I am so grateful, I want to say to the audience for those questions. Actually, wonderful talk, as you always give. And it has stimulated and generate many generated many, many questions and so people are responding to your education that you're providing. And so, if okay with you then I will segue to what comes after cannulation does that sound good. That sounds great. Okay, then I will take it away standard and access sphincter autonomy, how and how far to go. Here we go. All right. The focus in this talk is sphincter autonomy. And that includes standard or what you would more properly call traction sphincter autonomy that sphincter Tom that you bow is called a traction sphincter Tom access sphincter autonomy for difficult cannulations which I will basically go through just to review for you how I covered those and cannulation because access sphincter autonomy refers to sphincter autonomies that are done to help you access the bile duct which is really an extension of cannulation so it's an invasive way to cannulate, not so much a way to necessarily perform the cut so that you make the opening big enough to do things other than cannulate. Okay, but I'll gloss over access sphincter autonomy. And also controversies and evidence related to these techniques and suggestions on what to do. I also want to mention a couple of caveats that might be worthwhile for here and going forward with the rest of the course. One is that with my slides as I'm sure is the case with Ashley's. You will realize that our slide decks are not only for use during the live course right now here and today, but that they also become durable materials that you will go back and reaccess through GI leap. And it is also your syllabus and as such, there will be data laden slides that if we were just going to use for the talk. I would have ditched. I've chosen to leave them in the talk, so that you can go back and refer to them at your leisure to dig deeper into the details. So if I skip over and don't go over every line and some of the data slides that I show you. I want them to flash past your eyes during the lecture so that you know that they're there, so that you can go back to them and GI leap. Later on, so don't feel like you've been shortchanged the other thing is that some of that material is meant to at least stimulate you to ask some questions during the Q amp a. So, please glance at them. But if we don't dig down deep into the details of that data during the talk it's because hey we're only talking for 20 or 25 minutes, but I still want to give you what you paid for and give you the data if it's worthwhile for you so here we go. So you're saying there's different types of sphincter autonomy, depending on the reasons for how you get in but that's only one way to classify the different types of think sphincter autonomy. You could base it on anatomy, right. But there's pancreatic sphincter autonomy at the major papilla, when you've accessed the ventral duct. But there's also pancreatic papillotomy where you've accessed the, the minor papilla at the duct of Santorini and you can make an incision there as well. It could be classification based on reason. So you might want to enlarge the orifice at the papilla to improve flow, or you may be doing it to facilitate cannulation or get selective duct access whether that's to the pancreas or the bile duct, or you could categorize finger auto me based on the technique, whether that's using a traction sphincter tone, or if you're doing it with a needle knife tablet home. Food for thought. The thought or not to cut the indication justice with cannulation the indications, and the contra indications are not just details. They're really of core importance to sphincter autonomy to all patients undergoing ERCP need a biliary sphincter I mean I recognize that in many practices, just about everybody who is undergoing biliary ERCP is going to get a sphincter autonomy but is that truly necessary, if not which patients do and which ones don't necessarily, and which patients shouldn't have a sphincter autonomy at all you know remember it's not a technical requirement if you're just going to place a single stent, even a plastic 10 French stent, it's not absolutely necessary to do a sphincter autonomy to get that stent in and most patients. So it's important to know when to do a sphincter autonomy and when not, and to be able to justify your choice. Not only deciding where and when to do a sphincter autonomy but how big to make your cut what's the right size for a sphincter autonomy. Does every cut need to be flushed to the do a DNL wall, I would suggest in my opinion it's not. You know, is the right cut from here to here, or is it up to here, or here or way up to here, better not be up to here you'll have a retro parent Neil perforation but, you know, wide variants of opinion some say that you should do a complete sphincter autonomy in all patients others say you should right size it because the, the right size to do a sphincter autonomy is just enough of a cut. Are you having to take out small stones or do you have to go after a big one, and should that influence the size of your cut. Maybe if you're going to do a balloon sphincter of plastic can you just do a limited cut, since you're going to dilate it anyway. Maybe you need to make an allowance for more than one stent and maybe you do need to make