The next talk is for me, it's about pre-RCP procedural planning, and this is just, I think, a useful discussion to talk about, you know, what we need to do before we even start the procedure so that we're fully prepared and we can handle whatever comes. So in this talk, I'm going to be talking about making sure that we know how to assure a safe ERCP environment, assessing the appropriateness of the indications for ERCP, recognize patient-related features that influence ERCP outcomes, do we have the appropriate available pre-procedure imaging, and that we can anticipate potential challenges to successful ERCP. I think this is the one procedure where if you have to, you really want to make sure that you're fully prepared and you know everything that's going on with the patient, so if something happens, you maybe have a better idea of why that's happening. So ERCP is a process, and the process involves preparation, mind, body, and spirit. I think, you know, we know that if we have a challenging ERCP, it's always better probably at the beginning of the day when you really have all kinds of energy versus perhaps at the end of your day at your, you know, seventh ERCP. You need to make sure you plan, and now with a lot of the advanced imaging techniques we have, there's a lot of ways that we can plan now that we probably couldn't plan before, and then execution. We know that experience matters, and I think all of you who do ERCP can appreciate this as you've had problems in the past and how you've handled them helps you in the future, and it's important, I think, to stress that, you know, keeping up your skills is really important. It's just that muscle memory and, you know, remembering different maneuvers that you've tried and just the sheer number, as we know, always helps with making sure that we're staying sharp. So you know, there's a bit of a dilemma, and I talk to my advanced fellows who are looking for jobs. You certainly want a place where there aren't lots of practitioners doing a little bit, but of course, practices want more people so that everyone can share and call. So it's sort of a little double-edged sword there, but I think you want to, you know, not have many things spread out amongst a lot of people. We do this at our institution. If people's have, if a certain physician has a certain area of interest, we try to feed them those procedures like ESDs and EMRs or pancreatic work so that those individuals can have a real expertise in that area versus everybody doing a little bit and then no one really has a great expertise. And of course, it's important to have adequate training. I certainly, I was on the training committee when we developed the advanced endoscopy match and at that time, there were maybe 50, when I applied, there were probably about 15 programs that trained for a fourth year. Now there are about 75. So certainly there's more procedures that we are doing now back compared to when I was training, you know, pancreatic work and EMR and ESD and a lot more interventional things. So I think the, definitely the direction has gone towards doing an extra year of training so that you have adequate training. Not that everybody has to do everything, but certainly there's a push towards training in a fourth year where you have an intense one year of training. And then there are also some simulators that have been found to be good to accelerate skill acquisition. In addition, the ASG has developed a number of star courses that can also help with people who already have some degree of advanced skills who want to learn new techniques. There are ASG guidelines that were published in 2017 that said that a minimum of 200 supervised independent ERCPs should be performed before a learner competency can be assessed. And that number is pretty variable based on the endoscopist, as Sachinwani has shown, and that a trainee should be expected to form at least 80 independent sphincterotomies and 60 biliary stents. And regarding quality indicators, you should have a target performance of greater than 90% cannulation rate for native papillae. So that's just something that when you're looking at sort of how you're doing in ERCP, if your rate is lower than that, then you need to start thinking about, are you doing enough? Should you be doing ERCP when we think about patient benefits and risks? Again, there's ongoing training resources, including G.I. Leap. We have a lot of hands-on training courses. When we developed the IT&T Center, we have a pig lab right across the hall from a lecture hall. And so it's really nice that we can give lectures and then members can go into the pig lab and try these techniques. It's not perfect. Certainly cannulation of the pig is not really possible, but we do have models that are quite nice and we do some really great hands-on training courses. Again, there are star courses that are really fabulous for new techniques that you want to learn. And then at the annual postgraduate course as well. So the multivariable equation of successful ERCP is thus. Now this is an old picture, and I actually don't know where this was, but I got this from a slide from a friend. But there's the patient, which we know can be usually on their stomach. And so we like to think about having anesthesia with us, helping us out. Patient's anatomy, which these days can be variable. Always good to know. Yesterday they were transferring a patient for cholangitis for us until we figured out that she had had a Rewi gastric bypass. So always good to check that out before you start your ERCP, though I can say that I've had some surprises. Then there's your equipment, your fluoro, where your screens are, your monitors are. You have a CRNA in the room. This room looks pretty crowded here for sure. So you have the endoscopist hands, the endoscopist eyes, and then the fellow, some of us have, which can also be challenging depending upon what month it is in the year. You have your endoscopy nurse at the head. You have a tech at the head. And then your own mind, of course. So in preparation for ERCP, you have to think about the patient and what the indication is. And we'll probably