This is our time for question and answers. So please, I have a laptop up here, which will feed me the questions that you all give in from the audience. So use that QR code and send your questions up here and we'll try to get to as many of them as possible. And I'll start us off while we wait for some other questions to come in. I want to first ask a question to Dr. Casey. So Brenna, you talked nicely about when to not intervene on some of these acute pancreatic fluid collections, when it can be dangerous, when perhaps it's in the best interest to wait as long as possible. But when we do intervene early, the question that always comes up is sort of how immature or how mature is that wall? And whether it will support one of our stents, whether we're using a luminoposing stent or double pigtails. And I just want to ask your expertise in that scenario. What do you look for on a CAT scan? When do you think it's, even though it may be prior to four weeks, but the patient really needs that drainage, when is that okay for you when evaluating a CAT scan and trying to decide if a cystic gastrostomy is appropriate? I think one thing to really emphasize that's important here in making that decision is that you have a multidisciplinary approach. So we have a weekly, we have a pancreatitis service, acute pancreatitis service, and we have a weekly conference where we meet together and we have interventional radiology, we have diagnostic radiology, we have surgery, and we have interventional gastroenterology. We all sit together and review the films together to make decisions about that. We do not intervene in our practice endoscopically on fluid collections that don't have a mature wall, that we cannot determine have a mature wall on imaging in our multidisciplinary conference. And if they need that early intervention before that wall is mature enough for safe endoscopic intervention, we always do percutaneous drainage first. One thing, you know, if maybe the wall is not that mature, the patient's really sick, you could try just aspirating from the collection, prove if it's pus or not, to document if it was infected. But I agree with Brenna, we try to avoid that. So that brings up a good point, Uzma, because Brenna said in her talk, you were pretty adamant about not using FNA to sample these collections. Not using US guided FNA. US guided FNA. Percutaneous. But I'm assuming, Uzma, you're referring to US guided. Sometimes, I mean, if we're really pushed and, you know, the surgeons, they want us to check or see it, then we'll have a, again, we're having a discussion with them, but sometimes we might. Or if it's not, if it's maybe a little, not fully walled off, maybe you wouldn't put a lumen opposing stent, but just one single pigtail just to get access to go back later. And again, you're just trying to prove it's not infected. Great. Okay. Terrific. Let's, let me ask a question for Tim. Tim, the concept of self-expanding metal stents in the pancreas, I think, has always been intriguing to me. You know, we're used to thinking of pancreatic stents with side holes to allow for drainage of the side branches and, you know, using a self-expanding metal stent, which theoretically sort of pushes up against the walls of the main PD and blocks some of those side ducts, which seems counterintuitive. Tell me a little bit about that and what's out there so far on that topic. Sure. No, it's a great question. You know, I think it's, I think intuitively it sounds dangerous to do, but really the apposition that you get is not that strong. So you can get drainage out of those side branches around that, that stems. So, you know, I think it's something that people do. I don't think it's wrong to do, but I think based on the data that I showed, I think the multiple plastics are probably a better way to go if you're going to do stricture treatment. I think, I assume one of the reasons why people thought about using self-expanding metal stents in the pancreas, you know, I think obviously just because of the size diameter, but also, and I think this is true in the bile duct, if you look at the technical ease of placing multiple plastics, particularly in the pancreas, when you're dealing with a tight stricture, for example, versus passing, you know, a small catheter to deploy a one-time metal stent. I assume that's why one of the things that people find attractive about it, you brought up migration. What about using some of the newer fully covered metal stents that have anti-migration struts? Is that safe to do in the pancreas? No, I haven't used those myself, so I can't comment. I mean, conceivably, I think those would be probably okay, but, you know, again, I think what you said was really, really important. You know, we shouldn't do things just because they're easy. We should do things because they're right, and so I think that's an important message to get out. Okay. Okay. Uzma. Yes. Question about, this is actually more of a practice management question having to do with biliary strictures. So a patient, this is a common scenario that I see, a patient is referred to you from another gastroenterologist because there