a bigger cut and for patients with PSC Do you really want to do a primary cannulation every time you've got to go in and do a brush probably not. You probably want to make a sphincter autonomy if you know that you're going to go in repeatedly. So there's should be a lot of thought going into performing a sphincter autonomy, but also as to the size of the sphincter autonomy. When you do a sphincter autonomy it requires a knife because you're making the cut so let's talk about your knives. There's the catheter aspect of it. Some have a larger diameter some have a smaller diameter. There's guide wire compatibilities some are big enough to accept an oh three five guide wire but some are too small for that and can only take an oh two five and eight and maybe that'll influence your choice. Some have a longer nose, some have a shorter nose, and when we talk about the nose we're talking about the distance between the tip of the tome, and where the wire inserts most distally. There are different tip shapes some have a dome shaped others are cut square. Some have a single lumen or a double lumen the single lumen ones. Generally the lumen for the guide wire takes up most of the space so you probably are going to need to remove the guide wire in order to inject contrast which may be less convenient but may lead to a thinner catheter if that's advantageous. Some are even made to be rotatable if you actually need that most of us will do things with our scope to guide which way the papillotome goes but some are reliably rotatable to some degree or other. That's the catheter then there's cutting wire characteristics, you know, some have a longer cutting wire than others. Some of the cutting wire is monofilament like this one others are braided you don't see that very much anymore and some of them have half the wire coated with plastic that makes it insulated to make it less likely that you could inadvertently coagulate or cut one of the folds that might be overlying the papilla if you can't get out of the way of it. So that can be helpful, like this insulator right here. Bottom line is no matter where you work probably your choices are going to be limited with which vendor you contract with and how many different devices you can parse stock and you'll need to come up with some agreement with your institution and your group with respect to which ones you have and you'll have to use whatever's on the shelf. And that's true for me, just like it probably is for you. In life you have your power, because you can't make a cut without electricity. Most units these days have electrosurgical generators that are microprocessor controlled, which makes it a whole heck of a lot easier because you're not dialing in x amount of cut max amount of coag, but it's already set for you and you have alternating coag so that you're less likely to make an accidental zipper cut and end up with bleeding or perforation inadvertently and unfortunately, that incremental cut and coag, when it came along in the mid 90s was a great advance, along with the microprocessor It's so much easier these days to set your levels and most in units it's as easily done as just pressing a button. So those are the basics of sphincter autonomy, and if I only were able to tell you in one sentence the most important thing I would say that in the, in terms of landmarks and direction of cutting. It's exactly the same as cannulation. If you can align to cannulate properly, then you can align your sphincter autonomy. Well, as well. I know Ashley referred to the clock face, and that is the way I was taught and that's the way that sphincter autonomy and cannulation are taught in pretty much all programs. I tended to go away from that myself. I generally like to look at the anatomy of the ampulla endoscopically to help me determine the direction, primarily because it's easy because everybody's anatomy is a little different and I find just looking at the endoscopically is a lot easier than trying to, in my own brain figure out well what is one o'clock I don't see a clock on the papilla. I might be a little simple minded but I'll show you what works for me and you can decide for yourself. I won't delve into these details. I do have to say that your landmarks are important and I'll show you those in a second. Don't over rely on your elevator excursion, your elevator is not there to lift your knife as you're making your cut, you really should be doing that by withdrawing your knife back on the, the insertion tube of the scope a bit to put traction, so that the, the, there's an adequate contact between the cutting wire and the tissue. You also increase that load of the tissue on the cutting wire by using a little bit of left dial and a little bit of left torque. And then make sure that your guide wire isn't limiting your cutting wire contact with the roof of the papilla. And then aiming your duct is basically bisecting the bile duct impression on the dual DNA wall, and I'll show you that in a sec. What about pancreatic sphincter auto me well it's similar to pancreatic cannulation which Ashley went over for you. It is much less commonly indicated we don't have as many indications for doing pancreatic ERCP as there is there are for bile duct sphincter auto me, but the actual cutting techniques basically the same as it is for biliary sphincter auto me although it's usually a little