I'm going to talk about indications and radiation safety. So indications for ERCP, it used to be a diagnostic procedure. But it's no longer a diagnostic procedure. It's a therapeutic procedure. So there's an MRCP, as you know, which took place of diagnostic work. And as we just reviewed, ERCP was introduced in 1968. And it was designed to see the bile duct or the pancreatic duct. But now we are doing therapeutic work. So in 1974, sphincterotomy was introduced. And we do pre-cut sphincterotomy, brushing and biopsy, dilation, stent placement, cholangioscopy, intraductal ultrasound, ampulectomy, and radiofrequency ablation, and EOS-guided gastroenterostomy. I'll go over many of these with examples. There's a thing called the ERCP weather. In Houston, we have two seasons, hot season and hotter seasons. So every ERCP starts on a sunny day. And that's when you come in and you're chatting and how's life, Medtronic is great. And then 10 minutes later, you see that ERCP in the hospital is sweating. And all of a sudden, the room is a little bit quiet. And that's the time that you shouldn't talk. And then it gets worse, and some unpleasant words come out. And then clearly, it's sinking. It's time to get out of there. The benign indications and malignant indications. Benign indications include choledocholothiasis, primary sclerosing cholangitis, chronic pancreatitis, biliary stricture from radiation, congenital bile duct abnormalities, and biliary stricture from surgery, including post-cholecystectomy stricture and post-liver transplantation strictures and post-whipple strictures, malignant cholangiocarcinoma, pancreatic cancer, ampullary neoplasm, metastatic cancer. So let's dive into benign indications, stones. So stones are the most common cause of biliary obstruction. And the symptoms include biliary colic, right upper quadrant pain, obstructive jaundice, cholangitis, pancreatitis. So ERCP is quite sensitive in detecting stones, with a sensitivity and specificity greater than 95%. When ERCP cannot show the stone, we do pleural cholangioscopy, use a very small scope and get into the bile duct. And it's effective in 83% to 100%. So ERCP, sphincterotomy, and stone extraction are quite successful, with a greater than 90% success rate. And adverse events are about 5%. It all depends on the operator. And mortality is less than 1%. Now we have multiple steps that we can do. If conventional cannulation fails, then you can do pre-cut needle-knife papillotomy, or use an EOS to get into the bile duct. For primary sclerosing cholangitis, as you know, there are multiple strictures. So we use MRCP as a diagnostic workup, rather than ERCP, because once you inject the contrast, you cannot drain all contrast out. It can cause cholangitis, or by trying to get into the bile duct, it can cause pancreatitis, or bile duct perforation, bleeding. So post-ERCP hospitalization is as high as 10% after performing ERCP on PSC patients. If there's a dominant stricture, we need to brush and biopsy, and send it for cytology at times for fish. Antibiotics are indicated in this setting, and if there's a stricture, we dilate and try not to leave a stent, because leaving a stent was found to be not beneficial. It all depends on the situation, though. What about chronic pancreatitis? So pancreas becomes hard, rubbery. As you know, the distal bile duct is going through the pancreas, so it gets squeezed, causing jaundice. So the long-term success rate in chronic pancreatitis patients presenting with a biliary stricture is 10-30%, and complications include stent occlusion and stent migration. So you start with one stent, and add another, add a third, fourth, making it much bigger than natural size. So when you take all the stents out, it will remain as an average size. That way offers a success rate of 65%, but once you take all the stents out, that rubberiness of the pancreas closes down the bile duct again. So restenosis rate is as high as 17%, in a mean follow-up of 42 months. What about EUS-guided pancreatic duct drainage? In post-whipple population, technical success rate was 93%, with a clinical success rate of 88%. Many patients undergo laparoscopic cholecystectomy, and after cholecystectomy, the patient can have fever, jaundice, a few complications. And they're usually from direct trauma, and we usually do a sphincterotomy plus stent placement. Post-operative biliary strictures, cholecystectomy-induced stricture, they put the clip on the cystic duct, usually, but sometimes it kind of extends into the common hepatic duct. In those cases, we have to go in and put a stent in. And post-liver transplantation, there are two types of strictures, anastomotic stricture and stricture elsewhere. And the anastomotic strictures are usually easy to handle. There is a donor-recipient size difference, and then there is some stricture, so you just put a plastic stent or