Dr. Siddiqui, you're live, please go ahead. All right. Hi, everyone. Welcome from the University of Chicago, our CERT Interventional Center. Real quick, our team, stellar staff, Kelly, Yvette, Steve, Kayla's our CRNA, and I'm going to have my advanced fellow Divya Chalakonda present our case. So this patient was referred to Dr. Siddiqui for evaluation of a duodenal polyp, which is ultimately found to be an ampullary adenoma. She's a 79-year-old woman who underwent an EGD at an outside facility for evaluation of iron deficiency anemia, which identified a polyp in the duodenum, and biopsies revealed it was a villous adenoma. The referring physician specifically said it was distal to the ampullae. You can go ahead to the next slide. So we initially did an EGD approximately two weeks ago and started with a forward-viewing scope, which didn't clearly identify the polyp's involvement of the ampulla, so we passed a duodenoscope, which you can see clearly shows involvement of the polyp into the ampulla. Because Dr. Siddiqui's practice is always to do an EUS for staging for any ampullary lesion greater than a centimeter, we evaluated the EUS to look for biliary or pancreatic duct involvement, and there was no involvement of either duct, so the decision was made to proceed with an ERCP with papillectomy. All right, if we can switch to the endoscopic view. You know, for the panel, I think it's important to discuss when you're looking at polyps in the second duodenum, and as I always tell my trainees, do not just randomly biopsy or snare off polyps until you clearly identify the ampulla, because we have had cases referred to us where patients inadvertently had a polypectomy done, and it was the ampulla, and they came with severe necrotizing pancreatitis. So we typically pass a standard forward-viewing scope with a distal attachment cap first, and in 80% of the cases, you'll be able to identify the ampulla with that. But in this case, there was a lot of polyp in the area, so then we passed a side-viewing scope and identified. In that picture, I circled what I thought was the papillary orifice, but it actually was a little to the right. So I think you guys can see my endoscopic view now, and you see the polyp here. I did cheat a little bit before we came live, and I was probing the lesion, because sometimes that's the hardest part when you have a bulky lesion. Everything looks like a potential orifice, so I probed initially a little to the left, but then I was able to actually get into the bile duct to the right, and I was going to come out, but my nurse Kelly said, do not, in case we can't get access again. So I'm in the bile duct right now, and with the panel, we'll talk about different techniques. When you're talking about ampulectomies, duodenal EMRs, everybody has a different way of doing it. There's not a lot of data that will say one way is better than the other. So I will tell you how I'm planning to do it, and then we can hear comments. I usually like to inject both ducts. I do a biliary sphincterotomy just to prevent papillary stenosis, and then I like to get into the PD, inject, so I identify the duct anatomy every now and then. You'll get a divism case, and then I'll leave the wire in the PD, railroad a snare over it, do the ampulectomy, cut the polyp, put my PD stent in right away, use a net, and get the polyp. So that's my plan, and I'll open it up to the panel now. Hey, Yzma, this looks like a really great case. When you're doing the eclangiogram, are you also looking for any evidence of ductal involvement, or do you feel pretty confident from your EUS? I feel pretty good with the EUS, especially if it's more subtle involvement. I think the EUS is a little more accurate. Go ahead and inject. But I always, I still inject the BIODEV just to, again, confirm location, and there's nothing else obvious, and especially if there's been a significant amount of time difference since I did the EUS for staging. Do you like to do EUS for staging? You could argue it's validity. Yeah, I think that's a good idea. I think it's not incredibly helpful if it's a very, very bulky lesion. Oftentimes, we don't have good enough contact, but I think guidelines now do suggest that either MRI or EUS is suggested for proper staging. So I like to do that. I also like to just get a look at the ductal anatomy. I actually don't always cannulate beforehand, particularly the PD, so it helps me have a little bit of confidence in whether or not I'm going to run into a situation of a debisum and difficult cannulation. So do you do a biliary sphincterotomy, and again, for the whole panel? I do not. I don't cannulate prior to the polyp removal, because I feel that once it gets exposed or once it's resected, you actually get excellent exposure of the pancreatic orifice. Yeah, I actually do exactly the same. I don't routinely try to get in, because I actually find it's often easier after you've resected it. You may often actually even see the orifice directly. But I do agree with the EUS. Sometimes I think if you have a bulky lesion, sometimes you might actually be dealing with a cancer, and I generally don't think this is very effective for malignancies. There's amazing amounts of metastases that seem to occur on ampullary adenocarcinoma. So I think it's important to check for that. Sometimes you end up doing an FNA to show deep pancreatic involvement, and as you pointed out, sometimes you will find debisum, which actually will be important, because it may not be as important to place a pancreatic duct stent in that setting. Like you, I do try to protect the bile duct. I often stent it, but I do agree that a sphincterotomy perhaps will