Ali, you use, you do laser or EHL? No, EHL, because, you know, in Europe there is some regulation for the room layout when you use laser. So, sometimes you cannot move from one room to the other room, you need a dedicated room. We need to be flexible, and according to the schedule of the patients, schedule of the entire unit. But we do prefer EHL, and also much easier to be transported when we do this in operating room and specific situation, it's, it's already in the tower of ERCB scopes, whatever we need, we just plug in and we're ready to go. Right, right. For a standard like this, I would anticipate probably I should have used two different fibers because, yeah, yeah, yeah, a lot of time, you know, there is a sort of consumption on the tip. Right. And you have a limited number of shots that you can deliver over time, so you need to be ready to have a second one, because otherwise in the middle of the procedure, you remain stuck. Right, right, right. No, I agree 100%. We, we use EHL exclusively for all the reasons you mentioned for the regulations, for the, they have to, everybody has to pass a laser safety program. And then if you're sharing the, not all the departments like to share their lasers and So I think most places probably do use EHL rather than laser. I've found that lower power and that Raj mentioned this as well, almost all the stones you can fragment, I think with lower power, which then extends the life of your EHL probe. But even having said that, like you mentioned, sometimes you go through two or three probes with a really big stone and they are expensive, the probes, but for all the reasons you mentioned, I agree with you. Yeah. The point for the beginners is that the feeling is that when you use EHL, it's a little bit safer. So even though you are, you're going to touch the wall, doesn't, doesn't need too much, you don't raise it too much in terms of perforation, rather when you, when you use the laser, you need to be very precise and you, we, we saw these, it was very unstable position. You're a very expert endoscopist, a lot of skill in keeping the position stable. You may have some little issues with damaging the wall. So in general, I think it's a more generalizable to everybody. I agree. Yeah. I completely agree. I think EHL is a lot easier to try to pick up for people who aren't as accustomed to doing this work. Right. And according to what we know from previous studies, there are no differences overall in terms of efficacy. So at the end of whatever you're using, you may, you may break the stone and it may take the same time. So I don't know if it is a cost effectiveness analysis based on the cost of the technology and the cost of the fibers, but I don't think that using EHL, you are increasing the cost of the entire procedure. So it looks like we, we have been left abandoned. We are just the three of us, right? Well, this would be a good time also, Linda asked me this question, or I think is when do you chew? When do you know upfront that you're probably going to go directly to cholangioscopy as opposed to trying other things first, either mechanical or large balloon dilation or that sort of thing. How do you choose, you know, other than let's say you've got an impact, it's just a duck stone and that sort of thing. Do you want to answer, Linda? Oh yeah, no, I'm happy to. Yeah. And I'd love to hear, you know, your practice as well. I think for me, I think for me, you know, I have a very low threshold to do the sphincter plasty, balloon sphincter plasty. If it's a, you know, stone that's a bit large, you know, over five millimeter getting close to a centimeter or so. And it looks like I can do sufficient dilation based on, you know, how big the distal duct is. Cause you don't want to over dilate and perforate the distal duct cause you're trying to dilate just to how big the distal duct is and not the proximal duct. So yeah, I'll go very quickly to a small sphincterotomy. And Todd had mentioned this earlier how, you know, at least in my practice, I tend to do a small sphincterotomy rather than just balloon dilation alone. Although I know in Asia and whatnot, they just do the large balloon sphincter plasty and patients seem to do fine. And that's what I'll do first and foremost. And I think the data supports that that's helpful in terms of decreasing use of the cathode lithotripsy and whatnot. So that's my first go-to. And then if that doesn't work, then that's when I will move on to EHL since we don't have a laser. And just for the audience, sorry, one second, I'll go ahead, Ali, I'm sorry, go ahead. No, just on top of the comments, I mean, I totally agree. So I think what is important to remind everybody, you have to look to MRI well in advance. You have to make a plan. So you cannot start over without having a plan. So normally the main issues that I look at MRI is the size of the stone compared to the size of the ball duct, that's a very important point. And the other one is the shape of the stone. Because when the stone is squared, I can anticipate it's very hard to be broken. So when I see a very square stone, I always go straight forward to EHL and spyglass. I don't try to have any papilloplasty or whatever, because in this square stone, they may create a lot of damage and they are very difficult to be fragmented.

laser

EHL

stone fragmentation

regulations

room layouts