This is time for question and answer, but actually I'm going to start backwards. I'm going to start with the last session or the last presentation where we had our high load obstructions and RFA cases. Anyone on the panel have any specific questions for the panel? I'll actually start, Andrew Storm. Interesting presentation, especially the first case that you had presented where you placed that Y stent in the patient with the gastric cancer. I find that interesting that you attempted drainage of the left duct after having placed the stent on the right side. Is that typically your routine or why did you choose that in that case and what would have you done had you not obtained access, which I think you demonstrated in the second case. Yeah, no, you're absolutely right. So our typical way of working that would be to, you're right, drain the left first. That gives you a nice straight shot and probably an easier access for that second duct. In this case, the wire that I was given actually oriented itself over towards the right. So I had cannulated a pre-existing stent. The ERCP was done entirely blind other than with fluoroscopy. And so I was working over what I was given and you're right, had to make that tough choice of, well, I hope I can get over into the left. But an alternative option there would have been for me to leave my wire to the left or excuse me, to the right and use a second wire alongside to work over and place that stent towards the left. Absolutely, I think totally reasonable alternative. Well done though. What do you think? No, no, I think absolutely. The second, I think a lot of us probably would have started the second way with the second wire or having gone straight into the left, but well done. I have a quick question for you regarding Dr. Luo with regards to the first case and you had mentioned that there were some biopsies taken of the lymph nodes in the area. Is there any concern in those cases if this patient potentially either was a resection candidate or a transplant candidate in sampling those lymph nodes? Absolutely. That's why the multidisciplinary approach, we had discussed this with our surgeons and our oncologists first and because of his significant alcohol history and ongoing alcohol use, it was felt that at this time he wouldn't be a transplant candidate even if we were able to get him through chemo. We felt that the biopsies of the lymph nodes were going to be important in terms of helping stage him in terms of getting information. I think our surgeons are more worried about doing a transhepatic biopsy than the lymph node sampling and so I only went for lymph nodes that were kind of outside of the region of a resection. That's fair and really good point that transhepatic biopsy is where they really are concerned with the transplant patients. I'm going to piggyback off a question here that we have from one of the participants about how to make a decision in a patient who has metastatic disease, you know, to sort of keep doing ERCPs and Dr. Storm touched on this as well as, you know, a patient that might not want multiple ERCPs. How do you make the assessment where you're sort of trying to maximize benefit not knowing necessarily how much a bilirubin might respond to one more ERCP, but also importantly managing complications of stent placement. So one of the concerns sometimes is recurrent cholangitis in patients who are experiencing biliary reflux after stent placement. The technique that Dr. Storm showed, the Y or lambda technique, actually helps to reduce the incidence of recurrent cholangitis. There's going to be a really nice video GIE article that you can keep your eyes peeled out for demonstrating that lambda technique, but any thoughts from the panel about how to navigate patients through that conversation? I'll kick it off, but you've got some other experts here that definitely need to comment. I don't want to bias the audience. I do not use that Y technique very often. I do not use metal stents very often. It's our practice in Rochester to use almost exclusively plastic stents. They burn no bridges. They allow us to revise easily, and one of my worst nightmares, aside from the in-migrated pancreatic duct stent, is having to work through previously placed metal stents to achieve biliary drainage for someone with acute cholangitis. That can be a multi-hour procedure and a real headache for patients. So I think, again, there's some really interesting data coming out, again, an article in GIE for November showing that introductal plastic stents, potentially even smaller caliber, may be very successful in the medium to longer term, like four- to six-month range for achieving drainage. And again, having burned no bridges, that's what I would want. Putting that on my patients a little bit with some paternalism there, but I would want that stent to be able to be revised in the future. I strongly prefer plastic stents. And for that introductal stent, would those be Jolin stents as well? So the article that's in GIE this month actually talks about a stent, which I don't have available to me, with a little tail that hangs down. So seven French plastic stents that actually have that tail that makes exchange easier in the future. I think those things will be coming to us in the States before too long. But you're right, for now, you've got double pigtails or just leaving plastic stents, acknowledging that you'll have to do some work to go get them out later. Thank you. Anyone else on the panel? Joe? You're itching. Am I good? Yeah. Yeah. Well, without, you know, so I totally agree with Andy 100 percent, and without getting into the controversy and the evidence, actually, in the ACG guidelines, we didn't recommend four against plastic versus metallic at the high loam just because of the complexities of the existing data. But I agree 100 percent, and I will say every now and again I talk myself into metallic stents at the high loam, and every single time I end up cursing out loud. So I agree. I mean, your situation, your patient's situation was different. They told you this is the last one, and of course, you know, that's a different context. But in patients who have the means and are motivated to come back, my overwhelming experience has been plastic at the high loam is a better long-term option, and of course, it allows the possibility of doing, you know, adjuvant radiofrequency ablation, which is not well sort of studied or proven in the context of metallic stenting, plus the whole purpose of a metal stent is to avoid additional ERCPs, which is, of course, in conflict with the concept of having them come back every three months and get RFA. So in my mind, there's a