a metal stent, but ASGE recommends a covered metal stent now. Non-anastomotic strictures are from ischemia, and they're tougher to take care of. The response rate is as low as 50%. And then post-WIPO, in WIPO, there's a cholecystectomy and pancreatic osteogynostomy. Pancreatic osteogynostomy is connecting the bile duct to the small bowel, and that area can cause stricture and result in stricture and obstruction. So we tried a different method, rigidizing overtube. This was invented for colonoscopy, tough colons, tortuous colon. So we decided to use this one for post-WIPO anatomy. There is a toggling from flex to rigid. So long story short, in tortuous anatomy, like this, you can have a figure eight with your scope to get to the colodocal jejunostomy. By using the overtube, we were able to make it straight and perform ERCP. And this is one of my patients who had stricture at the colodocal jejunostomy and had a lot of stones. We got the stones out. Moving on to malignant indications, cholangiocarcinoma, pancreatic cancer, ampullary neoplasm, metastatic cancer. I'm going to focus on the first three, cholangiocarcinoma, pancreatic cancer, and ampullary neoplasm. As you know, the cholangiocarcinomas are very difficult to take care of. And the majority of them are higher, right at the bifurcation of right hepatic duct and left hepatic duct. And it's very difficult to successfully take care of these patients, and we just recently published our 25-year experience. So as you can see here, there's a bifurcation. And then right hepatic duct and left hepatic duct. This patient happened to have intraductal papillary neoplasm of the bile duct. So we were able to see inside and get some tissue. In cholangiocarcinoma, all hands are on deck. You can use one stent, plastic stent, or two stents, or metal stents, or combine the procedure with interventional radiology. Moving on to the pancreatic adenocarcinoma, in 2023, there were about 64,000 new cases and 50,000 estimated deaths. So number of new cases and number of deaths are almost the same. It's the third leading cause of cancer-related death in the U.S. And unfortunately, 80 to 85 percent of them present with an advanced stage. So overall five-year survival rate is 6 to 11 percent. And this is what we do in that setting. We get into the bile duct and place a metal stent. So if there's an indication and routine ERCP skills are required, then ERCP is performed. However, if there's no advanced skills available in the room, it ends up as a failure. So we cannot emphasize this enough. You have to have a right indication to perform ERCP. The benefits include relief of obstructive jaundice. The risks include pancreatitis. You can treat cholangitis with ERCP. And you can cause cholangitis by injecting the contrast into the duct that you cannot drain. If you inject it, you've got to drain. Relief of symptoms such as pruritus, and it can cause bleeding, cause perforation. Learning therapeutic endoscopy is a continuous journey. And journey requires a constant practice. So here I'm at MD Anderson performing ERCP on one of my children. And this is the CT scan for animals only in our lab. And we're performing RFA on my son, Pig 1 Lee. It's a Yorkshire pig. So and we performed the RFA. And we wanted to see what the effect of that was. So we immediately dissected the pancreatic, hepatic, hepatic pancreatic region. And assessed the damage. The speakers ahead of me were very nice. They actually gave me a lot more time because mine is from 9 to 9.30 and it's only 8.55. So I'm going to have a little time to go over this. Please let me know if I'm boring you. So here you can see we're heart surgeons, as you know. And suturing is done. And then we looked at the area where we burned. You can see that yellow spots. Those are the transmural damage. So it's not always safe to perform RFA in the intra-hepatic ducts. Because the hepatic artery, the branches are running right next to the bowel duct, especially the right hepatic duct. So before you introduce a new technology and new techniques, you really have to think about the safety. Learning from the mistake doesn't work here. You're learning from a mistake on your family. So it's really not acceptable. So you have to do all the precautions before you implement a new device and new techniques to your patients. It's a team practice, you can't just do it alone. So we have periodic training sessions, so we change the roles, doctors play techs, and the techs play doctors, and they go through the different roles and understand the difficulties coming from different jobs. So the bottom line is, it's a team sport or a team practice, every member of the team has to know his or her part. And then once you run into a little difficulty, I don't spend too much time trying to cannulate conventionally. If it doesn't work, I put a PD stent in, and then this is called a