So, we will next go to Dr. Raj Shah from University of Colorado, who will demonstrate another pancreatoscopy in a patient with pancreatic duct dilation. Hello, can you hear me? Hi, Raj Shah, we can hear you. Hi. Great cases. We have Kusuma here presenting. So, the case that we have today is a 68-year-old female with a history of cholecystectomy with a history of pancreatic cysts, now with progressive PD dilation from 5 to 12 and CDD dilation from 8 to 21 over the past couple of years. Her LFTs are notable for an L cross of 1454 and a normal T billy. She came for an EOS and ERCP last month, which revealed a prominent major papilla without a mass, a dilated CBD and PD, and three cystic lesions in the pancreas body. The largest was 5.3 millimeters and contained what looked like debris versus nascent. ERCP the same day also revealed marked dilation of the left main hepatic duct, the common hepatic duct, and the CBD. A synchrotomy was performed, and the synchrotomy site was ultimately clipped twice due to a deep mucosal defect. A 10 French by 3 centimeter plastic stent was placed into the common bile duct. The pancreas duct was not evaluated at that time, and the patient returned today for pancreatoscopy and phalangeoscopy. This slide shows her images from her last ERCP and that dilated common hepatic duct, dilated left main duct, as well as the dilated common bile duct. All right. So thank you, Kusuma. That was an excellent presentation there. And I just want to show you, if we have the fluoro image, we get the endoscopic view and the camera. We're just going to get the fluoro image for you to see. I'm actually in the pancreatic duct now. There's a prior biliary synchrotomy ulceration, some clips from a generous synchrotomy that happened the last time. But the biliary stent that I put in had migrated spontaneously, and so I'm in the PD now. And we're still waiting for pancreatic or fluoroscopy feed here. We'll get it in just a moment. There we go. So you can see that the pancreatic duct is dilated. Can you see the fluoro image there? No, we can't. You can't? Yes. Now we can. Yes. OK. So there we go. That's the larger one. And then I'm going to scroll. And I did a little measurement, about 11 millimeters. And you can see the duct is that dilated. I didn't overly fill this duct. But my plan is for the markedly dilated duct and to evaluate for main duct IPMN. I'm going to do... It's a somewhat patchy-less open, but not enough, I think. I'm going to go ahead and do a sphincterotomy. Go ahead and bow up here a little bit. In the vial, I'm using the 1, 2, 3 Irby setting. And usually with pancreatic sphincterotomy, you're going to try to go parallel to the biliary sphincterotomy. We have a little bit of room. A lot of room to cut. Yeah. We're only seeing the fluoro images. Is it possible to see both endoscopic and fluoro? Yeah. So you don't see the endoscopic view? We can see a small version of it. It looks like there's a pretty generous pancreatic sphincterotomy that you can do. Yeah, yeah, exactly. We could go side-by-side endo and fluoro. Is that an option? Oh, this is better. Is it a little better for you to see it? Okay. Especially if you're watching on your phones. But yeah, I think there is enough room. But I think we have enough for getting the pancreatoscope through. Do a little bit more here. Yeah, that should be good. Okay, relax all the way. So we have the clangioscope opened. It's the spy scope. And I'm hoping that what we'll do is if we can go to the screens that show, you can put fluoro as the smaller image. And then let's have the clangioscope view as the larger image. Or we could do all four quad. Do you want to try that, Kirk? That'll allow us to ‑‑ because I like to show the hand movement of the spy scope as being advanced. And I'm using a short wire. I tend to use a short wire for most of our clangioscopy and pancreatoscopy. And you can float it. Occasionally you can't float it. It makes it a little more difficult. But in general, you can. You just flush the scope with water, saline, prior to advancing over the wire. And I think that does help with advancement over the wire, floating it. So we'll see if our ‑‑ can you see our hand? Yeah. You can see Christy Tronick here is helping me. Our excellent nursing staff is supporting me. Lindsey is in the back as well. Without them, we wouldn't be able to do any of this stuff here at the University of Colorado. We have our anesthesia providers, as well as Proximy, who's helping with our video feed. Raj? Yeah. Sorry, it's