strong argument for plastic in that context, but hopefully we'll have some clarity in the upcoming years. I think one of the other things we don't know about as well is just the role of like multiple plastic stents in the same segment, right? Like, I mean, we're not committing people to just one plastic stent in each segment if you can get drainage. Like, if you can get multiple, sometimes it can get them out longer so that they can stay on their chemo longer and hopefully help with like decreasing the risk of cholangitis. I know we're running late on time. Just one brief point, sort of general construct around managing hylostrictures for those of you who do it. I think the best way to look at it is if the goal is to reduce bilirubin to two and a half or less, which is typically the goal of our oncologists, then in principle you have to drain at least 50% of the viable liver volume. The liver is divided from an endoscopic point of view, not a surgical point of view, but from an endoscopic point of view, the liver is pretty much divided into three sectors, right anterior, right posterior, and left lateral. And roughly speaking, each of those sectors accounts for about 30% of liver volume. So in order to achieve that 50% plus reduction, you need to typically drain at least two of those three. Now there are variants. There are patients who are going to the OR and you have to prioritize the future liver remnant. There are patients who have an atrophic left, things along those lines. But generally speaking, you want to capture at least two of the three. And sometimes that requires one stent to the right that captures both right anterior, right posterior. Sometimes based on the patient's anatomy or the characteristics of the stricture, it'll require two stents in the right. So unilateral stenting, but you're still getting right anterior, right posterior separately. And sometimes it truly requires bilateral stenting or trisectoral stenting. But the general principle is that if you can get two of those three sectors, generally speaking, the patient will eventually become a candidate for systemic therapy. And so in my mind, this sort of bilateral versus unilateral paradigm is sort of no longer applicable. And that's what we try to present in the ACG guidelines is we need to rethink our approach to, you know, to the more of a volumetric sectorial approach to drainage. Thank you. I think we have probably time for, you know, maybe one more question for the panel to address. So we've got several questions about post-ERCP pancreatitis, timing of rectal endomethysin, whether it matters before, during, after. And then also, you know, what is considered a high-volume ERCP center and sort of that balance between the volume, expertise, risk of pancreatitis. Does the panel have thoughts on that? Maybe I'll just do the timing briefly. So the RCTs are split. Some give it before, some have given it after. Our initial endomethysin RCT gave it after. There was a large-scale randomized control trial that was published in Lancet a few years ago. There was a complex study in terms of its design, but one of the aims was to compare pre versus post. And in that study, pre-administration, 30 minutes before the ERCP, was shown to be superior. The problem in a real-world clinical practice is it's really hard to predict 30 minutes before the ERCP. You know, things happen, patients get delayed, you find a duodenal stricture, et cetera. So essentially, what I have done in my practice and what we ultimately did in the SVI trial in response to the Lancet publication is split the difference. So typically, give it around the time of cannulation, because if you categorically want to give it before, the case may get delayed and you may give it too soon. If you categorically want to give it after, you know, it may be that the cannulation, the part at which risk of pancreatitis is increasing, happens and then you spend two hours getting a stone out, so you give it late or after and you're giving it too late. So typically in my practice, I split the difference and we give it around the time of cannulation, but interested to hear what the others do. So you're pretty uniformly giving this after the ERCP, acknowledging that that may not be right? Yeah. Well, I mean, no, it's not right. It's not not right. It's evidence-based. There are randomized control trials, including one of which I'm pretty proud that gave it after. So there's no doubt that there is value, but the question is, you know, all you're trying to do is hit the timing right and it's so variable that, you know, it might make sense to pre-pone it a little bit. I would say I'm usually doing it, you know, almost as sort of like a marker of cannulation, like, okay, we finally got in the bile duct, let's do the indomethacin now, or if for whatever reason there's a failed cannulation, do it before we start waking up the patient. And then just a brief comment on the volume outcomes relationship. There's no doubt that like in almost every interventional procedure, there's a clear volume outcomes relationship related to ERCP, however, the outcome in question is typically success, cannulation attempts, need for salvage procedures like PTC. There is no clear volume outcomes relationship for post-ERCP pancreatitis, and that's a very complicated thing to study because it's those who do the most amount of ERCP who are seeing the most difficult cases, the highest risk cases, and who are the last line of defense, so we tend to persist more and try harder. And so the relationship in terms of post-ERCP pancreatitis is quite complicated, but in terms of getting into the bile duct, achieving the clinical objective, avoiding PTC, avoiding hospitalizations, there's no doubt that there is a volume outcomes relationship, but where that cut point is, is a complicated discussion, but I think the general principle is that this is not something that, you know, we should be doing sporadically, it's, you know, folks who do it should be doing it on a regular basis. All right. I want to, on behalf of all the course directors, thank all of our speakers today for this first session. It was a really very thorough overview of some very complex issues. We're going to stop now for a break, and if we could ask everybody to try to return back around 10, we'll plan to start around 10.05 just to allow enough time for a break. Our next session is actually also going to include our ASG presidential lecture with a keynote lecture by Dr. Jennifer Christie, so you don't want to miss that. We'll see you shortly. Okay. Thank you, everybody.

ERCP procedures

gastric cancer

stent placement

lymph node biopsies

post-ERCP pancreatitis