more to the right, whereas bile duct cuts a little more to the left. And this is primarily required if you're, say just putting a PD stent and to reduce the risk of pancreatic, or rather, post ERCP pancreatitis you don't need to put a, you don't need to do a pancreatic sphincter auto me to put in a temporary PD stent and if you're particularly if you're putting in a smaller caliber PD stent, even for say, a pink duct leak, you can usually get away without performing a pancreatic sphincter auto me. That said, if, if you're doing a pancreatic sphincter auto me. I think it is wise to place a pancreatic stent in there. I usually cut the inner side flaps off if there are any to make it much more likely that the stent will out migrate spontaneously check an x ray to make sure it's passed if it hasn't been do an EGT to remove that stent, so that the stent doesn't dwell in there say more than two or three weeks, because you don't want to induce stent related pancreatic duct strictures, which can become serious. Be careful regarding the length of the sphincter auto me I think just enough is the right length, a pre cut can be done but Ashley talked about the risks and her sphincter auto me talk particularly at the minor papilla so be careful, maybe place a pancreatic stent to help guide you and reduce the risk of pancreatitis after ERCP, and also use into methods and rectally. And for the minor papilla remember that the scope position is different variable and sometimes and unstable position. And I already mentioned that sphincter auto me is really largely an expense, an extension of expert cannulation so if you're an expert can you later you're 95% of the way to being an expert sphincter auto mist. Ideally, endoscope and ampulla alignment that's the key to performing sphincter auto me properly. We'll talk about the direction. As we go into some pictures here in a second. sphincter auto me typically with attraction sphincter Tom is usually for therapeutic purposes, and rarely for access which is most often we've done in the United States with a needle knife sphincter tone because we don't do a trans pancreatic sphincter auto me what we call a golf. very often in the US, at least not yet. Although I think it's catching on, as Ashley mentioned, over the guide wire sphincter auto me is preferable to free hand. Take extra care of this. If the tome has an uninsulated guide wire, because you don't want a short to occur. That can that risk is higher when you have extra excessive traction or elevator loft pushing smashing cramming the cutting wire against the papilla tissue. Also the long scope position tends to accordion up the papilla tissue, so that when you tap on the tome. And then you let go after your cut you're shocked to see that the cuts much longer than you thought. So, so cut incremental and avoid a pedal happy technique where you just keep your foot on the pedal and do and let it, let the cut go through several times. You can always cut more later on. You can't cut too much, and then go back and cut less unfortunately there is no way to turn back time. So first let's talk about standard or traction sphincter auto me. The technique is to align the scope under the papilla, you need to get under the papilla, you're going to have only about a third to a half for the cutting wire up the duct you don't need more than that to make the cut and get the right knife angle get the knife under the cut so not the knife angle is not like this, it's like this. Okay, you're getting under the papilla. The cut is to bisect the ampullary bile duct impression on the duodenum. And the extent of cut as we said was the happy minimum, it's just enough to get the job done. This is the papilla, but we're not going to just concentrate on that. What we're looking at is the whole ampullary anatomy, this little this this impression this sausage looking thing here, this indentation out towards your scope appearance. This is the impression of the distal common bile duct on the duodenum. That is the bile duct behind the duodenum. And when you cannulate, you are trying to make your sphincter at home, go in the exact angle that that bile duct impression is and if you can get that up, almost a guarantee you're going to get your wire guided cannulation done. And guess what, that's the same direction that your cuts going to take when you make a biliary sphincter out of me, all you are doing is bisecting this bile duct impression on the duodenal wall. This is where the bile duct dives into the retroperitoneum. If you go past that, you're going to cause a retroperitoneal perforation. This is the top limit. And you're going to bisect between this and this to make your cut. And your cut length may go to here, it may go to here, it may go to here, it may go to here, but it better not go to there, where you have a perforation. So, those are your guardrails. There is where you are cannulating and starting, and your cut goes from there. And the max you can go is to that red line. There's your cut, you are bisecting the ampullary bile duct impression. Okay, done. Well, we're not actually done, but that's that's pretty much it. Okay. I just say, stay halfway between those green guardrails. Okay. And whether your brain operates in a way that you have to think of the bile duct impression as a cylinder, or as just half of a cylinder. That's actually what's