So I think we'll start, we'll continue with our didactics, moving on to the first step in achieving a successful ERCP, either going into the pancreas or bile duct is, how do we get into it? So cannulation and then sphincterotomy. So I think, I mean this is, to me, yes we talk about the techniques, so how do we get into the bile duct, how do we do sphincterotomy. But for me, I think the most important take home point for this talk and ERCP in general is this checklist, which all of us, we go through before we embark on ERCP procedure. As I mentioned earlier, pre-procedure, you want to make sure you have a proper indication. What is the number one procedure where our endoscopy is to get sued? It's ERCP. It's not colonoscopy, it's not upper endoscopy, EOS, POEM, or all the other fancy procedures we do. It's ERCP. And oftentimes they are successfully sued. So it's very important that you have the proper indication and that is also the number one reason physicians get sued on the procedure was done, they ended up with complication and the procedure did not have proper indication. Again cannot stress the importance of doing a proper HNP, talking to the patient, risks, benefits, and also reviewing all the imaging up front. As I mentioned, this is a therapeutic procedure, not a diagnostic. So we look at all the imaging. If there's a stone, if there are strictures, how do we approach the patient? Do we inject contrast both sides? Do we preferentially target one side versus the other to avoid contamination? Looking at the room, do I have people who are appropriately trained? Am I using long wire, short wire? If I'm using long wire, do I have the people who know how to handle long wire system? And of course, do I have everything in the toolkit if things were to go south? Do I need a cholangioscope? Do I need certain type of, certain length of stents? Or sometimes we have to fashion the stents out, especially in patients who need a really long stent because of the stricture higher up. You fashion it out of a nasobiliary tube. So you have to make sure we know about the patient. We check. We have all the equipment. All patients in our endo room, they get lactated ringer while they are in the pre-op area. Why? Because it reduces the risk of post-CRCP pancreatitis. So lactated ringer, hydrate them really well, and then intra-procedure rectal endomethasin and pancreatic stent. Those are the three things we do to reduce the risk of pancreatitis. We are looking at the patient position. How should I position this patient? Patients with the left lobe hepatectomy, you know, they are probably a little bit better. They have a J-shaped stomach. We try to do them in left lateral position. Any altered anatomy, post-ripple, you may want to start them left lateral versus supine. We want to make sure they have adequate and appropriate labs. Make sure they are not coagulopathic. If I'm planning on doing sphincterotomy, if a patient is cirrhotic, making sure, you know, they have decent platelets. Should I avoid sphincterotomy in those patients and do balloon sphinctroplasty instead? So it's important to have that information up front. Need for antibiotics. Later on, we'll hear talks from Dr. True and Dr. Kim going over what are the ASG guidelines about antibiotic and which situations require antibiotics. And of course, the sedation, intubation versus no intubation, prone versus supine, et cetera. We talked about all these important factors, endomethacin, using CO2. Everybody nowadays in the lab, we use CO2. Again, post-procedure discomfort is less. Patients are not extremely bloated. Sometimes it becomes difficult if you're using air, whether they have abdominal discomfort from massively descended belly from prolonged procedure, putting air in, or are they getting some complications like posterior CP pancreatitis. So always use CO2 in these patients. Support them up with LR, keeping in mind their cardiopulmonary risk factors. Fluoroscopy, judicious use, we heard Dr. Lee talk a little bit about that. And of course, during the procedure, we are talking about how am I going to get into the patient's duct? What else will be needed during the procedure? I'm going to skip about the fluoroscopy. So whenever we are starting the procedure, one thing that we always do, and I'm sure my colleagues here attest to that, is getting a scout film. So once a patient is on the table, we do get a scout film before we drop the scope down for several reasons. One, you have a baseline. If you have a pre-existing stent or percutaneous strains or large pancreatic duct stones, you want to capture that. Also you have a baseline. If something were to go wrong during the procedure, you can go back and check the baseline scout film. So it's always a good idea to start with the baseline. Here you see a metal biliary stent, a long plastic stent. You cannot see the other end, but this is a pancreatic stent. They usually may or may not have an internal flap. This is a single