Yeah. So we also have laser, we have both laser and EHL and agree, but sometimes when the stones are really hard and calcified, especially in the neck, the laser tends to blast it through quicker. Yeah. Yeah. We only have EHL here as well. So I wish we had more variety here as well. Well, I would say, you know, it would just be picking which one is available, honestly. Both are so equally effective. I know that the data says laser is better, maybe better, but both are equally effective enough to get the job done. Right, right. I mean, again, for the audience, with laser, I think that one of the problems is you have to have laser training, I think once a year, you have to have specialized glasses and everybody in the unit. So it's a little more cumbersome. Sorry, go ahead. Hi Mustafa, we're back with you. Oh, hey, thank you. So we're basically now back in the duodenum in a long position, looking at the minor. If I go slightly leftwards, you can see the major papilla. And it's a smallish minor, and this is as close as I can get, I've tried several times. Because it's a small minor and it's far from me because it's the best I can get, I'm going to go with a small cannula, like a 543, with an 018 wire and hope that we can engage the wire and take it from there. So I'm just trying to align myself. Usually it ends up more from right to left of screen. And so we'll see how this works out. The closer it is to the major, the easier it tends to be generally. So show me the tip of the wire, please, Omar. Do you like to give secret in routinely, or only if you can't get in, or only if you can't visualize? Yeah, I think I don't give routinely. In this one, this is my backup approach. Since we're going to send him for SWAL, I wasn't planning on giving secret in. I figured we can always try, and if this doesn't work out, we can go with the SWAL and see how he is and come back. So a bit more wire. OK. Pull back. And also, it tends to be below the little sort of ridge. It's not necessarily in the middle of it, which is the tricky part. The main issue here is going to be the distance, of course, and getting my angle right. Yeah. And then are you controlling wire here? No, I have an assistant. I have a 543. Omar is my very experienced and talented assistant in this one who's controlling the wire. And this is a tapered 543 cannula. This might actually be a better approach if I can just go upwards a bit more. Right where the light is is where I'm trying to get to. So Omar, gently advance wire. That looks good. Yeah. Advance gently. OK, keep going. So I think having experienced touch with the 018 is really important here. So I actually like to just do it myself because you can cause false tracks with 018 if you just kind of push because it's such a thin catheter. But this one went in quite nicely. Yeah, I think you're in. Yeah, I think we're in. So I'm just having Omar go in, and then I'll have him pull me in slightly. So keep advancing, Omar. The only problem with this catheter is you can't inject, right? No, we have a sidearm adapter. Oh, you do? OK. Yeah, so pull me in if you can, Omar. And if it doesn't go, then keep pushing wire. Push wire? Your resistance? OK, pull me. Let's see if you can pull me in a tiny bit more. Give me just one second. So I'm just changing my small wheel. Just trying to change my angle to see if you can pull me in. So pull me in some more if you can. It's pretty tight in here. OK, try and lock and see if we can inject a bit. Yes, it's filling. But I think we're in a side branch. That's why our wire isn't going. So Omar, you're going to pull back, and we're going to try and get into the main duct here. So pull back, pull back good. And now try. Pull back again. So I'm going to change my angle a bit. Try, Omar. We keep hitting this one side branch. It's very annoying, but keep trying. Yeah, go. OK, pull back. Try again. There you go, push, push, push, push, push, push. Keep pushing. So we're going to see if we can knuckle it in. Can you stop for a second? Yeah. this 018 wire is very thin and it can be very difficult. Yeah I mean it's good for small things but then these situations you wish you had a stiffer wire. The other problem with this candle is that I can only go with an 018 or an 021. That's actually not true. You can get a an 025 busy glide through that catheter I use all the time. We could try it. It's a tight fit and but what you have to do is you really I use I lube it up it's really not the advancement it's the exchange where it can become difficult but it will I do it routinely because when I do hepatical gastrostomies if I can't get the dilating balloon through and I have an 025 busy in there it'll go right through the liver capsule into the and then you can then you can get your balloon because it gets in front of the French. So we do it a lot. Okay so you can see my scope positions changed a bit too but we're really not getting so just to clarify Todd I don't have I'm not engaged stop one more I'm not engaged so I would basically have to pull out and try I think at this point if I was to switch wires. Yeah but I'll try it one more time with this and if it doesn't go then we can switch out. Yeah. Otherwise we have the star v which is a three and a half French which easily takes a 2.5 yeah 025 wire try wire stop okay show me the Todd do you also do your pancreatic therapy in the supine position? Every case I am I haven't rolled somebody prone in years I've done all my EUS guided therapies everything now one thing that was brought up is they wanted me to address intubation versus non-intubation we if we do simple relatively quick procedures we will do them supine about intubation as long as there's when you get in there there's no food or anything in the stomach advance they seem to do fine if it's if it's going to be obviously a prolonged or really complicated procedure okay I'd say most of them we intubate but we have done uh without intubation again with the caveat as soon as you have the stomach things clear everything out and obviously if there's any excessive fluid that you can't clear we then convert and stop yeah I'm trying to understand the old prone heavy go down but I think also for these quick cases we'll just do non-intubation as well patients um well it's funny that I asked Peter Cotton I said for sure why did they start doing ERCP prone when they started he couldn't give me an answer I mean obviously my theory is that you have to have the patient you're the prone or supine because of the fluoro and back then nobody could rotate fluoro right they were just basic cables so probably my assumption is they were worried about aspiration so everybody was prone uh when let's get this started but it's straight long I find that that the advantages are of course of people that do them supine is a you don't have to worry about the chest rolls you don't have to worry about 15 minutes of