Todd. I'm trying to ‑‑ I'm not putting together the biliary part of this and the pancreatic together. Are they separate or do you think they're connected somehow, as far as the two problems? Why, they're both dilated. I know. Well, it sounded like there might have been something in the left hepatic duct, or was it just diffuse ductal dilation? Yeah. It seemed like it was diffuse extra hepatic dilation. Okay. Right. So you're thinking if it was a mucin problem that it was obstructing the bile ductus from the common channel? I almost am wondering about two potentially ‑‑ I don't see a communication between the pancreatic duct and the bile duct. Right. So I wonder if we could ‑‑ do we have a camera view of ‑‑ can you show the room camera, too? Would you think of putting ‑‑ In your initial ERCP, did you do clean geoscopy to take a look at that bile duct and see what was going on? No, we were going to plan to do that today. Not necessarily on camera, but ‑‑ I guess what I meant is in the absence of a sphincterotomy, there is always a small kind of channel. Let's put spy view on the big one there. So you can get ‑‑ You can eliminate one of the ‑‑ By a lot of mucin. My scope is the big one. We didn't do clean geoscopy the first time, but I'm sorry, I missed some of your ‑‑ I was saying that in the absence of a sphincterotomy, you still have a common channel. So if you're filled potentially with mucin, you can also cause biliary obstruction. That's what my point was. I see. With the sphincterotomy, then that takes that off the table. I need to end it. I need a spy view here. Okay. But I need it on this monitor, too. Can you guys switch that? Yeah, I've seen pancreatic biliary fistula with IPMN. Right, right. And I'm not seeing that currently with the clandestine or the pancreatogram. And that's one possibility to explain both. Right. Colodopal cyst and IPMN, I don't think ‑‑ I mean, colodopal cyst and chlandrocarcinoma, yeah, a little more back tension. But I don't see it necessarily with ‑‑ oh, I'm going to patch it. In this case, like, are there really two different processes going on? The only thing we have going for IPMN is some small side branch cystic lesion, subcentimeter, and then the duct is markedly dilated, like 12 millimeters, which can't really be explained by ‑‑ Now, can you ‑‑ you can see the spy image? Yes. Yeah. Almost. Can we make the top camera part, can we make that plural? Actually, no, the endoscopic view. We don't need the endoscopic view now. Let's make that plural so they can see what the plural view is like, if we're able to do that here. I see the duct going in over the wire, and then Christy's got the wire. She's giving me a little back tension. Okay, I need an endoscopic view. Okay, let me see. Okay. There we go. So I have an endoscopic view, and then they have ‑‑ they need fluoro maybe in that top. As you suggested, that kind of back tension to, you know, sling your way up, especially kind of around the genu or in like stricture. Yeah, back tension exactly on the wire. Sometimes a stiffer wire can be more helpful. All right, so now you have fluoro, and I'm just ‑‑ there was a little bit of difficulty getting around this genu part. You can see the duct. Let me mag up one. I can see your flora image at the bottom there. Yeah, okay, you can see it a little better now. I just zoomed it up one. It's a highly collimated image, by the way. I'm only magnifying 32 centimeters, but the highly collimated image does help reduce radiation exposure for the patient and staff, which is an important point for our fellows and people newer to ERCP. Okay, so I'm going to ‑‑ I'm using fluoroscopy guidance mostly because of the back tension on the wire, and I'm going to see if I can actually use the spy scope to ‑‑ yeah, you see that on flora, I'm going to give me a little back tension. It's a little tortuous. What we may have to do is advance the wire. Okay, stop here. It's a tough angle, so what I'm going to try, let's advance that wire out more. This is a Jag revolution wire. I think a Jag wire or a Metro wire could be a little stiffer for this, but when I'm working with a PD, there you go. Good. Thank you. Now, you want to have the hydrophilic. You know what, let's come off of the magnet there. Okay, so we're going to get a view here for the pink radoduct in a second, but we're just giving a little back tension on the wire. There we go. Okay, I'm up there. I'm going to try, I'm going to mag out one. You straightened out that duct quite nicely there. Just going to try to