let you look up the duct a little bit better too. So if you are worried a little bit about intraductal extension, that's a nice technique. And then if I get a bulky lesion, and I guess we'll see the inferior part of this, I generally don't lift the ampullary portion, but I will lift the duodenal portion if there's something inferior or lateral. So that's my practice. Same. I don't inject the ampullary portion because you get that sunken papilla effect where the actual sphincter is kind of keeping the tissue tacked down at the papillary orifice, and then everything else lifts around it. So what I was trying to do actually is just, I do inject, you're right, if it's on the duodenal wall, but I think this one looks like it's pretty, it's not as attached as I thought to the duodenal wall. So I was debating whether to inject a little bit here before I cut. Should we take a vote on the panel? I probably would not. It almost looks like it has a very, very broad base pedunculated. So I think- Yeah, I'm thinking actually realistically, if we take off this big bulky part, there may be a little bit left on the side. And at that point, I could easily lift and just snare that off separate once I get the main portion of the lesion off and get my PD stented, because that's always the biggest thing. You know, I mentioned papillary stenosis, but it's probably less than 10%. Other risks include bleeding and pancreatitis. Obviously, that's the one we worry about the most. And those can occur in up to 30% of cases. In addition to stenting this patient, they're getting copious amounts of LR, they're getting rectal endomethysin. And we also admit all these patients overnight for observation. So we'll try to get into the PD. Let's see. And then when you guys go inject into the PD, do you like to use any methylene blue? Oh, we're a little bit loose. Again, I don't usually do that as a first step, but I think that's reasonable to do. Sometimes it can be when it gets bloody and whatnot afterwards, it can be difficult to find. Although you're going to leave a wire in, you said, right? I'm going to try. Yeah. Unless it gets really in my way, but yeah, I don't usually, like I said, I don't usually inject beforehand or cannulate beforehand. But the other thing also is I think that methylene blue comes out pretty quickly. And if you've got any kind of a sort of lateral component where you're spending extra time resecting that, I'm not even sure you'll see much of it. So I generally haven't utilized it. Now we'll just try to, now if I can't get into the PD easily, then I will just go ahead and cut. The only thing, you know, you always have that fear. What if you don't get back into the PD? It's rare if you get a good cut and you expose the pancreatic orifice, but it's not 0%. So it's nice to maintain access if you can. Try that. And then what's your experience with sort of the snare over the wire? Have you ever run into issues of being able to completely resect all of the tissue with that and ever any damage to the wire when you're doing that? I mean, again, if I feel like it's getting in the way and I won't get, you know, a mainly on block resection, then I'll just do the ampulectomy without the PD wire and stent after. But if it lines up well, I haven't had really a lot of trouble with resecting the piece and the biliary sphincterotomy helps because it kind of creates a little slit. So it allows your piece, your tissue piece to fall off the wire. I know. Uzma, is there a threshold or cutoff for intraductal extension that you won't do this on? I mean, unless it's really distal, just a few millimeters, maybe where you can do a big sphincterotomy and do biliary RFA. If there's extension into the bile duct or PD and the ducts are dilated, they're going to always talk to our surgeons. And so right here, are you using fluoro to help you with that orientation to figure out? Yes, I am a little bit, but it does not seem to be helping as much. And so this is a dash sphincterotomy, an O2-5 angled visiglide. But all right, if it's not, go ahead. Oh no, we're back in the bile duct. Sometimes it's hard to orient because you can't, I can't see the orifice that well. We'll give it one more try. And then I think we'll just go with our snare. And then in terms of the actual ampulectomy, you know, how big is your, do you try to get sort of it all off in one block and one piece? Like in this one, you mentioned maybe trying to get the larger nodule and then the lateral extension, but in general, how, how big do you, how big a snare is your max that you would use? Usually? Yeah. The snare that I usually like is a two centimeter snare. Okay. I think we'll go with the snare. The snare I like to use is a rotatable snare actually by Boston Psy. Usually when I do EMRs, I use a really stiff monofilament snare, but that snare sometimes gets deformed on the elevator of the duodenoscope. So for this, this is kind of a medium stiffness snare and it's a little bit more flexible. I don't know if you can show my hands, but before you pass any snares down the duodenoscope, if you can put it out, I like to, can you show the room view? I just like to make sure you just kind of shape your snare a little bit just to help it kind of hopefully maintain its oval shape when I put it out. Go ahead, close. Yeah. And then just put the tip to the end. What about you guys? Okay. Yeah. I like to use a 20 as well and you know, usually you can just kind of put the apex of the snare at the superior portion and if you just kind of, as you're doing right now, just kind of extend inferiorly and suction a little bit, you can usually grab a good chunk of the lesion if there's not lateral