getting them set up to actually do the procedure um and anesthesia loves it because they can control the airway large patients you know what let me have a style view on this you know um they can ventilate much easier when they're supine um and it's just a matter of the endoscopist then getting used to doing in that way because there are a little bit of nuances as you probably know to doing them uh supine yeah I agree I think we're getting so many like you know more exotic patient scenarios that require supine wound vacs all these things and you're right I think positioning is a little different I think there was a recent figure out in GIE about training in supine versus prone position and the benefits of that I think we're just creatures of habit um I think our anesthesia colleagues highly like keep going yeah yeah I mean honestly I did it early on and wrote an article probably 15 years ago um when I would see a lot of patients that had either external trains your point or had uh recent abdominal surgery whatever it may be um and uh once you kind of get used to how you have to rotate your body and that's where they becomes much more natural now fellows that come in for training from other places that have done a few disconnected guys prone uh initially are reluctant but after uh you know literally a couple months there it becomes a normal for them yeah I mean I think we've had to adapt kind of our positioning with new devices and single use scopes there's a little bit of positioning differences as well so clinical adaptability is something we're used to and so I feel like we're going to see more and more yeah I'm just supine positioning kind of come its way to the west coast eventually yeah and I think in Europe they've been they've been doing it longer than we have um also with hyler tumors you get you usually get a better look at the bifurcation when they're supine as opposed to prone but again without that there's so many people have rotatable c arms it probably doesn't make that aspect quite as important yeah I agree I agree do you guys ever find any benefit in changing the patient position in you know difficult positions so this is a little bit of a challenging position do you think if we were to change the position of the patient from you know either the prone to a kind of a pseudo left lateral or even a supine position you might have better access yeah sometimes it makes a difference for sure um now with them patients being intubated though it's a little harder to get them all rolled and but you're right you can do that I think you're like pd cannulation work in the minor is you know the more experience you have the better you get at it being able to feel the touch and the emulation of it and not falling backwards especially as well so maybe tom maybe while we're here you can talk about kind of your tips and tricks of how to cannulate the minor what you use typically because I absolutely go with a 543 right off the bat I get so small and tight um a 543 is good here so kind of what is your algorithm so my I I'm old school in the sense that I always almost always start with what's called a kramer catheter which is a needle tip catheter that cook makes and you can only get contrast in it you can't get a guide wire but it's so fine that you can almost always cannulate even with the smallest and what I find is is once you're in you can push the catheter and it kind of dilates the opening a little bit and then I go immediately behind it I'm still either an 025 or 035 wire I I never use 018 wires and for years I would do divism cases with 035 wire and um there's somebody in Minnesota that's north of uh Mayo that would say without being named um you can't do you can't do divism with anything but an 018 wire and I'm like I do it all the time with an 035 wire yeah so I've never been a fan of 018 wires they're just too flimsy for me but I'll go behind it and if I'm planning on doing sphincterotomy which most of the time I'll just take a standard sphincterotome cannulate and then do the pull sphincterotomy I used to do wire stint and then needle knife over the stent and people have looked at the two ways of doing minor papilla sphincterotomy there's not a big difference obviously I've gone back to doing more pull sphincterotome than needle knife over with stent um and but that's my approach but it like like you mentioned earlier or somebody mentioned I mean all these things are personal preference right people will tell me well I do this I tell people whatever works for you do it this is the way I do it I'm not saying it's the the best way but that's that's my approach with the cremer catheter first um and then follow with whatever afterwards I did one like that this morning actually because it seems like here what the trouble we're having as well is mostly the position you can't even get the 540 catheter in to anchor in right and the 540 catheter is you know it's it's it's flimsy it's really not meant to push against resistance well at all one of the things that we're seeing here is it's not really kind of being able to pop in like a smaller sphincterotome can right right and the other obviously is just it's such a difficult position the position I think is also really contributing quite a bit to not being able to push that catheter and the the angle actually looks yeah I tried to reduce but as you saw I fell back so yeah I switched cannulas we'll we'll try the larger 025 wire and then we'll have to decide like when is when is it enough versus keep trying for today you know I curious to know if anyone would do a needle knife and get out or just leave it alone and um as you know I have done needle knives I did one of your course last year yeah um on this one I just wouldn't be that comfortable because I'm so far away yeah I think if anything I might do a rendezvous before I would head in that direction and stop for the U.S. but um obviously that's personal preference but if I had a really close position and I felt comfortable with that and I couldn't get in um I have definitely done my share of pre-cuts of the minor and it's not hitters for sure yeah yeah not sure in this particular case Dr. Reyes yeah no I don't plan to I think we've done plenty for one day and if this wire doesn't want to take the turn I think I may stop here but yeah I kind of hope it'll go through but we'll see because we just keep hitting a wall the other thing is I don't know if I'm getting a submural yeah sort of build up there which is not ideal well the good news is you're protected mostly I think from post yes with the second exactly yeah thanks Dr. Reyes so as you're working on it we can go to Dr. Hassan and we can come back to you based on how the case goes sounds good thank you

pancreatoscopy procedure

pancreatic duct stones

endoscopic ultrasound (EUS)

stone removal techniques

cannulation difficulty

018 wire

procedure challenges