So we'll go next to Dr. George Webster from University College Hospital, United Kingdom, and his case is percutaneous cholangioscopy with spyglass. Dr. Webster. Hello. Thanks very much for inviting me to join you from London. In fact, we're going to see a prerecorded percutaneous cholangioscopy case because I'm actually committed to another meeting. But I hope that there's lots to learn and discuss after we've run the case. So this is a chap in his 50s presented to his local hospital with acute severe obstructive jaundice. As a background, he had a previous Roux-en-Y gastric bypass with a partial gastrectomy. And this appeared to be due to severe peptic ulcer disease, certainly benign pathology. On the MRCP, which I hope you can see, there is a large distal bardock stone. At his referring hospital, he had a percutaneous transhepatic external biliary drain inserted and then was referred over to our units at University College London for consideration of a percutaneous transhepatic approach. So we're now going to see the case. Okay, so this is an interesting chap in his 50s with previous gastrectomy and Roux-en-Y bypass who has a large distal bardock stone in whom there is not straightforward endoscopic access stop screening, thanks. And so he has had a percutaneous transhepatic biliary drain inserted. And our task for today is to do a percutaneous transhepatic cholangioscopy and see if we can manage this distal bardock stone. And you can see right from the start that there isn't much runoff through the distal end of the bardock here. And in fact, we are just delineating the stone there. So it's a great big angular stone in the lower duct. Okay, good. Stop screening, thanks. That's fine. Good. The first step is I need to change this 10.2 French biliary drain over the wire. One slight disadvantage here is that this is not an internal external drain. In other words, because of the obstructing stone, it does not go across the papilla. So that means we need to be extra, extra careful with this. Screen, please. Nice. Nice. Nice. In fact, interestingly, it looks to me like the wire has now gone through. That's interesting, isn't it? It's gone through the papilla, I think. And that's fine. That means I can remove this in a slightly more relaxed fashion. Okay, so coming out with this drain. That's beautiful. Can you take that for me? I'm, yeah, okay. So I'm using here an 11 French to rumo sheath, which I insert over the wire. Okay, that's fine. I've got that right to the hilt. So now I take out the trocar. That's fine. So here we are using the relatively new Boston spyglass discover scope, which is a 65 centimetre calangioscope, specifically designed for these sorts of indications for percutaneous trans-hepatic calangioscopy for intra-operative or trans-cystic calangioscopy. And it's ideally suited for this indication. Okay, now I'm inserting this over a wire. A little bit of tension on the wire. I'm inserting this over the wire. I don't actually need to. I could just insert this freehand. Screen, please. There we go. So we're in the right intrapadic ducts here, I think. Screen, please. Screen, please. Beautiful view. And then what I need to do, of course, is turn lovely, turn downwards. Stop screening. So a bit of debris there, but for those who aren't familiar, this is beautifully normal biliary mucosa, pale, pearly coloured mucosa. That looks fine. And then we just up and over here. I sometimes start with the wire because it just can help you orientate a little bit in terms of direction, but it's not strictly essential here. That's good. And then we should see this great big stone in a second, at about now. If we're right about the pathology, that is. There we are. There we go. There we go. Oh, a great big stone sitting there. You certainly can do transipadic calangioscopy with the conventional Spyglass DS-2 calangioscope. It's just a little bit more fiddly because you've got much more of the shaft of the calangioscope to deal with. Also, because it's a shorter scope, the angulation, both left to right and up and down, is even better with the shorter Spyglass Discover. Now, a question that the panel might have a view on is how we get this stone out. It's a big stone. We clearly need to fragment it with electrohydraulic lithotripsy, but this patient has not had any treatment of the sphincter. In other words, they've not had a sphincterotomy, which we can't really do. I know that there are examples of a sphincterotomy with an anti-grade approach. I don't think that's for the faint-hearted. We will want to do probably a primary balloon sphincteroplasty here, but I'm going to do that, I think, after I've fragmented this stone, at least to some extent. Can I have the EHL pedal? Thanks. 