going on. Okay. That's about as simple as I can make it for you. There are adverse events we talked about a potential for a perforation. And this extravasation of contrast is exactly that, you know, contrast that doesn't follow a duct, and is starting to spread out and has bubbles in it. You're not in a duct, that's probably a perforation. And you should try really hard to gently obtain guidewire access to the duct, so that you can place a stent, because that stent is going to direct secretions away from that perforation and make it heal up, and you'll never have to call a surgeon for that. Titus is actually the most frequently seen adverse event of a sphincterotomy, but you can get bleeding or perforation you really as Ashley said need to be an expert at managing all of these things. But it's always easier to prevent than to treat. It's easier to stay out of trouble than get out of trouble so prevent excessive tissue injury. Don't cram gently access there's a difference. Right. Be aware of high traction over cutting, I've said that three times already expertly prevent and be able to treat bleeding. If it occurs it's usually at the apex of the sphincterotomy. You can use a clip. Use a balloon inflated you can use a stent, whether plastic or self expanding there's plenty of literature that shows that both are effective, or you can use a bipolar coagulation probe and coagulate any of those are effective there are no comparative differences. Any are legit, use what you're skilled at doing and have experience with learn to minimize perforation risk and recognize and manage perforation skillfully. Okay, there's another perforation. I've had them. If you've done ERCP enough you've had them. It's okay to have them, they're expected as long as you've taken great care and done the best you can. But you need to know how to treat it. And you need to know how to recognize it in order to treat it. Okay, you avoid it by knowing your landmarks. Right, and performing the sphincterotomy expertly complications cannot be prevented 100% and you should tell your patient that there's a difference between neglect and a complication, right. It must happen when everything is done right. That's a complication. Now, not all papillas are created equal, and not all sphincterotomies are equally simple to do. If there's a hood of tissue lifted up that fold may actually stay back once you lift it up but you need to at least lift it up once so that you can see where the opening. Inside a diverticulum maybe if you cannulate get wire access, put a wire over, put a balloon catheter over the wire before the sphincterotomy, and then talk back gently you can evert that papilla out of the tech, and actually see your duodenal impression of the bile duct, so that you can see where you're going to make your cut. Look carefully. So here's a little video clip. We're staying halfway right between the left and right, the right and left bile duct wall and as you can see, as you cut that sphincter muscle, and the tissue is going to relax and the direction of cut is going to change That's exactly why I don't use a clock face analogy, because what used to be 12 o'clock is now 10 o'clock. Right, we don't care about o'clock, as long as you're staying halfway between, and I am just shy of a complete sphincterotomy there. So here is the inter diverticular papilla I was talking about I'm inflating a balloon and bringing it back I've already done that to evert it actually. And now the sphincterotomy in. We're going to want to make a cut. This part of the wire is insulated so no I'm not going to inadvertently cook tissue with that back end of the tome. You can see that this is for a stone case see the sludge coming out. Now there's the uninsulated cutting wire. I'm turning the scope dial to the left to make my cut. I am not lifting the, the elevator, the ramp of the duodenal scope at all. And I'm not afraid to start and stop my cut. There's nothing wrong with that. You don't have to go from start to finish without lifting your foot off the pedal will do what's safest. Okay. Don there's a question here I'm just gonna ask while we're watching this video of sizing the size of your sphincterotomy based on Boeing the tome which I personally, I do more what you do which is trying to pull the papilla out to see where I'm cutting. I'm not sure that I totally ever got that whole Boeing all the way and if you pull it out it's a big sphincterotomy because it flops out in a weird way it's not really like saying oh this is a big sphincterotomy I do it. Based on more like what you were doing there showing like, oh, when you go into your bowl little sort of helps you see the full papilla, and where you're going to continue to cut but what do you think about that. Yeah, I do sometimes sort of tighten up my tome up the duct and then pull back to ever the papilla. If I don't have a balloon out already or I don't want to do a device exchange, then I will do that. Now, if you use a stiffer guide wire, the degree to which you can evert that papilla with a bowed sphincter tome, as you're explaining, Ashley, is going to be limited. And what you can do is you can pull that wire back, because most wires have a taper at the distal end, the end that's farthest up the duct. So if you pull it most of the way back into the tome and only have a few CMs of wire still up the duct, and you