beat this dead horse, but indication is probably the most important thing for ERCP. The patient's condition, what are their comorbidities? What medications are they on? Are they on any antiplatelet agents that you need to know? Are they cirrhotic? Do they have a coagulopathy or some sort of platelet problem? What's their anatomy? Which is really important. And again, sometimes we don't know this and look for midline scars and things like that, but some patients just can't give you any details. So they had surgery, is it a biliroth one, a biliroth two, is it gastric bypass, in which case you're just never going to get there. So I will talk about consent as well. It's really important to talk about the likely risks, the anticipated benefits, and again, reasonable alternatives. The physician needs to be obviously knowledgeable, skilled, and experienced. And your facility needs to have the proper equipment. If you anticipate that you're going to need something that you don't have in your suite, is it something you needed to order in advance, making sure that you have it? And I think part of why they're having us do the timeout, even though it's a little bit more like an OR thing, but to make sure that we have the equipment that we thought we were supposed to have. If we're going to have spyglass, you know, cholangioscopy available, do we have that equipment there? Are the right personnel there? And do we have the right sedation? I can say that up until a few years ago, we used moderate sedation for our ERCPs, which I think we were a bit of an outlier, but we told our fellows that they would be really good at cannulating the moving papilla because of this, because, you know, they're not laying still. Now we do tend to do MAC or general anesthesia for most of our patients. But back in the day, we did moderate sedation. So patient selection is really, you know, the really, the big, big, big thing in ERCP to make sure that you are doing it for the right reason. If something bad happens, did I do it for a good reason? Because there was not really a great alternative. The minimum incidence of pancreatitis is three to 5%, and it can be up to 20% in high-risk patients. So is the patient apt to be better off if they undergo ERCP? And, you know, this is what we teach our fellows over and over again, because if something bad happens, you want to be able to sleep at night saying, you know, it was the right thing to do, and something bad happened, but, you know, I really can't think of a great alternative. So are there suitable alternatives? We have great imaging now, so we know that most ERCP is going to be therapeutic, not diagnostic, most of the time. And we also have EUS, so we can always, most of us who train now are not training purely in ERCP, but know EUS as well. And so EUS is a nice option for those sort of intermediate probability patients. And does everybody understand the risk? And I think that is really, really important. Again, if we reduce our marginal indications, we'll diminish ERCP complications like pancreatitis. So informed consent, remember, it's a process and you really shouldn't delegate it. And you know, we have a process now where our fellows get consent on the floor for inpatients and they come down and they're already consented. But I always do repeat it again. And ideally, if you can have a family member or a representative there, that's probably better in thinking about the fact that if the patient gets really sick, and then they're kind of are not the one making decisions, it's nice to have had a family member who was there who met you beforehand. It's challenging in this day and age, because a lot of us do open access ERCP, so we didn't see them in clinic, so don't really know them. And we're just meeting them before you do the procedure. And we know that patients are less likely to be litigious if they think the doctor cares and that they like the doctor. So you have five minutes to get these people to like you, right? So I usually go out and try and talk to both parties, make sure they both understand not just the patient, because if the patient gets intubated after the procedure, and you can't talk to them again, it doesn't really mean as much that you had a good conversation with them if their family member didn't have that conversation as well. So it's just something to think about. And some places aren't really set up for that, where, you know, you have the opportunity to bring the family member back, the patient only comes back, it's a little hard with COVID, we weren't having family members come back. So there are some challenges, but it's something to think about maybe making sure it was set up appropriately wherever you practice so that you have that opportunity. Maybe not for a colonoscopy or an EGD, some basic stuff, but certainly for ERCP, I like to, even if the patient's already consented, even by the fellow, I usually like to talk about it again with them. So when you're consenting the patient, you want to really tailor your consent, you know, again, based on a couple of things, based on their risk of post ERCP pancreatitis. So depending upon the indication of the patient characteristics, if they've had post ERCP pancreatitis before, they're probably more at risk unless it was, oh, they had a sphincterotomy then, and they got a stent in, and I'm just taking the stent out and stone out, maybe that's less of a risk. But this is something to think about, you know, patients are aware of it, if they've had it before, they usually don't forget that. Risk of bleeding, so patients who are on some antiplatelet agents that can't be stopped. And so you want to talk to them and say, hey, you know, typically, we'd like to stop these drugs. Do I know that you're going to bleed? No, not necessarily, but there is more of a risk. And maybe it's hard for me to tell you exactly what the risk is, but there probably is more of a risk and sort of have that discussion with them. Also for Jehovah's Witnesses, I had a patient who was a Jehovah's Witness who I did a sphincterotomy on and he bled a lot. And I don't remember if I had talked to him about the risk