pigtail. You see the fluoroscopic marker and a large shadow here, which is the pancreatic duct stone. So you can gather a lot just from a scout film based on the indication. Again, cannot stress the importance enough, making sure proper indication. Look at the labs. Look at the imaging. And also know when to stop. You know, the procedures are not what I can do. Whenever we think like, okay, what can I do? It's all about the patient. What is right for the patient? What are your own skill set? What are the limitations? Even now, after being doing this for 20 years, we have no problem calling colleagues in the room, hey, do you mind looking at this? What do you think? What should we do? Or actually giving the scope to somebody else. There's no ego or anything like this involved when you are taking care of a human life. So be cognizant when to stop. And it's okay to refer the patient if you think this is beyond your skill set. I think this is the most important thing. Patient first. It's not a cliche. Literally, patient is first. You would want to treat every single patient as you would your own family member. So when we are talking about cannulation, again, we stressed, addressed this a little bit in the previous talks. There are a plethora of tools that are out there. And if you talk to each one of us, we may have our own favorite on how we start. I start with the standard O35 wire straight and standard 4-4 tome. Some may start with a smaller tome with an O25. Some may start with a straight cannula. Some may start with a balloon if the patient has previous phenterotomy. So a huge list of procedure products that you can choose from. Some are single lumen where you can pass the wire. If you have to inject contrast, you pull the wire out. Others are multi-lumen which allow you to inject contrast while the wire is in place. Obviously multi-lumen is preferred because you really don't have to go back and forth with the wire. We start with the sphincter tome, especially with a native anatomy. Why? Because it allows you not only to flex the sphincter tome, get in an appropriate trajectory into the bile duct or pancreas duct, but also allows you to do sphincterotomy. So again, a little bit more of a cost effective tool compared to going in with a cannula and then switching to a sphincter tome to do a sphincterotomy. Again different sizes, different tips, tip configuration, different length of the cutting wire. They come in long wire and short wire system. So I hope everybody understands short wire and long wire terminology, correct? Okay so short wire is something that is controlled by the endoscopist where the wire, it splits about 5 to 10 centimeter from the end of the channel here. So the wire will come out somewhere here and I control the wire. I can direct the wire in the bile duct and the exchange is relatively short because it's just 5, 10 centimeter of the length of the device that wire has to exchange out compared to long wire where the wire is coming out from the other end of the device. So that's where your tech is the most important person. They are controlling the wire. So you tell them okay advance the wire, push the wire, and if you're exchanging it's really a long length of the catheter that you have to exchange the wire out of. A lot of us, I don't know, who uses long wire in the faculty? So we have few long wire, few long wire, and then we have few short wire. And we can debate about long wire versus short wire, not a huge lot of data out there but one randomized controlled trial. It showed that short wire risk of pancreatitis is less just because you're controlling it. Otherwise you're relying on your tech in terms of what tactile feel they are getting. So guide wires, another important factor in cannulation, we'll talk about guide wire cannulation, comes in different sizes. The skinniest is 018 and these are really skinny flimsy wires. The biggest one we have is 035. Most of us we start with either 025 or 035. 018 is usually limited more for interventional EOS procedures or if you're navigating tough biliary strictures or you are doing cholangioscopy and you want to leave a wire in next to the other device. So only wire compatible with device in the cholangioscope is 018. Come in different lengths. You can use 260 for a short wire system, longer length if you're doing altered anatomy or you're using endoscopes. They come either straight or angled. Sometimes I would go angled, fully hydrophilic if I'm doing the pancreatic work. They come in different coating, fully hydrophilic wire. So these are, I love this fully hydrophilic wire. I mean they're really slippery but that's a positive and that's also the negative. It just flies out if you don't know how to control it and especially if trying to make it work with a long wire system. But most of the other are a combination. So the distal 5 cm or 10 cm is hydrophilic which allows you to spin it enough. There are rotating devices even for the long wire system that