extension and often get an en bloc or section. Obviously, it depends on the size. So yeah, just like you're doing at the top here, but I tend to use, you know, the duodenum wall is pretty thin. If you start getting lateral, you know, you can start getting deep injury. So I tend to not go larger than 20 for this. I mean, obviously en bloc is the best because that's going to get you a nice clean path specimen and easier, you know, it's harder to kind of deal with tiny remnants, but in this particular case, I think we'll get this big chunk and there's probably going to be a little bit on the left side, which is fine. We'll get it out. You can go bottom up, but I do prefer top, top down if I can. Yeah, and if you can describe a little kind of that, the motion, once you anchor that snare, what you're doing with the scope. I'm just trying to kind of push it in a little bit to try to stabilize. And then I'm, I'm putting, relaxing my elevator slowly. So the question is, can I get this little piece on the left or not? Or is it okay just to leave it for this time? And I don't want to push the whole snare out at once because I want to get up underneath it. So now I'm pulling back a little bit. Yeah. And sometimes if this snare is too floppy, then I'll have you start closing just a little bit. Hold on. Okay. Then I might switch snares too. Also the 20 millimeter captivator's nice and I use the ConMed Beamer snare, but that's the one that's a little bit more stiff. And then sometimes I think getting the catheter actually out to act as your kind of a stiffening anchor. Yeah, just like that you're doing now. That's really beautiful. That allows you to even manipulate the other side if you need to. Open, open for one second. I think I slipped off a little bit off the top, but I want, I may just take this and deal with the, cause that left side is going to have to come off separate anyway. So I don't know if it's worth it to go, to try to be perfect on it. Open just a little bit more. Yeah. But yeah, just kind of taking your time and getting as much as you possibly can on that first piece is always the goal. Okay. Close. Okay. So just be prepared. There's going to be a little left on the side and at the top a little bit. Let me think about this. I think I'm just going to go for it. There is a little bit at the top, but my snare kept slipping off that. So I'll probably go for this. And then I'm going to lift on the left side and then I might switch to a different snare, but. And what settings are you using? This is EndoCut and EndoCut Q effect two. So we'll get this off. Actually, what I'll probably do is try to get into the PD right away. And then deal with the remnants. What about grabbing that specimen? Are you worried about that? We could actually, I'm so used to the, to doing my PD stent with the wire. We also have a PCF on standby too, in case it slips down. And the patient hopefully got some glucagon, even though I don't know if I said it earlier. Dr. Siddiqui, this is a nice demonstration. As you're working on it, we'll switch to another room and come back to you in a few minutes. Dr. Siddiqui, we are back with you. Can you unmute yourself? All right, perfect. It's done. It wasn't in one piece. There was some on that left side that I took off, but now I think we got pretty much everything. This is a tiny separate polyp that we can take off at any point, but now we're gonna put in the PD stent. Now, this lady has to go back on Eliquis. So the question is, she's held it already for like four days. Usually for all my resections, I try to see if they can hold their anticoagulants for at least 48 hours. For ampulectomies, I mean, I'll see, as long as their cardiologists or neurologists will allow, but if I can go longer, that would be great. And do you keep her, are you gonna admit her? Yeah, we admit all our ampulectomies afterwards for overnight observation. And then, but I was gonna bring up the blood thinner because would you guys prophylactically clip, especially the base of the resection, or would you just use one of our new, hemostatic gels or powders? I have clipped on occasion, I mean, the duodenal portion, I tend not to do the peri-ampullary area, but I do tend to, I'm always a little nervous about using some of the powders in terms of, you know, obstructing the stent or the orifice or whatever, but I haven't used that as much, but I do tend to clip if there's a lateral duodenal component. Yeah, I would do that as well. And I've been using the gel, the Puristat, because I feel like that's a very controlled application and, you know, you can even see the bowel coming out. So, although whether or not it's effective is really, I don't think that data has necessarily been established. I know they're studying it in Europe specifically for ampulectomies. It definitely makes us feel better. I know, I'm about to put Puristat on it, so. There we go. Now- A couple of questions from the audience. Uzma, just, I think you covered this, but can you just refresh us on your cautery settings? I think Endocut Q. So, I use Endocut Q and I think it's, and it's usually on Effect 2. Some people like Effect 3, but we have the newest Irby Vio 3. Now, and then, I don't know if the audience asked, but the PD stent, so normally when I'm just doing, you know, a routine ERCP and a PD stent for post ERCP pancreatitis, I'm just gonna put in a short five French three centimeter. I always do single pigtail and I probably will cut the internal flange off. These are cook stents. But for this one, I definitely do not want this stent moving anytime soon. So, I do go with a longer stent. This is a five French seven centimeter single