of bleeding, but it's always a good idea to, you know, talk about this because obviously these patients don't accept transfusions and you can really get into trouble. And then what are your complication rates? So you can cite what national complication rates are, but it is always good to know what your complication rates are. And this is challenging because we don't always know that patients get pancreatitis, right? They go home and maybe they end up in another hospital. Your nurse calls the day after and no one's there to answer the phone. So you never know that they get admitted, even if you tell them, call me if there's a problem. So it is a little bit hard to know your complication rates, but it's probably useful if you can find, figure out a mechanism to do that, to figure out what your complication rates are. So you can tell patients, this is my complication rate. So I was talking to John before we started this session and we were talking about it this week. There's a lot of discussion about post ERCP pancreatitis. So you'll hear this probably time and again, but of course this is our big complication, right? Patients can die from this. So it's definitely not something that we take lightly. So we will be talking about a lot. So I apologize for repetitiveness, but certainly the risk factors for post ERCP pancreatitis include prior ERCP induced pancreatitis, patients with suspected sphincter of OD dysfunction, women tend to have a higher risk, absence of chronic pancreatitis and patients who have a normal bilirubin. So again, you know, why are you doing it? Are you doing something therapeutic with a normal bilirubin? And these risk factors are cumulative. So you know, though alone, they may have a low risk as you start adding them up from female to female with a low bilirubin to a possible sphincter of OD dysfunction and a difficult cannulation, you can be up as high as 42% risk of pancreatitis. So you know, these are things that when you're consenting the patient and you're looking at them and sort of all these factors put together, you really want to make sure that they understand that they may be at high risk of pancreatitis and then risk benefit analysis. So you also want to talk to the patient about the consequences of not undergoing the procedure. So patients with marginal indications for ERCP are the ones who are most likely develop complications and Peter Cotton has written extensively on this topic. And obviously it'd be nice to talk to the patient before they show up for their ERCP. One little trick that we do when we've had patients who are referred by gastroenterologists for an ERCP, and we kind of don't really think that it's a great indication is we will often do an EOS first. So if they are sent because they think they have a stone and we look at all the data and we're not convinced, or we have new data since the time that they, you know, were sent for ERCP, oh, their LFTs became normal and they feel fine, well, maybe they pass the stone. So oftentimes we'll offer those patients an EOS. So one advantage of being someone who does both procedures is that you can easily just sort of pivot, do an EOS and say, hey, this is what I'm going to do. We do this ultrasound because ERCP is more risky than EOS. Do an EOS really quickly. Takes us a minute. We look at the bile duct. If we see the bile duct looks good, and maybe we look at your papilla and maybe you pass the stone, we're done. And if we see a stone, then we go to ERCP. So I will oftentimes consent these patients for both. And then that way, if I don't see any good indication, I can kind of get out of doing an ERCP. So again, careful patient selection is really critical. There are disputes about the extent of education and the consent process is often cited in lawsuits. Although really this is typically a secondary issue. It's really about indication for procedure. So I'll talk a bit. We're going to talk later in the day about infection issues and duodenoscopes. But with recent outbreaks of CRE, and when I say recent, I guess now that's a couple of years ago, related to endoscope contamination. You could consider this additional information in your informed consent process. Certainly in institutions where they've had these outbreaks, it's probably reasonable to do that. And this is one example where, you know, you can add this into your consent form. It's sort of like in addition to these other complications or issues that I've been told about ERCP, I've been informed of the following material facts pertaining to my procedure be formed at insert hospital name. I've been aware that there's, you know, infections with duodenoscopes, my hospital's taken all these additional steps, yada yada. So this might be something useful. If you feel that you would like to add this to your consent form is something that some hospitals have chosen to do. You know, these scope related infections were in the lay press a couple of years ago, sort of regularly. So patients may be aware. I can't say that we had too many instances or certainly there was no major outbreak in Cleveland. We don't have a lot of CRE, which was the one that was sort of the resistant organism that was traced in duodenoscopes in a couple of other cities. So we didn't have to deal with this problem so much as far as patients being aware. But certainly, you know, if this happens in your area or patients are aware of that, you know, make sure you assure your patients that our institution is aware and that we are taking measures to mitigate these risks. So just with regards to consent, you know, consider patient factors when you're obtaining informed consent and be sensitive to their preferences for information and their decision making styles. Tailor your consent, involve family members. Don't forget to discuss the alternatives, including EOS. Document this appropriately. And that's really important as we know. And considering altering your consent form if you feel the need for scope related infections. With regards to pre-procedure imaging, again, you know, we have great cross-sectional imaging now, so we can really get a good sense of if we're dealing