move that up. There we go. Okay, so now we have a full view. I'm going to try to get out to the tail more, and we'll get you some pink radoduct views. Okay, so let's go ahead and pull, let's pull out the wire, and we'll see what we can visualize. The most dilated portion of the duct was in the body. Can we get your pink retoscopy view as the main view? Yeah. Can we switch to spy scope and the main view then, Kirk? Perfect. Thank you. And I do reduce the amount of irrigation. So go ahead and irrigate a little bit. It's at, should be at 70, excuse me, 70%. Okay, go ahead and irrigate there. There we go. And so this is one of the things, when it's a tortuous duct, this mucosa looks normal. Oh, but there's a little bit of, okay. When it's a tortuous pink radoduct, it does make it a little more difficult to center. So sometimes you have to change your view or change your scope position to do a unit scope position. And go ahead and put the suction on. That's good, too. Okay, let's go ahead and section there. I'm going to pull back here. I'm in the mid-body right now. There we go. So I didn't stop suctioning. And then, there we go. That's a little better view. Okay, irrigate now. And then the suction while we're irrigating. Mm-hmm. Okay, stop irrigating. Yeah, nice. We're suctioning. We're using the Y adapter. There we go. That's a little better. Okay, go ahead and irrigate now. Go ahead and stop suctioning. Okay, so now, we're getting out even further than what the pink radiogram suggested. By a little bit more. It gets a little more torque to us, but we're going to try. And that's just trauma, right, from the scope trauma? And we will stent the patient post-procedure irrigator. Mm-hmm. And do you typically choose a long stent to kind of go all the way to the tail if you can? Or at least to the body? Not necessarily. Just transpopular, really. Unless I'm worried about some, if there's a stricture or something, I'll try to bridge that. Yeah. So that's a normal, we're seeing normal pancreatic duct, right, so far? Yeah, I think that's correct. I'm going to try to go up. The mucosa looks normal to me so far. Yeah, that's right. But I'm going to try to go. What I might try to do, you know, I'm going to come back, irrigate here. There's a little bit of debris in the duct there. Yeah, that's good right there. We can put it in the image. Let me get that picture. So I'm going to start coming back a little bit. Oh, see that? Yeah. Yep. Irrigate here. Yeah, there we go. Can we turn the spotlight down? Yeah. It doesn't look like a typical IV amnesia, but actually irrigate here a little bit. There could be. It's not. It's a little bit of a form. Unfortunately, a little bit digitized the image. I'm not sure why. Irrigate here a little bit. Okay. I mean, that's not from scope. I don't know if you can appreciate that like between three and seven. Three and six o'clock. Yeah. Now I have seen these changes. We described this 15 years ago. As being spent. Yeah. She's in the house. And sometimes you can get these. Not quite. Maybe. But you can see. Maybe reactive. Because she's. Todd or others. Okay. It's probably not going to turn out to be. But I do believe, like you said, it's. Normal enough to, to warrant biopsy. Can you describe for us? What you would typically see with IPM. Typically what we'll see is. There are five different hair classification. It's probably the best. I don't know. I don't know about. Fish egg lesions, which literally look like fish eggs. Tend to be more benign. The vegetative class five is where you see a mass. Form. Projections. Finger like projections and a vegetative. And that. Yeah, I mean, somewhere between. Yeah. Qualifies as any of that. Right. Like a carpet. Yeah. And there is. I would call it. Uniform. But. Coastal production. Uniform. Or that. Okay. But the vasculature around the area. Appears normal. I don't see any abnormal vessels there. Yeah. It's distinctly different from the. And, you know, we see a lot of chronic. Changes. In, you know, doing painkillers. But seeing this in the absence of a stent. It makes me wonder. If it could be a. A low grade IPM and lesion. Yeah. My image is just. I don't know. I forgot that this. You've done in the U S that they have chronic pancreatitis on a U.S. Right. Yeah. It was done. And. Other than a dilated PD. That's right. Yeah. She's over. So I wonder what the proximal duct looks like, because I'm not sure if this explains what's going on in the CBD. Right. Oh, yeah. Yeah. I don't think what's going on in the PD is going