was a highler stricture on cross-sectional imaging, and wherever that patient is coming from, perhaps there's no access to EUS or there's no access to ERCP with Spyglass. So the question becomes, you know, should that physician, and that patient has a very high bilirubin and is in the hospital, for example, should that physician embark on that first ERCP, try to get a brushing and stent it, or should that physician say, I don't have EUS capabilities, I don't have access to Spyglass, it's okay for this person to hang out with a bilirubin of 15, I'm going to send them to Uzma Siddiqui, who can do all those things together. So what are your thoughts about that? I mean, I think in an ideal world, it would be nice to do the EUS ERCP without having a prior stent in place, because, you know, the stents can cause some inflammatory changes and confuse the picture a little bit when you're looking at it. So if I can get first crack at it, do the EUS ERCP, Spyglass, or cholangioscopy, sorry, for CME purposes, you know, that would be my preference. But is that the reality? Probably not. Yeah, probably not. I agree with you. I think it really complicates things for our cytologists to interpret the data from brushings. We almost always, I'm sure you all have the similar experience, get that reactive. And they always ask, did this patient have a stent? Did they have a stent? How long has it been in? So likely reactive due to stent placement. So and a little bit further on that. So when you get a stricture and you're sampling it, are you doing everything? Are you brushing? Are you doing freehand biopsy or biopsy with direct cholangioscopy? Are you sending for FISH? And also tell me about FISH with PSC patients, because I know that there's some accuracy issues in that category of patients. This is going to be a whole nother lecture, Jonathan. I mean, we have time. We have time. Okay. And more questions. I'm not seeing enough questions coming in. So please use the QR code. So if I have a distal stricture, if there's a pink mass, I'm going to do an EUS first always. And I'm going to FNA that. So then that will potentially obviate the need for me having to do anything extra at ERCP. And then it also kind of dictates what kind of stent I'm going to put in, because potentially I can go with a metal stent at that point, once I've confirmed the diagnosis, partially or uncovered. But if it's a hilar stricture, and I know that going in, I'll do an EUS again to look for a mass, not FNA. If there's a chance, they'll go for transplant. If they have obvious metastatic disease, then you can biopsy it. And then I'll do cholangioscopy and we'll do biopsies. And then I probably, and I will do brush cytology and I will do FISH. I'll do everything at that point. Because again, if they're referred in, I don't want them, I don't want to miss my chance to do everything. So we'll do all that and then we'll get the results back. Now FISH, I will say we send it on our PSC patients. I think in the past, the guidelines, and even at Mayo Clinic, they would transplant patients who were only FISH positive, but then there were a lot of, I think there were a lot of patients who didn't have cancer at the time of surgery. So now the guidelines have shifted a little bit where if we did have a FISH positive, they make me repeat the cytology and FISH again, and it's not enough by itself to initiate the treatment. So that's changed the practice a little bit. And sometimes our hepatologists, you know, even if there's not a dominant structure, they ask, did you, did you brush for FISH? And I'm like, what, what am I brushing? But we'll, we'll do it. So it's still part of our algorithm, but it's a send out. It takes a couple of weeks to come back and, you know, it's just part of it, but it's not the sole decision-making tool. Great. Okay. Next question is for Brenna and for Tim. So Brenna, you, you talked about when you're dealing with a pancreatic fluid collection, a pseudocyst, that more sort of drainage holes are better and especially for these complicated, you know, collections with solid debris, et cetera. So when do you do that? When you first, when you're intervening upon a, a pseudocyst, do you, do you aim to put in, you know, your multiple access points at once at the first procedure, or is it something that you're typically doing in series? Like I'm going to put this in, I'm going to, you know, repeat a CT scan in a few days and see how, what, what the effect is. And then if there's no significant drainage, I'm going to have the patient come back and put another, say, luminoposing stent in, if that's what you're doing. So what are your, can you comment on that a little bit, and maybe Tim, your approach to, for multiple access points for complicated collections? I think the cross-sectional imaging that we have now is, is high enough quality that it's easier for us to tell if we're going to be able to get to a collection with one access versus two. If we're not really sure we're going to be able to extend our scope beyond the barriers of our initial access point, we're going to go for two right in the very beginning. So we'll do a