pigtail. Okay, but sorry. Go ahead with the audience questions. Yeah, I saw you left the flange, yeah. It was Todd Barron. Sorry to interrupt. Can you hear me? Yes. How about, and maybe Raman mentioned this, what the tip of the snare and do soft COAG to kind of cauterize that edge might be something you could do that the one that's oozing a little bit on the left. Well, that's true. That might be a good thing to do. Not a bad thought. I mean, I usually do that for my regular EMRs, which you could argue the lateral side was more of an EMR. We could do that with a snare tip. Yeah, but I would definitely, I agree after that, I would definitely do the Puristat and I agree with everybody saying that it probably makes us feel better than it does the patient, but I would do that as well. It depends who's on call. Yeah. I know, I won't be. My partner will be, so. Yeah, it's low risk and I don't think it would include your stent. Now, even so, you would be able to drain around because it's not like you have a stricture there, so you'll have a wick effect, but I don't think it would include anything. Todd, do you prophylactically do a synchrotomy for the bile duct or place a stent? I do not. I heard your conversation up front. I generally will just, and I haven't, I mean, every one of us has probably seen some cholangitis transiently if they don't put a biliary stent in. I guess if you were gonna put a stent in that you knew wasn't gonna migrate from the pancreas that you might have to go back anyway, you could put a small bile duct stent in, but I've not really seen cholangitis. I mean, I maybe have seen one case of cholangitis after not putting a stent in the bile duct or a synchrotomy. Yeah, I agree. We haven't seen that much. Now for surveillance, you guys follow ASG guidelines. Like I'll bring this. This patient does not have FAP, but one important point for the audience, if you're finding duodenal and ampullary adenomas, these patients are at higher risk for having colon adenomas. So she had an unremarkable colonoscopy without obvious polyps and she doesn't have FAP, but I'll bring her back in six months and survey. If there's any residual, take care of that. And then once a year, maybe up to five years. And then, I don't know, after five years, do you guys stop surveying? Yeah, so I do the first index look depending on how much dysplasia, if it's high grade, I often bring them back, especially if I didn't think it was a complete resection at three months. And then if it's low grade, six months to a year. And then to your point, if I go back at a year and there's absolutely nothing, I might go two years for the next one. If there's any residual at all, I go back every year. But your point about after five years, I don't know that any of us know, but I would say if you have no residual at five years, you're probably okay. Yeah, I agree. I think sometimes the patients are more nervous. FAP is a different story, because the surveillance there depends on their Spiegelman score and what their surveillance intervals in general. So that's a little bit different, but yeah. It's also important, I think, too. The other thing about the FAP I was gonna add was I think a lot of us are getting less aggressive with the FAP follow-ups, especially if they're relatively small. I remember in the old days, we would say, oh, they have a small polyp at the ampulla, we gotta take it off. I think most of us, and the literature would suggest that we can just survey those like the other small polyps and not emphasize those. Yeah, if it's under 10 millimeters, there's no villus histology, no dysplasia, then I think you're okay surveying it. Yeah. Uzma, there's another question from the audience about should you encounter a deep muscle injury here or do you see some signs of that? How would you manage that in terms of closure? So it depends, right? If I see a perforation or deep muscle injury near the biliary orifice, if you stent, that should be enough for that area. But along the lateral wall or other areas, I would first make sure that I had access to both ducts, whether it's a biliary, I'd probably put a biliary stent, put a PD stent, make sure those are secure, and then try to clip. And what are your cautery settings on the snare tip? It's a soft coag setting effect five. Yeah, I've had one that was around the area of the resection that was deep, and I went back with a full reviewing scope and actually did an Ovesco. So despite it being on the media wall, of course, with the cap that's on the Ovesco, a lot of times you can lean right into that area and still get it, because obviously you can't do it with a side-viewing scope, but I've had that work. Well, that sounds sizable. Yeah. I've also had experience with the X-TAC. It's not intuitive that you can do it through a side viewer, but if you manipulate it a little bit, some of the peri-ampullary area, you can do with that as well. But again, you're doing all this after you've secured your access to your gut. Yeah, absolutely, absolutely. And be very careful with an Ovesco around here, but. Yes. Todd? Yeah, 100%. Yeah, yeah, you want to make sure you're, yeah. So you're applying the Puristat now? I sure am. Yeah, yeah, yeah, nice, controlled. Okay, stop. Very nice, yeah. And on the back end of that, you're just, it's just three, it's a very small amount that actually is in the syringe. It ends up taking a long time. Oh, yeah. I think, there's only, I think like four cc's, but you cover a big area. Yeah. Thank you, Dr. Siddiqui, great case and nice. Thank you guys. Yeah, great job. Great job.

ampullary adenoma

duodenal polyp

EGD

iron deficiency anemia

ampulla involvement

ERCP