pre-cut papillotomy, and cut through the intracellular segment of the ampulla. Then EOS-guided biliary drainage, there's a rendezvous, and transmural stenting. Here you cannot see the ampulla, so where do you go? So then you go to the common hepatic duct, inject a contrast, and send a guide wire down, and then eventually you drain it. There's a similar case. In this case, two large diverticuli, and I couldn't tell where the opening was, and I thought this was the opening, and I asked my past fellow, hey, where is the opening? That was the mistake. He said, yes, it's right there. So I decided to go in, and it wouldn't go. And I decided to cut, and made some cuts, and it still wouldn't go. So the bile duct was tiny, so we were able to get through the bile duct, and this is going through the liver. And it's 5.37 in the afternoon, and then at 5.40, we're down, and 5.52, we're putting the stent in. So eventually, the stent came out, out of here, and this is where my fellow told me to go. No, it's my responsibility. So EOS-guided coli delco to adenostomy, you can do in multiple different ways. You can put a covered metal stent, or you can do lumen opposing metal stent, and here you can see a case, one of the cases that I did, and it's a large duct. So you inject the contrast there, and then fill that up, and then in this case, I used the guide wire to make sure that the stent is facing downward, so that the food does not go in there. And then we are able to put the lumen opposing metal stent. It's a one-shot thing. If you missed it, you're having a bad day. And you can see a gush of bile coming through, and then you know that you're in the right duct. Here is a large mass, ampullary mass, another indication for ERCP. So no ampullary mass, ampullary adenoma should go to surgery. They used to go to Whipple. That's a major surgery for this, not such a difficult problem. And then once you get into the bile duct, and you make some sphincterotomy, and make sure that you cauterize the base so that it doesn't come back. And another case, you're cutting through, and you've got to look at the base after you cut because there could be a perforation. And as you can see, there's enough margin there. And there is a little hole, but that wasn't a perforation. So we put a stent into the pancreatic duct, and then did more sphincterotomy in the bile duct. And we were able to put a stent in and cauterize the base. And similar cases, you've got to make sure that you understand the anatomy and where the tumor is because the tumor is all here. You've got to think like a surgeon and have a negative margin. And here you can see there's a tumor, and the resected piece looks just like the natural anatomy with the margins here, negative margin. And here's an ampullary cancer, and we were able to put the stent in. And the other difficulties that we run into with a malignant biliary stricture is that gastric outlet obstruction. So gastric outlet obstruction used to be handled by putting an uncovered metal stent in the duodenum. But now we do endoscopic gastroenterostomy. You find a nicely dilated segment of either distal duodenum or proximal jejunum. You can see there is a dilated segment. And then you puncture through with a luminal opposing metal stent. You've got to have a runway. Here the beginners get so impatient, and they just, I have it, I have it, I'll hit it. And then they don't land in the jejunum because jejunum is mobile. It runs away from you. And if you didn't land it perfectly, then you just cause the perforation. So once again, you'll see a lot of contrast coming through once you landed it perfectly. So what I tell my fellows is that when you're performing EOS-guided gastroenterostomy, don't fly in bad weather. If there's a lot of food in the stomach, don't do it. And today is not the only day. Then you can put a duodenal stent in instead of performing EOS-guided GE gastroenterostomy. And that's perfectly fine. And you can bring the patient back another day and perform EOS-guided gastroenterostomy on better weather. And if the landing is not perfect, do not panic. Like whenever we have a nail, when we see a nail, we want to hit it so badly. Sometimes you hit it too fast. It doesn't land right. And jejunum is really unpredictable because it moves away. And sometimes we have to dive in. In this case, one of my junior colleagues performed it and he was in a hurry. And then we landed in the peritoneum. So this is where I came in. I said, hey, don't panic. Let's go ahead and use clips. And we used a clip with a dental floss attached to it. And we used two of them and grabbed the jejunum. We're in the peritoneum now. And then using that string, dental floss string, pulled it into the stomach. From here, we punctured through the jejunum and put a lumenopoietic metal stent. Here you can see the guide wire going through. You got to make sure