pull back gently, you're going to have the soft part of the wire, the tapered part of the wire, is all that's going to be left where the bowing part of the tome is. And you'll get more bow out of it. You can pull it back to size up your sphincterotomy so far and see how much more you need to cut. So yeah, I do use that. I don't use it all the time. I use it where it's necessary and in substitution for a balloon if I don't feel like doing an extra exchange. Does that answer the question? Yeah, sounds good. Thanks. Absolutely. Thanks for the question, Ashley and team. So here I'm doing a sequential sphincterotomy. So I'm sizing it up there, turning to the left and the right to stretch the tissue and splay it out. And then here's one where the papilla is a little more laterally oriented. So I'm going to maybe push the scope into long position to see if that gives me a little better line up to bisect the ampullary bile duct tunnel. And I'm guessing that it probably does at this point. So it looks like I'm probably going to start my cut here. So we're going to tighten up that wire a little bit. You don't need to tighten it up too much. Don't over-tighten. It looks like I'm still not satisfied. Sorry, John. Sorry, go ahead. I think one thing people might be seeing is how much you're moving around. So when you do a sphincterotomy, you're not just staying in one spot and you cut and then you stop and you cut more. You're going in, you're going out, you're moving left, you're moving right. Because as you said, as you cut, things change. And you got to move, you got to adjust a little bit as things change to really get the cut where you want to go. So don't be afraid to just feel like you have to stay in the one position that was really good when you started to complete your sphincterotomy. Yeah, I think that's a really important point. And that's where I think you need to be really facile with understanding, for example, what is going on with your scope in the long position. Remember the long position, the big dial is going to give you some left and some right, as well as doing what it normally does. And you're going to get sort of less action with your left and right dials. And torque starts to come into more play. And if you want to talk about that more, happy to address that in future Q&A as well. I just wanted to show you some of these videos to demonstrate how to do sphincterotomy expertly. And it's really doing it incrementally, reassessing where you're at, and understanding that the more you cut the muscle, the more the tissue configuration changes. And so you're going to need to alter your scope position in order to stay aligned, and also your sphincterotome position as well. I also tell my fellows to do a practice swing, especially with needle knife. Sometimes, depending upon your scope position, especially long position, like you said, you're up-down dials doing your left-right. So you got to know when you're making that move where things are going to go. So it's always good to do a little moving around, a little practice, see which way things go when you elevate. Yep, thanks for that advice, Ashley. So an overlying fold's not going to prevent you from getting in as long as you push the tissue around. Although, do that gently. You don't want to induce unnecessary edema. And you're trying to move the fold around. You're not trying to push the papilla around when you're doing that. Remember that there is even data that suggests that the number of touches of the papilla correlates with post ERCP pancreatitis risk. So you don't want to unnecessarily touch. Ashley covered access sphincterotomy. So I'm going to gloss through these slides. But I show you these pictures because, remember, I mean, with a needle knife, all that current's going through that tiny little tip of this device. So you need to be really careful not to be knife happy and just really, really touch the tissue and don't put too much pressure down. Because remember that electricity is, that voltage is just like water pressure. And if you have water under enough pressure, you could cut concrete with it. And a pair of spike heels on a woman can exert as much pressure per square centimeter on the floor as an elephant's foot. So you really want to be careful with all that current going not through the surface area of the loop snare that you take your polyp off with. This is a much smaller surface area. So you need to be careful. We talked about the anatomy. I just want to keep showing you that picture. Get under the papilla. Try to bisect that ampullary bile duct impression. Stay away from where the bile duct dives into the retroperitoneum. You don't want to exceed that. That's the max limit. What isn't controversial is that alignment is key. Short scope position is preferred because it's more stable. And all the dials work the way you expect. And back in the sedation days was more comfortable for the patient. Now if they're under MAC or GA, they're comfortable no matter what position you're in. But obviously, if the short position doesn't work, then the long position is worth a try, whether that's full long position or a partial long position. I'll usually push it into long position. And that tends to be an overcompensation. So I'll slowly bring it back. And something halfway between long and short often works well. What is controversial, though, is