up. But, you know, as I was listening to your talk, I was sort of considering, you know, how my day starts in my own endoscopy suite for ERCP and some of the pearls that you gave regarding, you know, consent and how to put it into perspective for the patient, I think are really, really super important. You know, because I think one of the things that you were alluding to is, well, let's use a patient example. Let's say that somebody is there with a common duct stone and you're going to perform an ERCP and you're describing to them that, you know, there's a risk of procedure-related pancreatitis. But gosh, you know, the patient needs to know what's the risk of pancreatitis if you don't take that common duct stone out with an ERCP. It's actually higher and post ERCP pancreatitis is generally much less severe than gallstone pancreatitis. And we're talking about a patient who doesn't have a zero risk option available to them. And so I think what you're saying about, you know, giving them some perspective there is super important, right? Yeah, I think, you know, I think just especially with things like that, you know, we do all kinds of other things for sick patients with cancer and we're going to put a stent in and, you know, those patients are already really sick and they, you know, they've been in the hospital maybe, or they kind of get that maybe they're not going to live that much longer, but it's these patients where, you know, 35 year old comes in and has a stone. I mean, that is not the patient that, you know, expects that, oh, I could have a serious complication. I could be intubated. I could be on dialysis. I mean, you know, all these things that we know are rare, but can happen. And so, you know, I don't think that I tell them, well, you could end up on a ventilator or on dialysis, but certainly, you know, I do like having the option of the EOS if I'm really not sure, because it's a nice thing to be able to do because you tell them the risk and you go, but, you know, we're going to do this first. And then if you do the EOS and it's negative, they're like so relieved and like, oh, that was great. I'm glad you did that. So I do like to have that option for patients who, you know, I'm kind of on the fence about because it is a, you know, it usually goes well, but if it can go bad and it can go really bad and, you know, it's kind of a scary thing, I would say. You know, at the top of our day, we're required to have a team huddle where we run the entire list, what each procedure is, and, you know, what we're planning to do with each patient, what kind of anesthesia, if that's even an issue, because sometimes it's predetermined and also, you know, what scopes and what devices are likely to be used. And then before each procedure begins, we have a timeout. What do you think about that sort of paradigm of managing your day and do you do similar things? I think it's a good one. It's just we've never been hugely successful that honestly, I mean, we don't do so I have my day is not always like it's my ERCP day, you know, I do a little bit of this and a little bit of that. So I'm a little back and forth between two rooms. So, but I do have a fellow and she's pretty on the ball or they usually are as far as equipment that we need. So generally, it's pretty good. I mean, the timeout, if you're in the room and you're like, all right, do we have the, you know, the lithotriptor and we don't have it, that's kind of not good. So I think the huddle is a smart thing. But honestly, we, I usually try and do it myself. Like I'll go and run the list with the charge nurse. But I have to say, we're not quite as good as you are. I don't think about that whole huddle thing. But so there are a couple questions. One was, do you do a sphincterotomy if the patient can't come off a NOAC or PLAVIX? John? Yeah, you know, generally with a NOAC or PLAVIX, the answer is no. I mean, you know, I think if you have a situation that is emergent, then you have to sort of tailor that recommendation, right? But how many times... Just had an MI, got a stent, drug eluding, has a stone and they're like, yeah, they are going to be on that drug eluding stent for a year. So, you know, I mean, I think the bottom line is there's a difference between how urgent is the procedure and how urgent is the sphincterotomy, right? You don't always have to do a sphincterotomy. If all it requires is to drain the duct because of cholangitis, you can put a 10 French plastic stent in there and you don't need a sphincterotomy to do that. So I think you can always temporize that way. But unless there's really some one-off mitigating issue, I don't perform sphincterotomies on a NOAC or on PLAVIX or on someone who's actively anticoagulated. You know, if they're on aspirin, sure, no problem. I think there's plenty of evidence and guidelines to suggest that aspirin is okay. But, you know, and if they can't come off of it, then that's a different story. Then you've got to, then that's an individual patient to patient decision. But I think that in your procedure note, you ought to spell it out either in your procedure note or in a visit note or some kind of a short documentation. You ought to spell out your decision-making. You know, and I also talk to the patient about it. I usually tell them, look, you know, this is a really important procedure for you. And, you know, would you rather have a stroke or a heart attack or would you have a GI bleed, which I can usually treat pretty expertly. If I were to hazard a guess, you'd probably rather have the GI bleed and let me tackle that for you. Right. You don't want a stroke or a heart attack. You might not recover from that. And so, you know, it's kind of like what you were saying about perspective. I really try to couch it for them. And then you, they usually really appreciate that. And they're not going to come back and sue you after that kind of discussion. They're going to thank you. Sure. I agree. You know, we do a lot of pegs on Plavix, right. And, or anticoagulation. And we just, you know, you just talk to the family or the patients to say, you know, typically we like to do it off of these drugs, but we get that you can't. So, you know, there's more of a risk of bleeding. We don't know what it is, but, you