with something complicated in the pancreatic or biliary tree as far as what we are looking at so that when we get in there, you know, this fluoroimaging and rotating the fluoro, you know, can get a little bit confusing. You inject contrast and contrast is now throughout the biliary tree and you're not sure what you're looking at. So it can be helpful to have a roadmap. I mean, it's not always, you know, the end all you're looking for, you know, where's that dilated duct that I saw? And John will talk about this with hyler lesions, which I think are so challenging because you're trying to match your, your calendar gram with the one that you're seeing on your cross-sectional imaging. And it doesn't always work out that way. You can't always get the contrast where you want to, but it's really important to make sure that you have all the imaging that you've reviewed before you go in and do your ERCP. With regards to electrosurgical current and ERCP complications, you know, we used to use pure cut which would sometimes cause like a zipper cut when you're doing your sphincterotomy. And now I think many people have these smart generators that give a fractionated cutting mode so that you have a little bit of a blended current and these generators have become smarter and smarter and the newest versions of some of the generators are pretty amazing. So there's probably fewer complications with relation to perforation and bleeding with these generators. So when we're talking about patient challenges and overcoming these, certainly sedation, like I said, has probably changed in a lot of institutions. We're now doing MAC and general anesthesia or having anesthesia involved with ERCP. In fact, our nurses kind of freak out if we want to do moderate sedation, if anesthesia is not available because they are now so used to not having to sedate these patients. And I have to say, you know, I don't really care about most other procedures about having anesthesia present and I do most under moderate, but it is kind of nice for ERCP when the patient's on their stomach to not have to worry about them either staying still or being over sedated. So certainly talking to your anesthesiologist, some people are, you know, very much require general anesthesia. I'm kind of more of a MAC person. I think that works fine for me. And it's nice to have an anesthesiologist who appreciates that this is not open heart surgery and it's endoscopy and, you know, they will adjust their anesthetic sometimes for that. But again, the position can be challenging and if patients are obese or they have some issue with laying on their stomach and the anesthesiologist doesn't think they can ventilate well, we sometimes have to move our patients. So we may have to do them on their back and can our fluoro or our monitors move so that it's not, doesn't give us a, you know, a neck ache when we're done with the procedure. If patients have had recent abdominal surgery, I don't really worry about that as much. Certainly anesthesia can sedate them and then we can put them on their stomach or if they intubate them, obviously it's not usually a problem. We I think most of us now are using CO2 insufflation. I think it's really made endoscopy easier for teaching fellows for colonoscopy. And also I think it's really when you're doing more invasive procedures, I think CO2 is really the way to go. And then again, managing their coagulopathy and their anti-platelets agents. It's not always, it's usually easy to know when to stop it, a little harder to know when it's safe to restart. And typically the post sphincterotomy bleeds I have found are mostly in patients who had to restart their anticoagulation. Staffing is another issue in ERCP that I'm sure you're all aware of the challenges there because these techs and nurses need to be well-trained for ERCP. I am a long wire person. So I do require a nurse or a tech who knows how to use the wire. But certainly those who do short wire, maybe it takes a little bit of the nursing out of it, which is probably good, but I never learned how to do that. And I know those systems are about twice the price of the long wire. So at our institution, we just decide to stay with long wire. So that's where we are at our place. There's also this ASG ERCP bootcamp, which I was faculty on a number of years ago. It's a lot of fun. You can bring your whole group, your techs, your nurses, doctors, and really like go as a group when you're in the IT&T center to each station and everybody learns how to do their part. I also train my fellows. They need to learn how to be good techs. As the physician, you need to know how everything works in the entire unit. So you cannot rely on your nurses and your techs, because again, especially with staffing these days is pretty challenging. And so you need to be the person who knows sort of what is going on and make sure that everything is working well. So I always want to make sure that I know everything in the lab, how to hook up everything. Especially the lithotriptor, they don't like that. So again, for pre-ERCP procedural planning, it's all about careful patient selection. We'll beat that dead horse today. Tailor your informed consent with the patient and the family, because we do do a lot of invasive procedures now, but the other ones are, I think the patients are a little more aware of the risks. You say we're going to go in and clean out your pancreatic flu collection and get the necrosis out. I mean, obviously these are sick patients, but a patient comes in with a bile duct stone. I don't think they expect that they're going to end up with a one month hospitalization for post ERCP pancreatitis. So I think just really informing patients that there is that risk and we're going to do everything we can to keep you from getting pancreatitis, but this could happen. Again, review all your available imaging carefully so that you know exactly what you're in for and consider anesthesia or your sedation needs based on your patient characteristics as well as anticoagulant issues. Thank you.

pre-procedural planning

ERCP

patient-related features

training

guidelines

imaging