Good morning, everyone, and thanks again on behalf of my co-partner here, my co-pilot. And again, a huge thanks to the faculty for taking time out on such a short notice from their busy day to be here. We're going to make this a really fun-filled education day for you guys. But I'll just take next few minutes to go over the historical aspect of a procedure that we are going to spend next few hours learning about. I always find history really fascinating. So who did the first ERCP? Who's credited with performing the first ERCP? It was actually one of the obstetricians, not a gastroenterologist, not a surgeon. He was an OB-GYN, Dr. William McCoon, in 1968. And he was able to partner with one of the people here in Chicago. They basically fashioned an endoscope here in what he called as a garage. It was a flimsy thing. They attached an accessory channel, literally took a tape and taped an accessory channel to the fiber optic scope. And then they used a balloon to cannulate. The goal was to cannulate any duct. And they managed to get into the bile duct. So Dr. McCoon is credited with performing first ERCP. And I really, you know, I mentioned the cannulation rate because we're going to be spending some time talking about cannulation, which is the most important step in performing ERCP, cannulating the desired duct, either biliary duct or the pancreatic duct. But when they started, the cannulation rate was 25%. We have come a long way since then. For us, the target now is 99%, either with the basic ERCP cannulation skills or we add an advanced skills, plus minus EOS. So we definitely have progressed significantly. So another thing I would like to point out is notice it was not called ERCP back in 1968. It was called ECPG, endoscopic cholangiopancreatogram. And I like this quote from Dr. McCoon when he published. And the first publication was actually in GIE. And we have an interview from Dr. McCoon published in one of the historical archived articles in GIE. So if you are most interested, they can also read that up. So what he said in that article was anyone who looks through one of these instruments, basically they are looking through a tiny peephole, they have to have two personality characteristics. First, they have to be honest because if they see something, others who are standing next close to them, they would want to see that too. So they have to be honest in what they are seeing and saying. And second is you have to have an undying, blind, day and night, uncompromising, persistent. I think both of these, they still hold true. And as all the faculties are sitting here in the audience, they can also agree with me. So moving a little bit fast forward, so ERCP continued to develop. Now this is 1972. You see the publications here. All these are pioneers. All the people here, Oye, Kasugai, Kramer, Cotton, Klassen, Safrani, and Van Ness. So all these people were the first ones who really took the field forward and look at the success rate. Not too bad actually, but they defined success in getting any duct, pancreatic or bile duct. So just off note, Oye was credited with partnering with Machida and Olympus, and he was the one who designed actually first side wing duodenoscope with an elevator. Everybody knows the history. They're shaking their head. Excellent. So kudos to these people who really pushed the field forward. So when we talk about cannulation, once you get into the duct, for us to do any therapy, next thing we do is make an incision in the sphincter, the sphincter of Oday, either in the pancreas or in the bile duct. So Dr. Klassen from Germany and Kawai, both simultaneously, they performed successful sphincter atomies. And both have been credited in moving the field a little bit forward, going from diagnostic to therapeutic. Now you have a little bit of a bigger orifice where you can now do therapy. That happened in 1973. 1974 is when we saw the term ERCP coined. And it's the same group of six people that I showed earlier, their cannulation success rate. They got together in the Mexico City and they voted and came up with the term ERCP in 1974. And we've been using this term since then. So okay. Can we go back? Yeah. Okay. I missed it. So just a couple of points I would like to make before we start our day is more than the ERCP. I would like to believe that ERCP, the four important factors are four P's. Whenever we are doing the procedure, it's the patient, it's the procedure itself, it's the product that we use, and then finally fourth P is the provider. And provider includes your endoscopist, your nurses, techs, and our industry representatives in the room. I cannot, I mean I can think of so many instances in my own experience in life. For example, when first luminoposy metal sand came out 10 years ago or so, I was using it for the first time and it was one of the device rep who came in and suggested that, hey, we think that we should be doing this under EUS guidance and not endoscopic guidance. And I was scratching my head. I said, what the heck are you talking about? And guess what? I mean this is the safest technique. And oftentimes we learn so much partnering with the industry. So you guys, you are an important part of the team when you are there. So it really, courses like this, as Dr. Mostafa said, Arayan said, it empowers everybody. You learn and you become an important partner in the endoscopy room. So just a quick thing about moving forward. So patient. You know, when we are talking about the patient, it's important to look at a few things. Indication. I cannot stress the importance of having a proper indication enough. ERCP is a procedure that carries risks. We have to be sure that this is indicated. It's not a diagnostic procedure. We see in rare instances, for example, if you're suspecting PSC, MRI, MRCPs are normal. I can think of just a few subtle indications where you are using this as a diagnostic tool. But largely it is a therapeutic procedure. In the procedure room, when we have the patient, you have to decide how are you going to position the patient. Supine, left lateral, prone, whether the patient is intubated, not intubated, what kind of anatomy the patient has. So all these factors help us in deciding how we are positioning the patient. Looking at the risk factors, young individual, young female, you know, highest risk for complications like post-ERCP pancreatitis. Our team will be going over what are the risk factors in terms of post-ERCP pancreatitis. How do we manage the adverse events? A lot of data shows even if you're doing ERCP in 80, 90 year old, it's safe. We'll talk a little bit about ERCP and radiation safety and in pregnant women. And of course we talk a little bit about the anatomy itself, how the anatomy of the patient has effect on the success rate of ERCP, native versus somebody with altered anatomy. Now moving on to the procedure, we'll have talks about the room setup, what is an ideal room setup, what are the equipments we will be needing, how do you position the patient, the toolkit that needs to be stocked, who are the people who have to be in the room. We talk about the cannulation, the important and the first step in getting an ERCP done successfully. We talk about the basic cannulation techniques and then the advanced techniques for successful cannulation and of course if adverse events were to happen, how do we manage those? Finally what are the products that we use for ERCP? There are different devices we talk about for cannulation, moving on to dilation, performing therapies like putting stents, taking biopsies, looking directly within the bile duct with cholangioscopy, managing complications like bleeding, what equipment do we have and tools we can use both here in the didactics and in the hands-on session. And then of course touch base on the disposable equipments that we have now to mitigate the infection risk from the procedure. Finally the provider, talk about the trained personnel in the team from RNs to techs to the reps to the endoscopist. What bearing does the training of the endoscopist and the experience has on the success rate of the procedure? And finally I leave you with this quote, a good judgment is a result of experience and experience is the result of a lot of bad judgment. Hopefully we can prevent a lot of bad judgment here. Thank you so much and happy learning.

ERCP

historical evolution

therapeutic functions

cannulation success

training and collaboration