you can use. So tons of wires out there that you can try. While using standard tools and techniques we are able to achieve successful cannulation in the bile duct or pancreatic duct 80% of the times. But then if those 20% is where you need to go a little bit beyond. So you're using advanced skills like double wire, going over the pancreatic stent and then finally pre-cut sphenotomy. If that doesn't work then now you're looking at the EOS or even IR percutaneous access. So starting with cannulation, once you have identified the papilla, should I go directly once you have engaged the papilla, go and inject the dye or should I advance the wire? I think most of us now with the research we go in with gentle probing of the wire. If you have a straight tip versus angled tip, again depends upon the trajectory. We start with the wire, they are soft hydrophilic tip. But you have to be mindful, even though we are not injecting contrast, even repeated manipulation with the wire increases the risk of pancreatitis. So this is where I personally prefer short wire system because I'm controlling it. I can feel if I'm getting the resistance. You can look at the trajectory. Am I going in the bile duct, am I going submucosally or I'm going in the pancreatic duct? So an example of a wire guided cannulation, so you look at the orientation of the papilla. So usually you're on FUS, you're looking straight up and bile duct is cannulation. We usually try to go in between this left upper quadrant, anywhere from 10 to 12 o'clock. You are gently touching the roof of the left upper quadrant of the papilla. You're aiming upward. This is a nice alignment. It's not a floppy redundant papilla. This is an easy cannulation. You saw the tip of the wire coming out of the sphincter tome. It's a little bit flexed. You see a little bit of a tension bow here in the wire to give you a proper orientation going up. And then you did all that, there's the wire going into the pancreatic duct. So this is a double wire technique where the first wire went into the pancreatic duct. My goal is to get into the bile duct. Here there are several ways you can get into the bile duct. Some of us, once you are into the PD, we may just choose to leave a pancreatic stent at that point. Why? You want to protect the patient from pancreatitis now that you have instrumented it. Two, leaving a PD stent, it also gives you and straightens the orifice, knows exactly how much you need to flex the sphincter tome to orient towards the biliary orifice. There is data however, it shows if you leave the PD stent in first, the chances that now you have to do pre-cut sphincterotomy goes up higher. In other words, me being able to get into the bile duct without having to cut papilla, they go down a little bit. Still I favor, instead of buying another wire, I put a PD stent in and then I go. But the double wire technique is essentially the same and it serves the same purpose. You leave the wire in and then you take the sphincter tome out, take another wire, load it in the sphincter tome and now you try to go above the PD orifice. So again, wiring the PD serves the same purpose. It gives you the trajectory, how much you need to bow so you can get into the bile duct, straightens the angle. So that's the double wire technique. One thing, again, it's very important. If you go with the double wire technique, always leave a PD stent in again. If the patient were to develop pancreatitis, there's no way you can justify why once you were in the PD you did not leave a PD stent in. So you do in the end end up leaving a PD stent in. So I personally, I just leave the stent in and then I try to cannulate above it or go with the pre-cut sphincterotomy. So this is another video showing a double wire technique. Notice here there's a diverticulum. So presence of, just like colon, people can have diverticulum in the second portion of the duodenum. The presence of diverticulum is higher in older patients. So if you are going to do an ERCP and octogenarian, chances are about 30% of those, there will be a tick in the vicinity of the papilla. And that makes it a little bit more challenging and it depends where the papilla is. If the papilla is in the middle of the tick or it's on the side of the tick, sometimes it's not visible at all and it may make procedure more technically challenging. And not only it makes access difficult, the landmarks are also skewed because once we are trying to get in, next thing we go once you're in is to do sphincterotomy. And the risk of perforation is higher in this patient. So that's the base of the tick. This papilla is located at the margin. So a little bit easier. You notice that the wire was in the pancreatic duct. Presence of wire helps in the PD, helps us getting into the CBD. And again, another example of double wire technique in somebody with diverticulum. We talked about the advantages and again, it's important to leave a PD stent in and it's also recommended by guidelines. We'll