know, we'll do everything we can. And I think it's sort of similar because we have had patients who, you know, cardiology says they're going to be on Plavix for, and they can't stop it for a year and you're not going to stent them every three months for a year. So maybe you do a small sphincterotomy and balloon dilate, maybe that's a little less of a risk, but it sort of, these are sort of individual cases. They are. And I think it's worthwhile to point out that that's not an evidence-based recommendation. And so it depends on the patient's comfort that requires a discussion, the operator's comfort, take a deep breath and ask yourself, and then, you know, probably also the comfort of your team. You ought to have a discussion at your huddle and what have you. Ashley, I just want to point out that while there's one more unanswered question, while you were lecturing, I answered three in chat form, but I'd also like to bring them up live. So we've got the one that Kenneth just asked, there's Sue Neal's, and then I've got three more to pitch at. Yeah. Okay. So there was a question about do all patients have to have endotracheal intubation for ERCP? So I, you know, at the VA where I practice, we MAC everybody. The only time I intubate is large pancreatic fluid collections that I'm draining, generally. I mean, I don't care. Anesthesia asks me what I want, but I find MAC to be fine. I have a colleague at MUSC who insists on intubation and a lot of the anesthesiologists at the university intubate, because I think they can intubate and then the CRNA hangs there and they walk out and it's like easy for them. But I kind of feel like it seems like a big deal for, you know, if it's not a long procedure. I mean, sometimes it's like you're pulling a stent and sweeping the duct and it's like two minutes and the patient took, you know, 10 minutes to get intubated. It just, to me, seems like kind of a big deal for something that's generally not such a big deal, but I don't know, what's your practice, John? So 100% of our ERCPs are endotracheally intubated. That is an anesthesia departmental decision. And so, you know, bottom line, pure and simple, that's it. There are no MAC ERCPs at Mayo Clinic. Now, you know, some of that has to do with the fact that we perform all of our recovery on our GI or GA patients in our own recovery area right across the hall. And so we don't lose any time really by doing GA. And it's propofol GA. We can use gas, we can use propofol or a mixture of the two. Now, where I used to work, the logistical story was different. If the patient had GA, then we didn't have a space to recover them. And we would lose the CRNA and an RN from the ERCP suite. They would have to go several floors up the elevator with the patient to the PACU, and they would have to do a handoff and complete stage one recovery before they could come back down and set up the next ERCP. And as a result, we erred on the side of trying to MAC them as much as possible. But since we don't have that sort of a logistical loss of time by doing GA, where I work now, they're all done under GA because that's what anesthesia is comfortable with, and that's what they support. Yeah, I would say that's similar. You know, we now have phase one and phase two recovery in the lab at the university, so it doesn't really change things. But at the VA, they go to the PACU, and it's not too big of a deal because it's right next door, but it does take a little more turnover time, a little bit longer. So I think a lot of it really is based on anesthesia preference. It seems like at the VA, they seem to do what I like them to do, but I don't think that's generally the case everywhere. As long as you don't have to chase the patient around the room to get the procedure done, you're going to be able to get it done. And I think what none of us miss is moderate sedation ERCP, where you are the one watching the monitor and asking to tickle with a little more Fenton Versed, and in a long case, you'd end up having given, you know, 420 or something like that. That wasn't that long ago. I mean, I would say in the last three years is what it changed. But for my first, you know, 12, 14 years of practice, we did under moderate and somehow they survived and we got them done. But I do like it better with anesthesia for sure. So another question was, is it standard of care to do EOS prior to ERCP? Are most endoscopists trained in both? I would say, no, it's not standard of care. I think it depends upon your pretest probability. And we'll talk a little bit about that in another talk. But I think I do it for those patients that I'm just not sure. And I, you know, if their numbers are up and you know, you're doing some sort of therapeutics, you don't know what's there. It's a stone, it's a polyp, it's a tumor, it's a whatever. I will go straight to ERCP. But if I'm sort of not sure, I want to take a look first to see, because we're wondering if it's tumor or stone, and maybe I can get more information, I'll do the EOS. Or again, if it's sort of an open access, someone thought the patient needed an ERCP, we just sort of kind of do a little quick change up, patient shows up and consent for both. I would say that most advanced endoscopists are getting trained in both because I think there's, you know, EOS is a nice adjunct for lots of things that we do with ERCP. Do you agree, John, most people get? I totally agree with you. I don't really know of programs that separate them out anymore. Now, you know, I'll say that there are practical reasons for that primarily, right. And it's driven by consumer demand to some extent. But the reality is that I don't think there are North American programs that separate the two out. And a lot of where, you know, therapeutic endoscopy is going really requires the capability to do advanced EOS. So I think that makes sense. Do you agree? Yeah, I think so too. I think, yeah, gone are the days where you just do, you know, one procedure. I think the only people that are trained in that way are people who've already been in practice maybe and then want to go back and learn maybe, you know, some facet of EOS or just learn to do ERCP. I think, you know, both of them take a fair amount of volume to really be good at and be comfortable at. And I, you