multiple gateway, but we'll do luminoposing stents, and we might put one through the duodenal wall. We might put one through the stomach or two through the stomach in different areas, one through the anterole area, maybe one through the body, so that we have multiple gateways to get in and out of the collections for debridement. But I will also say that if there is pericolic extension, like you saw from my patient on the slides, those deep pericolic gutters are not drained well endoscopically, transgastrically. You can get a stent down there sometimes, but you can't always get down there and debride. And it's better for these patients to early on have percutaneous drainage so that they have tracts matured for BARD. They recover faster. Give me your approach to this. I would agree. I think, you know, in this era where we have the LAMs, I think it's much easier to create those gateways. It's very quick. And I think debridement, you know, for necrosis is something that you can do right away. The only point I would make is we typically go ahead and do debridements initially on our first LAMs placement, but it's also important to make sure that there's not an underlying malignancy there. You know, I've had the experience of debreeding a mucinous cystic adenocarcinoma, and I don't want anybody to have that experience. So it's really important that you have a really good history of an antecedent pancreatitis and not that this was something like a mucinous cyst adenocarcinoma that books for all the world like Waldorf necrosis. So really important to establish a diagnosis, and if you don't have it, then just make sure you probably don't want to debride and intervene on that first go around. I was going to say, I usually, if I place a lumen-opposing mental stent, I don't debride the first time when I place the stent. I'll give it a couple of days to open up and then go in at that point. Yeah, so that was going to be a question I was going to ask for Tim. That's sort of my practice too, Ismael, but for Tim, if you go into debride right away, do you dilate that lumen-opposing stent right after you place it? Yeah, yeah, we do. I mean, we try to get the 20 millimeters in there and then dilate and go ahead and debride. We also use hydrogen peroxide in our practice. And again, it depends on the extent of necrosis, but typically we'll go ahead and debride up front. Great. We dilate as well. I typically don't go to two centimeters on my first dilation, but I'll dilate up to 15. Do you guys leave pigtails stents? Yeah, we leave pigtails. You need to leave the pigtails and not just the lumen-opposing. I think when you have real necrosis going on there, particularly if it's infected, because what happens is the stuff is adherent to the walls and it comes loose and then it just blocks up the opening of your limbs and nothing drains out and they become febrile and get sicker. So when you have the pigtails, it holds things open enough that you get a little drainage between your sessions. I love what you said there, real necrosis, right? There's necrosis and then there's necrosis and there's a big difference between a little bit of solid debris and real necrosis. Okay. Let's talk for a second about Ezolol. And I know that not every endoscopist, therapeutic endoscopist who deals with pancreatic disease actually has experience using Ezolol, but I'm not sure actually, Tim or Uzmo or Brenna, how much you guys have utilized it in the past for dealing with patients with chronic pancreatitis. Tim, perhaps you can tell me, you know, or tell us, you know, what's the role of the interventional endoscopist when working, say with a urologist or somebody in those cases? Yeah, I think it's a really good point. I mean, I think the first thing is to make sure it's an indication for Ezolol, a large stone that you don't think you can get out and that should be identified before you ever intervene. And so I think the relationship is really important, you know, with your colleagues and talk to your urologist, what we like to do. We don't do it much at my center, the Ezolol. We typically use the EHL, but what we'll typically do is talk to the urologist. We only have lithotripsy available, I think once or twice a month. So we have to have the machine come up. We usually do the Ezolol in the morning, and then we subsequently go ahead and do the ERCP in the afternoon. And that's our practice. It's not something we do all the time. And I know there's data out that you can do Ezolol by itself and allow the duct to flush and people do it slightly different, but that's kind of my practice. And like anything, it's really about the indication and having that good relationship with your urologist. Do you have to have a pancreatic stent in before the urologist targets the therapy? Yeah, my urologist doesn't require it. And usually they just can focus in on the calcifications of the stones to do that. And sorry, just one more. Do you after the Ezolol portion of the procedure, do you go back in with an ERCP immediately and you know, try to flush out as much as possible? Or do you just leave that stent in and let it ride? What's your