that the stomach is clean before you do this. If you have a lot of food in the stomach, it's not the day to perform this procedure. And we were able to put the second stent. And finally we landed in the jejunum and the patient did well. Lastly, take your time in finding a good runway. And this is a very nice runway because the lumenopoietic metal stent is going to come in this direction. So we're constantly moving to more complex technology. I know Medtronic is one of the leaders. And we perform joint procedures with the surgeons. This is a robotic surgery. And if you're not moving forward, you're a dead fish. So yes, you completed your fellowship and that's when your learning really begins. So we constantly learn and try new technology and apply that to our patient care. So AI is now in and where it's going to take us to, we'll see. So in this study, AI was actually better than ASG guideline in predicting that there is a stone in the bile duct. Radiation safety. So radiation safety is very important because if you got 5 millisieverts today and then you got 5 more 10 years later, you have 10 in your body. It doesn't go away. It gets fossilized. So if you got 50 today, 50 tomorrow, 10 years later you have 100. So really got to be careful. Don't walk into ERCP room without protection. And the radiation can come from the bottom or from the top. And there's a mobile unit, C-arms. C-arms are in general less protective than the tables because there's no curtain, no skirt to protect you. And now the technology has gotten better. They try to reduce the amount of radiation exposure during ERCP. And if you magnify the view, you're getting more radiation. So as I mentioned before, it will accumulate over your lifetime. The mean effective dose for diagnostic ERCP is 3 to 6 millisieverts. And for therapeutic ERCP, 12 to 20 millisieverts. But if you see an endoscopist who has a lead foot and constantly going with it, just be careful and don't get in front of him because he's a shield for you. So what about during the pregnancy? In this study there were 68 ERCPs in 65 pregnant ladies. There's no perforation, sedation adverse events, post-sphincterotomy bleeding, cholangitis or procedure-related maternal or fetal death. Another study, 907 ERCPs were performed in pregnant women. And it didn't say which trimester the patient was in. But there's no difference in maternal mortality, fetal distress or fetal loss when compared to age-matched pregnant women. So can we perform ERCP without radiation? Yes. You just cannulate using your sphincterotome and aspirate. And if it shows a bile, you're in the bile duct. And you perform sphincterotomy and use a balloon and pull the stone out. Or you can put a stent in and the stent will prevent cholangitis and bring the patient after delivery. So in this case, in this study, five patients with a pregnancy at 20 weeks. And they were lying on the left lateral decubitus position because they cannot really lie on their back or stomach. And lead shield was used from every direction, below and both sides. And midazolam was used. And selective decannulation was confirmed by aspiration of bile. And sphincterotomy and stone extraction were performed. And there were no complications. So when I was younger, when I was going through training at Harvard, we were using Versed and Demerol. And my mentor, Dr. David Carlock, I'm sure that many of you know, ran out of the medication. So Jeff Lee became the medication. Jeff, get on top of the patient. So I got on the patient like a frog. And the radiation thing was moving back and forth and I was dodging, holding the patient down. I'm sure that I got a lot of radiation on that day. But now I'm much more civilized. I'm using two-piece lead aprons and the jacket and apron. And then thyroid shield. I never used a thyroid shield going through training. So now I use a thyroid shield. And there is actually a little gadget that tells me monthly how many millisieverts of radiation I received. And make sure that you protect your eyes as well, because you can get cataract. So three principles of radiation, distance, time, and shielding. The farther the better, the shorter the better, the more shielding the better. And use a pulsed fluoroscopy, do not put your foot on the radiation stepper forever. And minimize the fluoroscopy time. And limit the use of enlarged images. Because whenever you enlarge the image, you're giving more exposure. And use shields, wear the proper apron, thyroid shield, and leaded glasses. And collimation is important. Take-home point, four points. Learning therapeutic endoscopy is a continuous journey. And the journey requires constant practice. And also it requires a team practice. Thank you.

Endoscopic Retrograde Cholangiopancreatography

ERCP safety

therapeutic endoscopy

choledocholithiasis

cholangitis prevention

radiation safety

pancreatic cancer