go over that in a lecture later today. We talked about the disadvantages of the double Y technique, the most important is the risk of pancreatitis. If you compare the double Y technique to other advanced techniques like access phendrotomy, the success rate is similar. Hence the rationale behind me going directly to the pre-cut sphendrotomy if needed. So moving on to advanced skills like what is pre-cut sphendrotomy or access papillotomy. So pre-cut, pre-cut, you know when we do sphendrotomy we are already inside the bile duct or pancreatic duct. And that's, you blow up the sphendrotome and you do sphendrotomy, you cut the biliary or pancreatic sphincter, the figure of eight sphincter or fodi. But pre-cut is where you are not able to get in and now you're able to make your way in by incising the mucosa and then getting deeper down into the biliary fiber. So it's an incision made into the ampullae of water or CBD prior to getting into the bile duct. When do we do it? A lot of data shows the earlier it's better. So gone are the days where people are sitting around working at the papilla for another 45 to 50 minutes trying to get in. Research shows the longer you work at the papilla trying to get in, higher the risk of pancreatitis because of all the manipulation and edema. So generally most everybody in this room, we agree, you try it for about 5, 7, 10 minutes max. If you're not able to get in, it's time to move on to pre-cut sphendrotomy. People they also have defined that, you know, as a difficult cannulation. So if you work for 5 to 10 minutes, you didn't get in, or if you got into the pancreatic duct 3 to 5 times, that's also defined as a difficult cannulation. So move on to access sphendrotomy. Extremely high success rate in experienced hands. Earlier, you know, this was considered as one of the risk factors for post-CRCP pancreatitis. Not so now. In experienced hands, if you are doing a proper pre-cut sphendrotomy and if you didn't spend half an hour before getting to the sphendrotomy, there's no increased risk of post-CRCP pancreatitis from pre-cut. And of course, it significantly reduces the duration of the procedure. Whenever we know that we are dealing with difficult cannulation, you are making sure that the patient is prophylaxed. They are getting rectal endomethacin. Some of us, we do blanket endomethacin on everybody. But you have to be mindful of the cost associated with it. Believe it or not, Medicare, they get billed $1,500 for a $2 suppository. Second, you want to make sure that they don't have a significant anaphylactic reaction to non-steroidals. And if you were in the PD, always leave a PD stent in. This is an algorithm that most of us follow some version of this when we are trying to get into the bile duct. This is published in ERCP book by Barron and Kozarek. Again, we start with a guidewire cannulation. Why? Because it's not really a good idea to be injecting the contrast, especially if you get into the PD. Opacification of a PD, especially if you inject a lot of contrast in the PD, is a known risk factor for post-ERCP pancreatitis. That's why we avoid using injection of the contrast as a way of us knowing if we are in a duct. We always go with a guidewire and see on fluoroscopy which direction it's going. And if you are successful, excellent. If not, this is where we get into the realm of difficult cannulation. And again, it depends whether we got into the PD or not. If we got into the PD, you can use the double-wire technique or you can leave a stent in and then go on to cannulate above the stent. If successful, excellent. If not, you move on to pre-cut sphincterotomy. If you didn't get into PD, which means like no duct at all, this is where you have to assess your own skill set. Are you comfortable with pre-cut? A lot of people are not. So all of us here, we have gone through an additional year of training for advanced endoscopy. But that's not the reality in our country. Majority of the ERCPs, 660,000 or 700 of ERCP in our country are performed by people in the community. And majority of the people they are grandfathered in, they are not fourth-year trained. That's the real life. But so this is where you make an assessment of your own skill set. Are you comfortable with pre-cut? Yes. Can we go on to that? If not, stop and send the patient where you have a better skill set. Sometimes just bagging the case and bringing the patient back two to three days later, the success rate is about 85%. And this is another graph which essentially goes through about the same thing that I mentioned earlier on the how do we go about achieving a successful cannulation. So talking about now different pre-cut technique. The first one is the papillotomy. So this is where we are going through the orifice and making an incision upward. You know, you're engaged in the orifice and you're making an incision upward. A different version of that would be trans-pancreatic sphincterotomy. Let's say you got engaged in