15 and high. 15 and high, that's good. Okay, so lovely view on top of this, and let's see what we can do in terms of treating this. Here we go. Hopefully, it'll be one that explodes, but let's see. Oh, maybe it is. So, we've burrowed a little bit of a hole through the middle of that stone. Hopefully, we can keep going and fracture the whole thing up, I hope. One of the interesting things, as we'll probably come to see, is that removing a stone out of the bile duct with an anti-grade approach is much more challenging than it is with a retrograde approach. In other words, pulling a stone out of the bile duct downwards is much easier than pushing stones out, which can be a very frustrating exercise. And again, it'd be interesting to know what people's techniques are for that. Okay, so this is nice. Lots of fragmented bits of stone now. That's always a good sign. And actually, this is a stone that's breaking up quite nicely. And there are, of course, different approaches to with altered foregut anatomy, Roux-en-Y gastric bypass, the options. One is a double balloon enteroscopy or enteroscopy-assisted ERCP, so making your way all the way around the Roux loop. I think there are some shortcomings of that because the technology, even if you get round to the ampulla, particularly for a big stone like this, it's often difficult. The working channel and the length of the enteroscope can often preclude, for example, doing spyglass. This is a lovely view, isn't it, down the bile duct here? It looks amazing. The second option, of course, the trendy new kid on the block of EDGE, EUS approach from the small bowel loop into the remnant stomach and then putting in a luminoposing metal stent and then actually doing a conventional ERCP from that. Data is very encouraging. Crucially, we've had one or two patients referred for that who have had total gastrectomies. It can only be used in patients who, or largely it can only be used in patients who have had a gastric bypass for a bariatric procedure who have a remnant stomach. Third option is a laparoscopic ERCP. The final option is what we're doing here, which is a percutaneous transhepatic approach. One needs to just assess very carefully what will be best for individual patients. Not been much of a head-to-head so far in terms of comparing them all. One wants to be careful to have a view of the bile duct. We've done, I don't know, maybe 600 or so cholangioscopies for stones. We've not to date had any bleed or perforation or anything related to that, but you want to be careful. You don't want to be frying the bile duct wall. Maybe come down a little bit more. I must say this stone, it's a long cylindrical stone. Big stone, actually. Yeah, that's great. Thanks. There's a temptation to put lots of contrast in to see how you're getting on, but if you do that, you can end up with a sort of blurry view. Now, one question for us is what we are looking at there. Is that the papilla? Let's just see. Screen, please. Screen, please. And inject. See if we've got any runoff now. Keep injecting. There we go. Yeah, good. Lovely. So that's nice, isn't it? So that's beautiful. So we can, I think we've got a bit more work to do, but we've delineated that quite nicely. We'll just see if we can break these up a little bit more. Nice. I think we can fancy our chances here. Stop screening. What I'm planning to do is sort of 10, maybe 11 millimetre sphinctroplasty. I have to say, I don't know what others do, but I'm never very happy doing a primary sphinctroplasty much more than 10 millimetres, to be honest. I don't care. One of the things we always have to remember is that just because this is anti-grade rather than retrograde, we have no reason to think that there's no risk of pancreatitis. Why wouldn't there be? So the patient does need rectal diclofenac. Let's have a wire, please. So we're going to come out with the EHL. One of the other things about SPI, of course, is you can cannulate under direct vision. So what we're going to do now is leave the wire in, come out with the SPI. Screen, please. So plan of action is going to be to do a balloon sphinctroplasty. I'm probably going to go 8 to 10 millimetres, to be honest. See how we go with that. There we go. Oh, this is such a control procedure. I've got such great control of the instrumentation with the short calangioscope and a nice wire in place. So now we're going for the 8 to 10 millimetre CRE-RX dilating balloon from Boston. That's it. Okay. Well, I think that's okay. The stone is now above that. Let's put a bit of contrast in there. Let's go to 9 atmospheres, which is 10 millimetres. Nice. 10. So let's hold it on that. So the ESGE European Society advises that primary sphinctroplasty up to 10 millimetres is safe. You know, I only would use it where a sphincterotomy is not feasible, such as a case like this. Okay, let's deflate all the way. So we've kept that balloon up for 30 seconds or so. I'm going to deflate now. Okay, good. So now we're going to go with a balloon, an extraction balloon. We're going to use the Olympus Multi 3 V Plus balloon, and I'll probably demonstrate the frustrations of removing stones with anti-grade, trans-hepatic stone clearance, because with the stone fragmentation that we've achieved, and having done a 10-millimeter sphinctroplasty, if we were doing an ERCP here, it would be utterly straightforward. You know, we'd now have the most straightforward part of the procedure, just pulling out those fragments, but as we may well see, not quite as straightforward doing it from the top. There we go, there's that bit of stone. They're pretty small now, aren't they? We've done pretty well. Okay, so I'll tell you what I want to do. Let's drop the balloon down. Screen. And a bit like we say for any stones, don't try and get too greedy. So I'm going to go near the bottom here to start, I think. Can you blow up