just about everything else to one degree or other, whether that's what type of sphincter, tome, and wire combination you prefer or what the preferred access technique is for standard cannulation or what your algorithm is for difficult cannulations. When do you abandon standard cannulation techniques? Do you go straight to a needle knife? Or do you use non-invasive techniques for difficult cannulations like Ashley enumerated for you? There is some data, as she pointed out. But there's a lot of discordance or even disparity. And a lot of the data is dirty. So it's hard to know exactly what to do because exactly what to do isn't evidence-based, at least in terms of high-quality evidence. So there's no way for us to make this cut and dry for you. You have to sort it out. But we're here to help you figure out what the best way is for you to do that. So what is controversial is that next in importance to having a good aim is to recognize when to pull the trigger. When do you pull the trigger and go to invasive efforts to cannulate? David can't tell you that. But at least he's got the premise right. So just a quick review of difficult cannulation. There are non-invasive ways to deal with that. Oftentimes, we'll reach for an ultra-tapered catheter with a very thin guide wire, sometimes a hydrophilic one. We might use the two-wire technique, as we say, or the pancreatic stent insertion, and then use a small tome or a wire to try to cannulate the bile duct beside the pancreatic stent. Or you may go invasive. And that might be a pre-cut, like Ashley went into detail about. It might be an entry cut with a traction tome. It might be a goff septotomy, like she talked about, which may be gaining some traction in the US after it was originally described about 25 years ago. It's an old technique, actually. Fistulotomy, which is another old technique from the 80s or early 90s that's starting to gain some traction in some hands. Or a needle puncture fistulotomy, which is fistuloplasty, which you might call, because it's actually not a cut. It's a balloon dilation after wire access, creating a needle fistula into the duodenal impression by the bile duct. And these are different techniques that are performed in different frequency in different countries, because we don't even have a marketed device to do this in the US. Ashley showed you some of this stuff, but I'm going to show you some pictures. I usually actually will try using an ultra tapered cannula with an 018 wire as my first access technique. I'm so familiar with this and have done it thousands of times. So it's relatively easy for me. And it doesn't burn any bridges, because I'm not cutting anything. So I usually reach for this first. And I'm not a big fan of the pancreatic, the two wire pancreatic guide wire technique. So if I've gotten into the pancreatic duct, it's easy for me to put a stent in there. And I'm going to want to leave it behind anyway to reduce the risk of post ERCP pancreatitis if I've made multiple cannulation attempts unsuccessfully. So I'll leave that panc stent in, go next to it with an ultra tapered cannula with an 018 wire, and try to get into the bile duct that way. And the vast majority of the time, that will lead to success. And then I'll go over. I'll exchange that ultra tapered cannula over the 018 wire for a sphincter tone, pull out the little wire, and put the 035 wire up the sphincter tone, proceed with my case. This is just a beautiful video that my friend Nalini Guta now in Milwaukee made when he was a student of Marty Freeman in Minneapolis. He just does a nice job of this needle knife sphincterotomy. So I just wanted to show you that. And of course, this is a needle knife pre-cut. Nice job, Nalini. And this is Nalini with Marty again, showing the same technique with a pancreatic stent already in situ. These are both needle knife pre-cut sphincterotomies or pre-cut papillotomies. One without a pank stent in, this one with a pank stent in. And in both of these, the back wall of the ampulla is protected from that current by an insulator. Here, the insulator is the pank stent. And the other one, the stone's an insulator. These are pictures of the pancreatic guff septotomy. These pictures are analogous to what Ashley already showed you in her talk. This is a needle knife fistulotomy, where you're using a needle knife to basically cut through the ampullary bile duct impression into the bile duct. So this isn't at the papillary orifice. This is above the papilla on that cylinder part of the bile duct that's pushing out the duodenum and drilling right into the bile duct and then getting a wire through there. We don't have a device to do the artifon needle puncture septoplasty or fistuloplasty, as I should say. Here, they've got a needle that's puncturing right into the bile duct. They aspirate bile. They know they're in the right spot, put the wire up, come back, put a balloon over this, and dilate the tract and put the stent in. There are some pearls for needle knife use. Perform a pre-cut over a pancreatic stent when possible, for the reason I just enumerated, which is protecting that back wall of the ampulla. Except where there's a bile duct stone, that stone's going to protect that, keep you from drilling too far back with your needle knife. That pancreatic stent, though, has some other advantages. It adds some stiffness