the pancreatic orifice, or this is also called a GAAF technique. I may have used it once or so. You get into the pancreatic duct and then you tilt your sphincterotome towards the biliary direction. So you move it a little bit leftward, more towards the laminar position. So the idea behind that is you're cutting the sphincter in between to get into the bile duct. Research shows they're all comparable. My favorite is pre-cut fistulotomy. And this is also recommended by ESGE. Fistulotomy is where you're sparing the orifice. You know, you are going above the suprapapillary portion of the bile duct. It reduces the risk of pancreatitis. There's data showing that because you're not instrumenting, manipulating the biliary pancreatic orifice. And again, this is really an old video showing the fistulotomy technique. So we didn't talk about, you know, the RB settings, you know, our current settings that we use. We use a blended current. But this is, we are using a pure cut. It's not recommended to use pure cut because you get a zipper cut and the risk of perforation is higher. There's some data which shows if you use a pure cut in the pancreatic sphincterotomy it may reduce the scar tissue formation and subsequent problems like pancreatitis. So for pancreatic, some old timers may still use pure cut. But for pre-cut sphincterotomy, always use blended. But this is a pure cut. You can see the nice. So this is all the intradudenal portion of the bile duct. Another thing when we are doing these procedures is trying to identify the landmarks. Okay, what is the upper end of the bile duct? Well if I were to make an incision here, I'm asking for a problem. This will be a frank perforation in the dudenal wall because I'm going above and beyond what we call the intradudenal portion of the bile duct. So understanding which fold I can go up to, what are my landmarks is what is responsible for safe technique. And this is where I think initially all that taboo came about as well because people were really concerned. We were not able to tell exactly what's the top end of the bile duct. And you don't know how high you go. You can see free perforations flying around because they went a little too high, a little too deep. It is a very controlled technique, although this video doesn't look like it's controlled like a mask of Zorro going on. It's a very controlled technique, teasing mechanism. So you're starting with the mucosa, open that up, slowly teasing, opening it up till you see the biliary fibers. And if you follow these safe techniques, I mean this is an entirely safe procedure. So the orifice is lowered down. So we started a little bit higher up. You notice how quickly this is flying with a pure cut. And you soon start seeing a little bit of a yellowish, pinkish, biliary fibers. Another telltale sign is we start seeing a little bit of a peristalsis, which also cues me in that we are looking at the bile duct. You see the pinkish fibers coming out. Once you feel comfortable that you have exposed the biliary fibers, you go in again. That's a wire-guided cannulation. You saw the little bit 2 to 3 millimeter wire sticking out and that was gently advanced and that's how you achieve a successful cannulation here. And in the end, you know, you go on to finish the sphincterotomy and do the therapy that needed to be done. So this was actually a video that I took from my iPhone. This is our advanced fellow doing pre-cut sphincterotomy in their third month of training. So they started in August. This was taken in October. So more and more we are letting our trainees do this procedure early on. This is, I mean, as you can see, this is a really nice, big, juicy papilla because of an impacted stone. This is really a great case for anybody to, you know, if you have a trainee working with you, you start them on papilla like this. So this is like a papillotomy started at the orifice and then you're going up. And then you'll see a gush of pus coming out. You'll see a small diverticulum here on the side. The papilla is a little bit skewed because of the impacted stone. Lot of generous landing space here. The upper end of the sphincterotomy could be as high as up here. So a lot of space and now you see the stone coming out. So the procedure itself is really safe, especially in situations like this where you have impacted stone with generous papilla. We talked a little bit about the trans-pancreatic sphincterotomy. Anybody in the faculty, do you guys use trans-pancreatic sphincterotomy, GOF? So we have two who use GOF. So you're basically engaged in the pancreatic and then you're cutting across the septum to get into the bile duct. Pre-cut over the pancreatic stent. So this is what we talked about, right. If you get into the PD first, you have the wire in the PD. Instead of double wire technique, you leave the pancreatic stent in and then you go on to do your pre-cut sphincterotomy above it. So here you see a single pigtail plastic pancreatic stent. So this is