Okay, so we're going to start this day off with John giving a talk on ERCP perspectives from yesterday through today and to tomorrow, John. Thank you very much, Ashley. Well, to know where we are today and where we're going tomorrow, we certainly have to have some understanding and appreciation of where we come from. And so that is the reason that we'd like to open this morning by talking a little about some perspectives on ERCP based on the illustrious history of many, many innovative people who put a lot of hard work into developing what we enjoy performing today for the benefit of our patients. So what were you doing back in 1968? Many of you weren't around yet in 1968. But for those of us who were, we do have some memories. There was a lot going on around the world in the United States, as you can see, a lot of revolution, whether that has to do with politics, governments, militaries, music, going out into space or to the moon. Or if you were a kid who loved cars, Hot Wheels matchboxes or looking at real ones. Here's what a Camaro, my favorite car when I was a kid, looked like back then. And of course, 1968 was a stellar year for ERCP because that was the first year when ERCP, as we know it, was described, this type of duodenoscope, which is what our current devices descended from, didn't even exist then. When a group in D.C. actually described the first year of ERCP, they actually used an eater duodenoscope, which is a barbaric looking device, but actually were able to perform a pancreatogram and a cholangiogram with it, which is very remarkable. And this is what that device looked like. It looks like a blood pressure cuff connected to a stiff metal tube with a little flexible component to the tip. And this was an American made device that came out of Clyburn Avenue in Chicago. This is actually the building now. If you Google map it, that's what it looks like. And in that humble little building, the device that was that ERCP was originally done with was crafted. It was Bill McCune and his colleagues at GW, and they reported cannulation of the ampulla of vodder using that device. And that device actually, that little thing had a forward and a side viewing lens in it. And it had that endotracheal cuff type of device near the lens that helped just sort of deflect the scope a bit, because obviously only part of it was flexible. And he taped on the outside of that ITER duodenoscope, a small plastic tube, and that tube was essentially what was used to be the accessory channel of the scope, because the device was made only for viewing and not for actually actioning anything at the tip. So they just taped a hollow tube to it, and then they drove their cannula through that. And the papilla was then cannulated under endoscopic guidance, and they found that the success rate of cannulation was about a quarter of the time. And McCune said, anyone who looks through one of these things has to have two personality characteristics. First, he has to be honest, and secondly, you have to have an undying blind day and night uncompromising persistence. Sounds a little like you and us, right? So we carry the tradition on from over 50 years ago. ERCP plotted along for six years, and in 74, at which time Watergate was in high gear, and Stolzhenitsyn was coming out with his Gulag archipelago tome. Leonard Skinner was hitting with Sweet Home Alabama. Patti Hurst and the Camaro had grown and morphed into this fastback style, and Hank Aaron beat Babe Ruth's record. Well, ERCP had made a huge, huge stride. No longer satisfied to be just a diagnostic procedure, sphincterotomy was described and brought ERCP into the realm of therapeutic endoscopy. Interestingly, in 74, two groups independently described sphincterotomy, Kawai's group in Japan published in GIE, of course, ASGE's journal in English, and Meinhard Klassen and his group also described the technique in the German language, Deutschmedizinisch-Wochenschrift, which is the German weekly in medicine, and so described in the English and German language. Who were these great people? Let's go through some historical pictures. Meinhard Klassen in Germany with his teacher, Demling. They are both gone now, but he was the one who described sphincterotomy in the German journal here when he was young and here in later years before his recent passing. Keiichi Kawai and Masa Tsuga Nakajima were the Japanese team that published in the ASGE journal about sphincterotomy. Here they were when they were younger, presenting about ERCP at the World Congress, which was in Mexico City in 74. Fukumoto, this is Kawai when he was younger, Masuda and Nakajima presenting about sphincterotomy. And it's fun to look back at old issues of ASGE's journal, GIE, and see what these homemade devices were that they used to perform sphincterotomy. Looks very much like the needle knife of today. And amazingly, they were able to accomplish what we consider to be routine procedures. By then, the duodenoscope had taken on a pretty familiar form, as you can see here, although with an eyepiece, not a video device, and truly a fiber optic device where the endoscopic images were actually carried by glass fiber bundles to the eyepiece. Soon to come would be a sharing attachment that could be attached onto the top of that eyepiece so that the assisting nurse or tech could also view what was going on. Amazing to see what they were able to do with this degree of spatial resolution in the images, right? But they got the job done. And even with the old analog fluoro, you can appreciate where the filling defects are in the duct and appreciate that the scope here is in a long position. Amazing stuff. This is where we come from. This, of course, is Jack Venice in Minneapolis, University of Minnesota, working with his team. The hairstyles reflect the time. I notice there's a window air conditioner there. And of course, gloves were optional back in those days. But with the eyepiece, as you can see, it was technically much more challenging. And the IV bags weren't around. There's an IV bottle. And here's Jack attending that same meeting at World Congress in Mexico City in 74. Here's Kazue Ogishi from Niigata in Japan, Laszlo Szafrani. Here's Meinhard Klassen again. There is Kasugai, who you saw earlier, Peter Cotton, and Jack Venice in younger years. And here's Peter with Ogishi. Peter went to Niigata to learn ERCP from Ogishi, who was his teacher, showing them together and showing his first ERCP and the fully opacified pancreatic duct from his pancreatogram, complete with acinarization, which he has obviously subsequently warned us against doing many times to reduce the risk of post-ERCP pancreatitis. Just amazing. And what an illustrious career. And so many of these operators had. Here's Michelle Cremier in Brussels, showing the log from their first ERCPs done in Brussels. Here's Kees Huybregtsa from Amsterdam with Joe Geenan in Milwaukee and Peter Cotton, luminaries from the ERCP days. And as you can see, these fiber optic scopes, when you finally had an eyepiece and a video attachment, were quite heavy. And so he's got it tethered with a cable here. Joe Geenan retired after a long and illustrious career, only recently, around the same time that Peter Cotton did. Here's Jack Venice again. Jack and Steve were both at the University of Minnesota in the Minneapolis VA Hospital. They also went to Japan to learn ERCP back in the early 70s and were really seminal in sort of promoting and developing the practice of ERCP in the United States. Here you can see this is later times. So this is actually a video attachment, or rather a true video scope without the eyepiece. So gloves are no longer optional, but I guess gowns and PPE were. Here's Nib Sohendra from Hamburg, his first dedicated duodenoscope, which looked more like a modified pediatric gastroscope, right? And his homemade sphincter at home here. We all are familiar with Nib for some of his innovations, including what we call the Sohendra crank lithotriptor, or rescue lithotriptor, or the Sohendra stent extractor, which is also used as a screw dilator. His eponym is also attached to the catheter dilators that we use that sort of look like the biliary equivalent of a thin savoury dilator. So as you can see, ERCP has come a long way, and over 50 years, we are at the 54th year after McCune first described ERCP in DC. And I just wanted to take a moment to offer sincere thanks and a moment of respect for many of these great innovators. As you can see, many of them have unfortunately left us as they've passed away. All of them who I've described have retired. But they are incredible innovators, hardworking gastroenterologists, all clinicians. And a thank you to these clinicians and technical experts who've made it possible for us to do what we do every day for the benefit of our patients who have pancreatic biliary disorders. That's where we came from. And we'll talk today about where we are today and where we're going. Thank you very much.

ERCP

history

evolution

pioneering work

sphincterotomy