to the ampulla and helps it align better, in addition to protecting the back wall, and also assures pancreatic drainage. Because if it was a difficult cannulation, you probably want to leave that stent behind to reduce pancreatitis anyway. But if you aren't doing it that way and you're doing it freehand, be very, very careful. Cut in a layered fashion, because remember, you can always cut more, but you can't go back and cut less. So you don't want to burn bridges that you don't need to burn. First, align the way that you would for cannulation, any kind of sphincterotomy. The alignment's the same as a cannulation. And Ashley already told you, take some unplugged practice swings first. Just don't plug in first, OK? You don't want to accidentally burn or perforate. Carefully perform multiple superficial incisions instead of making one deep one. And when bile comes out, you know you've cut enough. Flush with water to clear up the view. You need to see well, or you can't drive. Once access is achieved, you can extend your sphincterotomy with a traction tome over a wire or dilate with a balloon and proceed accordingly. Now, I told you I have some data slides. I am not going to go through these in detail. I want you to know that they are here. But there are different recommendations given for how long you should try. And there is no hard and fast rule here. The bottom line is you shouldn't feel rushed, OK? Don't contact the papilla unnecessarily. That alone may increase the risk of post-ERCP pancreatitis. Let that also figure in. It's not just the number of times you've injected or the number of guide wire cannulations that may even be the number of times you've touched. But these things all need to be taken into consideration, OK? Pancreatic guide wire versus persistence or a pancreatic stent, there's some data here to suggest that actually the guide wire technique may not be the preferred technique. Some more data you can look back to. Guide wire versus pre-cut, no difference for cannulation success. Lower pancreatitis with pre-cut in one study in this meta-analysis, OK? But a lot of times, these comparative studies leave some things out here. They didn't compare it to pancreatic stenting. Gosh, most of us do that. So that's something noteworthy. So that's something missing. Also, pancreatitis is lower in this meta-analysis if the pre-cut's done early. And fistulotomy also significantly decreased the odds of post-ERCP pancreatitis. There are also a lot of interesting submissions in DDW a couple of years before everything with DDW got messed up with COVID. So I want you to know that there is some data. And I'm not going to go through it. But the bottom line in showing you this is that there is data. And there's even an algorithm from the European Society. But you're still going to have to tailor this to yourself. Because the bottom line is that the data is not definitive. OK. And we can go through some of this stuff in the Q&A. Points to consider. Almost all this data comes from expert centers, not from community centers or from low-volume operators. The studies with pre-cut data represent procedures that are performed by expert endoscopists. They're performed only for difficult cannulations, not for standard cannulation. And there's a good bit of data. But we said a lot of it's hard to compare. And not all of it is clean. In fact, most of it isn't. And a lot of that data is from before endomethacin. A lot of us use endomethacin or any rectal and sed suppository before, during, or after ERCP if we've had a difficult cannulation or pancreatic entry. Some give it to all ERCP patients. And most of this data doesn't include patients that were given rectal and sed suppositories. So where's the beef? What's the bottom line? The good news is that the evidence is growing in both quality and quantity. But we're not there yet. There's a new guide. There's a guideline I just showed you. It's evidence-based. But the evidence it's based on is still heterogeneous. So it makes it hard to compare. It's still overwhelmingly from expert centers. Some studies don't incorporate pancreatic stenting. And others don't incorporate rectal and sed suppositories. So I think for now, the take-home message is still sphincter, tome, and wire-guided cannulation demonstrate comparatively clear evidence for increased cannulation success, safety, and efficiency. Needle knife pre-cut entry demonstrates good performance compared to prolonged persistence. But the data is generated in expert hands, high-volume centers, and can't necessarily be extracted to other settings than operators. Other invasive techniques, such as entry cut and septotomy, are less studied but merit consideration. And actually, septotomy is a subject of a prospective NIH-funded trial. Actually, the first full paper came out from that group about a year ago, which I reviewed and wrote an opinion piece about that was published last year. Fistulotomy is less used in the US. But you might give it some consideration because technically, it's actually easy. Less invasive techniques, though, abound. And you should consider those as well. And it might be worthwhile to have ultra-tapered cannulus and 018 guide wires on your unit for this purpose if you don't have them. If the pancreas is wire-accessed, why not put a pancreatic stent in there? Cut off the internal side flap so that