there, please? Yeah, yeah, inject. So you can see we've got a nice run-off now. See if we can push this one out, but it can be very annoying. Yeah, there it goes. Jump past me, you see? That's what quite often happens. And I don't want to force it. Inject there. You can see that stone is just sitting there. Good. So we go again. Screen, please. Again, a little bit of tension, a little bit of tension. That's nice. Nice, nice, nice. Back a bit more. That's it. This is this last remaining stone. Sometimes you can actually push it through with the spy scope, but it's not terribly effective doing that, to be honest. So here we are now in the small bowel. Yeah, so we can check whether the patient's got celiac disease now. Oh, there's all the stone debris. And we come back through the sphincter, which is just about here, I think. There we are. That's the sphincter. And we've just got this stone sitting above it. And clearly, percutaneous transhepatic clandestinoscopy, not just for stones, highly restricting who have had either unilateral or bilateral percutaneous drains inserted. And then one can pretty straightforwardly use the track of those drains to do clandestinoscopy. One of our fantastic nurses, Hazel, is saying, we don't seem to be using the mechanical lithotrip too much these days. And I think that's absolutely correct. I think the two major advances in stone management in the last 20 years, I would actually put clandestinoscopy number two. I would put number one, increased use of safe, careful, large endoscopic balloon papillary dilatation, what we call balloon sphincteroplasty in the UK. I think that's numerically had a huge impact on stone management when done carefully and properly. In our practice, if we don't succeed, or for whatever reason, balloon sphincteroplasty is not appropriate or feasible, then we reach for the clandestinoscopy. Screen, please. There we are. So actually, I can start pushing some of that stone through now, which is probably not a bad thing, really. Yeah, good, pushing them. Okay, good. Excellent. So let's come out with the the spy, and then we'll go in with the balloon. I think we're going to be pretty much done now. Let's inject. That's good. No, I don't want. Yeah, stop there. There we are. That's through. Nicely through. Yeah, take that for me. I must say, our usual practice, you know, when we've done such a long procedure and put so much fluid in, potential of cholangitis, is, you know, we usually just put in a 10-French biliary drain for, you know, a few days, and then it falls well, we take that out. A bit of tension on the wire, just to lock that pigtail. Just to lock that pigtail. There we go. Beautiful. Really nice runoff. Stones cleared. So I think that's a great result. So we're going to leave that drain in, really, just for a few days, to be honest, for him to recover, and then just to see there's no cholangitis or any other problem, and then good result, and I hope an interesting demonstration of percutaneous trans-paddock chlangoscopy. Thanks very much, and thank you, team. Great work. Great case, George. I think it's the first time I've ever seen a twin observe their brother's procedures. No. Modern technology. There you go. The comment you made about balloon sphincteroplasty, and it's a subject that's sort of near and dear to my heart, because the one study that ruined balloon sphincteroplasty for us, I think, was flawed, and I won't go into why, but when you look at it, the problem with that study that was in gastro many years ago, which was a randomized trial in young patients, was that the, we don't know the background incidence of pancreatitis for the respective endoscopist, and when you look at all the percutaneous literature, if there was a real problem with balloon sphincteroplasty, we would have known it many, many, many years ago of people getting severe pancreatitis, so what they couldn't do is dice out what was the sphincteroplasty, what was the cannulation, and all the other factors that go into it, and the reason I bring it up that I feel strongly about it is I've done a lot of, now, hepaticogastrostomies in room Y for stones and done very large primary balloon sphincteroplasty, and I've never had a severe pancreatitis. Now, the other problem with that study, of course, is it was before we were putting in prophylactic pancreatic stents and before we were giving rectal NSAIDs, so unfortunately, for the West, it kind of ruined people's, you know, enthusiasm for it, but I think there's a place for it in routine ERCP in people that need anticoagulation or are on fully anticoagulation or need to go back on it immediately, and so I personally don't think that it's as dangerous as we thought, and I think 10, what you did with 10 was fine, but honestly, if you look at some of the Asian groups, they've been doing large diameter without sphincterotomy for several years now, so I'd like to hear everybody else's thoughts about that. It almost seems like we need somebody to say, really, it's not as bad as we thought it is, but people are really scared to do it, at least in the Western world. Would you agree with that? From my perspective, I think that, so the two questions being primary sphincteroplasty or sphincteroplasty, large balloon sphincteroplasty in general, and, you know, we continue to get referred