Uh, hi. Thank you guys for putting this on. Maybe, I don't know if that's a little echoey. Is it my watch? I'm not sure. Um, I just had a question when you're talking about, um, post-op bio leak, uh, placing stents. How do you decide what type of stent to use in that instance? Is it always a specific one or how do you go about that decision-making process? Okay. So I think that is pertaining to what I talked about. So may I take it? Yes, yes, please. Yeah. You can take all the questions. You can just watch and learn from me. I'm sitting over there. You're in the middle. Amazingly smart. So, uh, back in old days, uh, you used a plastic stent and French straight plastic stent. You have to use a non-permanent stent because that structure is benign. So someday, the patient will have no stent. So we started with the plastic. Plastic, as you know, is, it goes as high as 11.5 French. So we usually use 10 French because 11.5 French is very stiff. So if your colleague put the 11.5, you're following that procedure and three months later, you don't say good words about your colleague who put 11.5. When you compare the 10 and 11.5 head-to-head, there's no added benefit by going with 11.5, but 11.5 is very, very stiff. So we use a 10.5 and then the idea is making bigger than natural size. So when the, when you pull all the stents out, it'll shrink a little bit, but it'll still stay open. So you go with the second, third, fourth, but you never go bigger than natural size of the donor bile duct. So if the donor bile duct is five millimeters, you don't stretch to 10 because it can cause perforation. So it goes to five or you can stretch a little bit to six. So you put second, third, and fourth. And then ASGE guideline came out. Go ahead and go with a covered metal stent, which is usually about 10 millimeters in diameter. And it's very easy to remove. So instead of going through a second and third and fourth gradually, just go in because metal stents go in all compressed. And when you release it, it opens up. So you can definitely choose the size. If the donor duct is only three millimeters, then you don't want to go with the 10. You can go with the eight millimeters, even six millimeters, depending on the natural size. And then you leave it there for six months or so, and then you go back to see whether it's going to stay open. Oh, you're welcome. So, Jeff, I think that was very good about strictures, but I think you might have asked about the bile leak also. Yeah, so bile leak, there was a study about sphincterotomy. Is that enough? Or sphincterotomy and stent is better? So the conclusion is sphincterotomy and a stent placement is better than sphincterotomy only. Yeah, so we go with the sphincterotomy and the stent placement. Same kind of protocol. Yeah, so for the bile leak, we usually use a short stent, 10 French stents, small sphincterotomy, and then 10 French stent. And that's usually good enough. But at times, there's a persistent leak. Then we go back and go with a covered metal stent, blocking off the cystic duct, take off. But if there's a lot of bile already collected in the right lower quadrant, then you need to train that. Usually, we do it continuously. I think it also depends on the size of the bile duct, what it's going to allow. Unlike strictures, because there is a blockage, the duct will be dilated about. So you'll have space to put a metal stent. But the bile leak, it's the opposite. There is a leak. So it decompresses the bile duct. So if the bile duct is only four or five millimeters wide, if you put eight or 10, the smallest, skinniest, fully covered metal stent is eight millimeters. So does the duct allow that? Because otherwise, you'll just end up stretching the duct even more. So sometimes, the only option is a plastic stent up front. And then you see how it goes down the road. I think one of the things that, over time, you've learned, I don't know, Jeff and Arshad, what's your experience? We've seen these patients of getting partial cholecystectomy now. Surgeons go in. They open. They remove, like, one third or half of the gallbladder. And these are the ones that I feel that sometimes, the plastic stent doesn't work. So if there is a garden variety leak from the cystic duct remnant of the duct of Luschka, then yes, absolutely, a 10 French plastic stent would work, smallest length, 10-5, probably. But if there is extensive leak from remnant gallbladder, then what I do is a fully covered metal stent and try to cover the insertion of the cystic duct and leave it for a few weeks. You know, the anatomy is different for some people. Dr. Luschka was just mentioned. It's an accessory duct that drains into the gallbladder. Or sometimes you see additional duct. So really, I have a lot of empathy for the surgeons, especially when there is a canker and gallbladder and that field is all messy. You can't really see very well. Yet, they still have to take care of the patient. Sometimes the clip goes on