half the time, it'll out-migrate without having to sedate and perform another EGD within the next couple of weeks. Each incremental attempt at the papilla, you know it counts increasingly for post-ERCP pancreatitis. And so use that to dictate when you're going to use advanced techniques and quit persisting in conventional attempts to cannulation. But whatever you're doing, always take the time to align and aim well. Whether you're a tennis player, a golfer, or still play softball or whatever, I'm sure you align yourself to home base or align your putt on the green or whatever. Well, I would think your patient is at least important. They're actually more important than your ball. So take time to aim well, regardless of the technique that you used. Expert cannulation technique is the foundation of expert sphincterotomy skill. It's not the knife in your box. It's your hands, your brain, and your eyes. Alignment and ampullary anatomical knowledge are essential to success and reducing the risk of complications. Sphincterotome choices are driven by features, operator preference, and what you actually stock on your shelf, which may not be your own decision. It's not for me. Be thoughtful regarding sphincterotomy and only do sphincterotomies on patients who actually need them. Tailor the length of your sphincterotomy to the needs of your patient. You're going to take out a big stone or just a little stone. And attention not only to expert technique, but also to proper indications. And preventing complications is better than managing them every time. Thank you very much. Thanks, John. That was awesome. So much information. There were a lot of questions. I answered a fair number of them, hopefully OK. There were questions about one question about managing or accessing and doing sphincterotomy with diverticulum present at the papilla, which is always a challenge. There are lots of tricks that people use. I think you talked a little bit about getting up there and pulling the balloon down, which I think is a great idea. Because sometimes you can't really see how far you can cut when you've got that diverticulum. Looks like it's not much. You get a little nervous. Do you have anything to add to that? Yeah, I mean, I think that's a really useful technique. You really only need a small balloon up there to do that and evert the papilla. But I equate it to driving. I live in Minneapolis. And I commute an hour and a half every morning and an hour and a half every evening between Minneapolis and Rochester, Minnesota. And for those of you who aren't aware, it actually snows here a lot. And it is extremely windy. And I'm constantly washing my windshield. And sometimes it's so cold that the windshield washing fluid freezes on my windshield. And I couldn't tell you that there's anything scarier than that, where you realize you're still driving 70 miles an hour. And you suddenly can't see a doggone thing. And it's dark in the morning. And the road is narrow. And you wouldn't drive that way. You're going to pull off the road and scrape your windshield so you don't get killed or kill somebody else, too. And you want to be equally careful with your patient. You've got to see what you're doing. You've got to see where you're going. Wash your lens. Evert that papilla. I did a sphincterotomy the other day with a scope inside the tick. And you can actually do that. And if that's the only way you can get it done, then you need to do that. You've got to do what you've got to do. Just make sure that the patient actually needs it done. And if they actually need it done and it's important, just do it as carefully as you can. And even if the outcome isn't always great, if the process was correct and you were doing it with the right thing, with every ounce of sincerity that you have, your patient will thank you for having tried. And they're probably not going to sue you, as Ashley so rightly pointed out. And I think it's really important when you're talking about perforation. One thing you have to learn is to just be calm, right? It's scary. I had a patient recently, I forget, I think it was a malignancy, which these tumors, you can go right through them and into who knows where, and you're injecting contrast and you don't see anything tubular and you see it sort of running off the side and you know you're in the perineum. So your natural tendency is to be like, all right, I'm out. But I think the key is to persist because you've already done what you've done. And the only way really to fix it, not that necessarily that patient's in big trouble, but you do kind of worry is to keep trying and I got in the dock, get a stent in, especially if you're putting a metal stent in that patient and then put them on antibiotics. But being persistent in that case, I think is really important because you can fix your own problem. But it is, I mean, I feel it. This was just like two weeks ago. I mean, you still get a little tachycardic and you're like, geez, when you don't see tubular or you get a submucosal injection, I mean, your heart just sinks. You're like, ah, I've done it. So I think you have to just kind of get a little zen, get a little calm and keep going.

sphincterotomy techniques

difficult cannulations

ERCP procedures

expert cannulation technique

needle knife pre-cut

guff septotomy

fistulotomy

ultra-tapered cannulas

thin guide wires