patients who have, you know, referred over for cholangioscopy for stones in whom no real attempt has been made to perform a post-sphincterotomy balloon sphincteroplasty of any degree at all, and I think that's really something that people need to get comfortable with. They need to follow the rules of not dilating to wider than the duct above the sphincter, being sure that there isn't a stone impacted against the balloon, and in most cases, obviously, to have performed a sphincterotomy, but so from my perspective, I think that I absolutely agree that I'm surprised that the number of endoscopists who remain nervous about having balloon sphincteroplasty as part of their standard management. If we can just maybe shift to the percutaneous cholangioscopy and stone. So we've talked about this before, but, you know, here typically in the U.S., it's not integrated so much for the endoscopists to be performing percutaneous procedures. Talk a little bit about how it is to integrate that in and, you know, should the radiologists be doing this or, you know, can we be doing this? I mean, clearly we can. You just did a beautiful job and it's what we do in retrograde anyways, but just talk a little about that. Yeah, so in our unit, the radiologists do the percutaneous puncture. They get the drain in. We let that track mature, usually for 10 days or so. And then, you know, in my practice, you know, I'm now experienced and comfortable at taking everything on from there. So others do it differently. Others have the radiologists with them for the cholangioscopy phase. You know, there's certainly a complete disaster if you lose biliary access in doing the exchange. So I think if one's starting off, then definitely one wishes to have the radiologist definitely by your side. In other parts of the world, in Germany, they do the puncture, they do the PTBD, they do the whole shooting match. That isn't our practice. Radiologists, I know that there are some, you know, excellent radiologists in the US doing the percutaneous cholangioscopy. I don't think there is anything inherently wrong about that. You know, we're the endoscopists. Clearly, we have a lot of experience of knowing what we're looking at, but also working with wires and catheters. But, you know, many radiologists are similar to us in that regard. Yeah, I think that's key. I mean, in this case, it's just stone management. But, you know, if you're doing anything in terms of analyzing the ductal epithelium, certainly we've done a lot of work with that. And I think it's important that we, you know, be comfortable doing it from both ends. If I have time, since we have George and Todd, you mentioned, Todd, US-guided pedicogastrostomy, and you can do the same thing, right? Put spy through those ducts. So, what would you work at? When would you do percutaneous versus EUS-guided with the same thought, like altered anatomy, large stone, for example, in this case? What are some things that you think about and which way you would go? Todd, you're muted, I think. Because I've done so much EUS, I pretty much do that for pretty much all my altered anatomies. And I've even done them abatico-duodenostomies with plangioscopy going through that way as well. So, I haven't referred them anymore to percutaneous. Yeah. And I think, you know, it's an interesting debate. There's not a lot of head-to-head. But of course, we now have, for the patient, for example, who's got the Roux-en-Y gastric bypass, we have four approaches, you know, laparoscopic ELCP with all the pros and cons of that, EDGE, DBE-assisted approaches, and percutaneous. And, you know, I think we individualize that choice. I think our success of DBE approaches isn't great. I think EDGE is increasingly finding a role. This is the case I showed here. That patient had already had a sort of salvage percutaneous drain put in, having presented with obstructive jaundice acutely at another hospital, and it seemed reasonable to use that track for this procedure. Yeah. I forgot. I'm sorry. Did you use the newer short scope? I missed the very opening part. Yeah, the Spyglass Discover 65 centimeters. It's really nice to, really nice control, rather than having the, you know, the whole length of the Spyglass scope looped over the patient. I think the key is knowing you saw that large stone altered anatomy, you know, EHL is probably what you're going to need to do. And so it eliminates your enteroscopy approach, but you still have now with both spy catheters, you have an ability to go either percutaneous or endoscopic. And, you know, of course, expertise, what you have available makes a big difference, but it's nice to have that ability now where before we didn't really have that with altered anatomy. And I think that knowing that seeing this patient's MRCP beforehand, if a laparoscopic ERCP had been an option, it wasn't because he's got a partial gastrectomy, but if it had been an option, I still wouldn't have pursued that because the trouble with a laparoscopic ERCP is you have to get the job done in one go, largely. And we couldn't guarantee beforehand that we'd clear it. Thank you, Dr. Webster, for the case and discussion. Thank you.

percutaneous cholangioscopy

obstructive jaundice

biliary drain

electrohydraulic lithotripsy

balloon sphincteroplasty

altered anatomy