a hooded sort of a papilla. You have this cutting wire coming out of the needle knife. So it's very important when you are doing needleized sphincterotomy, you're communicating with your assistants on how much cutting wire you need. Because not every papilla, every papilla is different on how much tissue needs to be cut. That determines the length of the wire that needs to be out. As you're teasing and opening, splaying, open the papilla, you need less and less wire. So here, you know, you saw the pre-cut being performed over the pancreatic stent. you gain access and get into the bile duct. So this is just to show you, you know, how important it is to look at the scope position while we are doing sphincterotomy. So usually when we are doing biliary sphincterotomy, the aim is to go like 12 o'clock position, between 11 to 12. And sometimes that is not possible to do in a short scope position. I'll pause this one. So you notice here, the 12 o'clock would be in this direction here. Here I'm going in the pancreatic direction. That's where the pancreatic sphincterotomy would be. So trying to orient the papilla, sometimes you cannot get it on fast. It's facing medially so you lose a landmark. You still have to keep in mind the clock face. So the 12 o'clock position would have been here. And if you have a large stone that's coming out, because of this now overhanging cleft of the tissue, it may get trapped. So it's important when we are cutting, we cut in a 12 o'clock position in the trajectory of the bile duct. So it's easy for us to remove the stones out and to get in and out of the bile duct easily without hanging over these folds. Now that may not be always possible in a short scope. And that's where we may have to go in a long scope position where we push in the scope a little bit. You're making a little bit of a loop in the stomach. And now you have successfully oriented your sphincterotome in a 12 o'clock position. And you can do the sphincterotomy. Again the procedure itself is quick, safe, but again it's important to look at the landmarks and make sure we are going in the correct direction. So to summarize, again we looked at the different pre-cut techniques. There are a few that are out there. Everybody has their favorite. You can pick and choose any one of these based on underlying indication, patient anatomy. If you look at the data, they're all comparable in terms of safety and success. It boils down to the personal preference. Always keep in mind that we are taking care of the post-ERCP pancreatitis prophylaxis by giving them rectal endomethasin, loading them up with fluid, and leaving a pancreatic stent in where necessary. So I think these are some of the things that we already talked about, prevention of post-ERCP pancreatitis. I'm sure Dr. Arand will go over the management of adverse events. One important point I would like to point out is, if you leave a pancreatic stent it's very important that we follow up those patients. I cannot stress the importance of this enough. Sometimes when we leave the pancreatic stent and they have those internal flaps, the pictures that you saw, they're not going to fall off on their own. Majority they don't. They stay in because of that flap. And that's where we recommend getting an abdominal x-ray 7-10 days later. And if the stent is still there, which if you have a flap it will be, you'll bring them back for routine upper endoscopy for removal. If you left a short stent, for example 3-4 cm long without internal flap, majority of those they pass out on their own, about 95% of those. So you don't need an endoscopy. It boils down to again, what kind of stents you have in your endo unit. You may or may not have to bring them back for upper endoscopy for removal. But it's important to follow up on these patients. So to summarize, I think again, for any ERCP we have to be careful that we have a proper indication. Avoid marginally indicated ERCP. We'll go over what are the guidelines. Make sure during the procedure we follow all those guidelines. We are taking care of the patient appropriately. Look at the patient and procedure risk factors. Know your patient inside out. Know their history inside out. Know your own limitation. Know your toolkit to reduce the risk of complications. Again, if this is something that you're not comfortable doing, it's okay to stop and send that to people who have more experience and training than you do. Make sure you have a well-stocked toolkit to take care of the complications. We'll hear a little bit more about them. If you have difficult cannulation, it's important that we go on to pre-cut sphenotomy early on. It's safe and it reduces the duration and risk from the procedure. And those of us who do interventional EOS, EOS is another trick and null toolkit that we use to achieve successful cannulation. Thank you so much.

ERCP

cannulation

sphincterotomy

post-ERCP pancreatitis

patient evaluation

guide wire cannulation

pre-cut sphincterotomy