approach? Yeah, that's what I do. If they do Ezolol again in the morning, I'll go in there that later that day and do it. Okay, great. Okay, we have a few more minutes, a couple more questions. Uzma, this goes back to tissue and biliary strictures. You talked a little bit about the different techniques when you're biopsying using direct phalangeoscopy. And I've noticed a lot of people now have changed, you know, they first started doing one bite at a time, which is time consuming and painstakingly, you know, annoying. And then there's this concept of multiple, multiple bites, just drop them in the bile duct and try to suction them out. I mean, what do you do? How effective is that? Has there been any studies on that? There has been, I don't know how many, but there was some initial data that said you'd have a little bit higher yield. I tend to still take one and pull out and go back in. I know it's time consuming, but I know I'm grabbing that tissue each time. And I kind of go by feel. If I feel that I actually got some tissue off, then I'll count that and take it out. But it is time consuming and also maintaining your position. What's the angulation at the tip of your ERCP scope that your phalangeoscope and your devices have to navigate to get into the bile duct can sometimes make it a little more challenging. This could be a question for all three of you. This is a non-endoscopy question having to do with the management of patients with chronic pancreatitis. And for the interventional endoscopist, you get these patients and sometimes their gastroenterologists that are referring them to you are more involved and sometimes they're less involved. But for those that are less involved and you're trying to manage their pain with medicines, can you tell me what your approach is to the types of medicines that you're using adjunctive to your endoscopic therapy? Tim. Yeah, I can tell you. I take care of a lot of patients with chronic pancreatitis, hundreds actually. And so again, I think it's a step up approach, not a step down approach. So what we'll typically do from an analgesic perspective is NSAIDs, Tylenol, neuroleptics like Lyrica, Gabapentin, et cetera. In my practice, I use a lot of medical cannabis. I think it's really effective for chronic pancreatitis. So we use that. And then if that doesn't work and we can't find a good endoscopic intervention or surgical intervention for the patient, then we go ahead and unfortunately prescribe opiates. But I think there are patients who need opiates for chronic pancreatitis pain. We try to limit it. And then there's the whole issue of resection procedures like TPIAT, which we offer at our center. So I think, yeah, step up approach, trying to avoid opiates. And again, I think being really present with the patient is probably the most important thing. I have a simpler approach. I refer them to my medical pancreatologist, Dr. Bradford Chong, and he will he will take care of them, which I think it is really useful to have someone like that, though. He has a pancreas clinic and he is focused on the medical management. And we do a monthly pancreas conference where we do discuss these more complex cases. But he manages the pain and we have a slightly different approach. We have a multidisciplinary clinic that meets weekly for pancreatitis, and in that we have a pain management center that's run by an anesthesiologist. So I actually don't personally manage pain either. Well, great. All right. My last question for the group as we're approaching the end of time here, and Tim, you led us right into it, which is total pancreatectomy with islet cell autotransplantation. I know that we could give a whole lecture on this. I realize that. When do we do it? When do we refer? When do you pull the trigger on that in a patient with chronic pancreatitis? Yeah, it's a great, great question. Lots of layers to it. But essentially, I think what we found in our practice is a few main points. One is that you want to make the younger the patient, the better, the more intermittent their pain, the better. Genetic etiologies tend to do better. Certainly patients who are not already on opiates tend to do better and have a centralized pain situation. And then like any transplant evaluation, that they can have the support and the character to be able to handle such a big procedure. Because even though we tell patients that it's unlikely that you're going to get diabetes, about 60% to 70% of them end up with diabetes, difficult to control afterwards. So I think it's really important to, again, get this whole issue of consent. So young, genetic, not on opiates, those are kind of the major patients. Do you guys feel the same? Yeah. Ours is the same. It's really important for the patient selection and not being on opiates is really key to success overall. Great. Well, listen, I'd like to thank my three speakers. That was a wonderful session. I really appreciate your talks, your participation. Thank you to the audience. Thank you.

pancreatic fluid collections

biliary strictures

endoscopic interventions

multidisciplinary approach

total pancreatectomy

islet cell autotransplantation