know, I just think for ERCP, certainly you want to be comfortable being able to do all things ERCP. You don't want to go into this lightly because if bad stuff happens, you know, I don't know. I find it hard to sleep at night when bad things happen, even when I think I did it for the right reason and did a good job. So, you know, it depends upon your personality type. I think that means you're a good doctor. I know my threshold. It's good to know your threshold too. I, you know, I have a lot of colleagues who have strengths in different areas and I'm not shy about saying, hey, you know, this case, would you mind doing this? And, you know, there are people who love doing it. You know, I love taking out big polyps, so I'm perfectly happy if my colleague isn't comfortable and wants me to do one for them, I'd be like, yep, sure, love it. So, you know, I think it's something, know your limitations. And, you know, I actually, when we were putting this whole thing together, there was a talk on, you know, Hyler lesions. And honestly, I'm terrible at it. I mean, I readily admit, I just, I have a plan in my head and it never goes as planned. So that's why I said, John, you take that talk. So I know my limitations. It's good. I think we've got time for one or two more, right? All right. You want to pick? So let's see patients scheduled for CBD stent removal stones remove on index ERCP to reduce x-ray exposure. How safe is it to do without fluoro or EOS? So there are definitely times when we try to minimize fluoro, especially the pregnant patient, for sure. Because we know that we try to sort of shield them, but it doesn't always quite work. So there are techniques that you can use. Certainly you need to use a little fluoro. If you want to make sure that the stones are gone, I would say in general, but you can certainly minimize it by cannulating and aspirating. And if you get bile, you know, you're in the bile duct, pass the wire up. And, but I think you need to use a little bit of fluoro for sure. If you're not sure about whether there's a stone, certainly I would do an EOS, but I think most of the times, if we're doing something for pregnancy, we know a fair amount of information before we dive into that for sure. Yeah, I agree. I mean, I think, you know, these days we've got digital fluoro machines, and as long as you're not taking spot images, if you just flash live fluoro and look at your last image hold and never actually hold your foot down on the pedal till you take a real shot, a still shot, then you're not going to get a huge exposure and it should be fine. So minimize the fluoro, use fluoro, and don't take a real shot. That would be the way that we perform it to reduce as much as possible fluoro exposure. I think it's particularly, if you have a bad outcome, it's hard to support not using fluoroscopic imaging to perform ERCP. I think if you're just going to pull a stent, that's an EGD, that's not even an ERCP. But if you actually need to image the duct to know where you are or something like that, I think you got to use fluoro. I mean, Ashley, I'm sure you see it all the time, you know, where you think that wire's going in the biliary direction, but, you know, if you push the wire a little farther up, it's going to jog to the left, not to the right, and that's actually pancreas. It's going to be bad. The other thing is you could go cystic duct as well. So you don't know, even if you're balloon sweeping, it could be cystic duct. I think, you know, removing a stent without fluoro, which was part of the question, I remove PD stents without fluoro. If they're, if the surgeon's like, yeah, we pulled the drain, the leak is, is sealed, just pull the stent, fine. I mean, honestly, for bile duct, even if it was stented, cause they weren't sure they got all the stones out or stented because I don't know, for whatever reason, I generally do a cholangiogram. I mean, I don't, I don't, cause sometimes you can get debris up there even with a stent in, right. Or the stent was placed because of bleeding or some other reason. I think you can get grunge up there. So I do like to do just a completion cholangiogram most of the time. So it's pretty rare that I will pull out. The only other time is our transplant surgeons now are putting stents in every single patient. And then they ask us to pull the stent. So those patients I will, um, oftentimes do without fluoro. However, we have had some migrate in. So if there's an X-ray that shows that it looks like it's up in the liver, then we usually do those under fluoro. So we don't get stuck having to move patients to a different room. We'll just do an EGD and pull it. But, um, typically I do do a cholangiogram. Do you do that, John? Pretty much. Okay. Pretty much the same. I, uh, for pink stent pulls, I put them on the fluoro table because I have a floor room anyway. And, uh, I don't use the fluoro. If the stent has not in migrate and it's pretty unusual to see a spontaneously in my migrated pancreatic stent, because if you cut the inner flaps off, then they don't tend to ratchet into the duct. And, uh, so we don't see that very often. Hey, there, I think we have time for one more quickie. This one says most community gastroenterologists who are performing ARCP are not EUS trained. I think it's more of a comment than a question. No, I, um, that is probably true. Um, I guess that's going to change though. Right. I mean, we don't have programs training people in ERCP alone. Sure. Sure. I mean, there are some places where they're, you know, the third year fellow does a lot of the ERCP and then goes out and does procedures. And, you know, I, um, that's, that's probably true. Um, I just think the advantage of being able to do EOS is it just gives you another tool in your toolbox, especially for those patients that you just really are not super wild about doing an ERCP. Cause you think that you're, you know, it's not really needed and the patients shown up and, you know, as you're looking through their stuff, um, you've kind of decided that maybe you don't need to put them at such risk for, um, or procedure. So anyway, sure.

endoscopic retrograde cholangiopancreatography

endoscopic ultrasound

informed consent

risks in procedures

procedure planning

procedure preparation