to explain the. I was really worried about. You're here. So we. You're right. We're going to be looking at the head. And so. I'm doing these biopsies. Try to turn into a. Close here. And then I push out a little bit to kind of share it. The tissue. And then pull. You tend to get a little bit. Go ahead and take that. I sometimes I'll try to get two bites with each one, but. It was a little difficult to get to this spot. I can quickly get down to show you. If you, if you have time. Yeah. I like you. I try to take. Several bites. Cause what worst case scenario, you drop one, you still have at least one, you know, rather than take it all the way out and go all the way back down again. Yeah. Yeah. I agree with that. I think it's easier to pass the clean. Just go up and all the devices easier. Single use scopes. And then. I think a lot of us do the walking of the. Biopsy force-ups. It tends to get resistance through. The clean. Just go up itself, but I agree. Especially when you're in a tough position. I try to maximize each. To the limit. He passes. Back and forth. Of the force-ups as possible. Yeah, I've noticed when there's less angulation. At the. Yeah. It's a little easier. Yeah. Close here. Yeah, that was, that was, that was. I might just take that one. Yeah. Okay. So I want to come back then. Do we get pieces on the first one? Okay. So we're going to come back. I think my, I agree with you guys. My suspicion for that. It's a little low. But it is abnormal. Okay. That's good. And then I'm back here. A little bit. So when you're suctioning. You have to be sure. That the. That the wide app is closed. Yeah, exactly. Finger there. Okay. That's good with the suction. And then let's irrigate a little bit here. Okay. So now closer to the genuine. So that was kind of mid body. Lindsay. Label that mid body. Yeah. And then as we're coming back. A little bit. And. Oh, go ahead. Okay. So when I'm with drawing, I do tend to put a gentle lock. On the dials. It helps you stabilize. I don't do a hard log. That's a gentle lock. Sometimes the dial can break. But this looks very normal here. Yeah. This is not the area that was more dilated. The more dilatation that shows you on that scalp. Initial pancreas. 11 millimeters. Okay. So just coming back. Maybe a little. No. Actually. Some side branches here. And. Okay. And so. What we're planning to do. This is normal. There's a little band. Now that's normal. I don't see scar there. Okay. Our plan. I don't know if I'll have time to show here. Our plan is to go into the bio too, because of our concern about. And. But nothing that looks like mixed type IPMN. And that I don't even. It's pretty clear. So in many ways, this is helpful. I mean, she turns out to have a cold local cyst. Then. I don't know. If you choose this to go that route versus surveillance. Sorry, Raj. Can you explain how. Diagnose a cold local cyst. Yeah. Basically see the rain. Yeah. Typical of scar, like a very benign appearing. So I can see that with chronic pancreatitis. Yeah. We have a case series. Patients who have progressed. From. To dysplasia. And it was. Right. What I mean by that is. Sorry. Sometimes we see a patient referred. With a dilated bile duct and the read is equivocal. And it's a common hepatic duct for whatever reason. And it's a common hepatic duct for dilation. And as you know, some people just dilate. Maybe at the common hepatic duct for whatever reason. Even without assist. So from that perspective. Can you, does it help you differentiate. A dilated duct from a cyst or no. Yeah, it can. I think because. What we'll see sometimes. With a cold. Is we'll see a. You'll see intestinal. You'll see. That actually looks. Okay. And I'm just going to quickly go up into the. Maybe. Now. I think. Yeah. Okay. And then we gave pre-procedure antibiotic. And with. Would give two liters of fluid. Medicine as well. And then I'm just going to go up to the bifurcation here. If you want to see this. Pretty normal here. Yeah. So we've kind of flown through so far. Yeah, so you'll see what you look for. I'm going to do a biopsy to look for that. Good section here. But now we're up. We are. Yeah, up into the left main. Enter a paddock there. Normal. In here. So, yeah. So. I think you need to go to another room, but I'm going to do a careful inspection. On the way back, looking for. Some subtle change. Yeah. And go from there. Thank you so much. Yeah, absolutely. Thank you.

pancreatoscopy

pancreatic duct dilation

University of Colorado

patient

cholecystectomy

pancreatic cysts