the common hepatic duct, completely blocking the common hepatic duct. And at times, that may require another surgery. But a colleague of mine used a magnet to open that up. So put one magnet through the liver, and then another magnet coming from the bowel duct, and let them be about 5 millimeters apart, and then give about three or four days. And then you go back, and they're connected. We're constantly thinking, as you are. So excellent discussion. I just want to add another point. So when we talk about Frenches, right, 10 French, that is 3 millimeter. And the biggest covered metal stent is 10 millimeter. So we think, well, it's just three times bigger than the largest plastic stent. In reality, it's equal to nine of those 10 French stents. Because when you look at the 10 millimeter, in reality, putting in a 10 millimeter covered metal stent is equal to nine of those 10 Frenches. So that's why we go for the fully covered in stricture. So excellent discussion. Any more questions? Yes. Good morning. I'm an account manager here in Chicago. Oh, boy. Oh, it's right here. I came to Medtronic Endoscopy a few years ago from Olympus Endotherapy. When we were there, I had actually seen on the screen, Dr. Lee, it was a combination sphincter dome and papillary dilation balloon. It was called the Stone Master V. So my question is, again, during my time there, it wasn't necessarily a widely adopted technique. Is that something that you guys are seeing a lot more, using a lot more? What's been your experience with papillary dilation for management of large bile stones now? So it goes back to the Korean study. South Koreans are very innovative, and they move pretty fast. So when there is a large stone in the bile duct, should we do sphincterotomy really large, even larger than the stone, and take it out? At times, it's impossible. Because intradermal segment of the ampulla is limited size. You cannot cut it to 20 millimeters, but stones can be 20 millimeters. So they performed a large balloon dilation to 18 millimeters without sphincterotomy. Unfortunately, a couple of people died from pancreatitis. So then they got a little wiser, made a small sphincterotomy, and then put the large balloon, 18, 20 millimeters, and stretched it out, so that the force will go into the cut section, not toward the pancreatic duct. And you can get the stone out. So if there is a large stone stuck in the bile duct, yes, I make the sphincterotomy almost as large as we can go. But I want to leave a little bit, because I'm going to dilate that. Without that little comfort zone, dilating becomes a little risky. And then you dilate it as much as you can. And then you go with a mechanical lithotriptor and break it. But now, I think one of my colleagues is going to talk about cholangioscopy. Now you can do cholangioscopy and go in there and break it. But old method is using something called a suhandra lithotriptor. It's a basket that goes in there in the bile duct, and you grab the stone. But you have to have a handle. If you don't have the cranker, you know what the handle is if you're doing the motion. If you don't have the handle, the wire will be coming out of the patient's mouth. You're going to the operating room, because you cannot crack the stone. So you have to make sure that the handle is there before you use it. So if there is a large stone, number one, sphincterotomy. Number two, dilate. And try to take the stone out. If it's not possible, mechanical lithotriptor. But with a handlebar, if that's not available, cholangioscopy and the stone extraction. Thank you, Jeff. We are approaching close to our break time. Just final words from you, Harshit and Amit, about days when you are deciding balloon dilation. What are some of the thoughts that are going through your mind for stone extraction? So like regular stone, I mean, you always have to assess. You know, you have to do a good cholangiogram to assess the size of the duct. The main thing that I see is what is the size of the stone as well as the size of the duct below the stone. That's very crucial, because sometimes you'll have a situation where the distal CBD is not that wide and the stone above it is wider. Now then, an amateur will go in and just try to pull. I mean, it's like, you know, you have a drain with a big rock and you're trying to pull the drain through the rock. I mean, it's not going to happen, right? So in that way, dilation really helps. If not, then you might have to do lithotripsy. But if it's a garden variety case, the duct is pretty big. You assess how big the duct is, how big the stone is. Gauge the size of the balloon dependent on that. And you have to have a balloon which kind of obliterates the entire duct. So if the duct is 10 millimeter, I would take a 12 millimeter balloon or 10 to 12 millimeter balloon and then sweep it. Also ensure there's an adequate sphincterotomy, which can't be like pulling out a stone where the stone is bigger and big and the sphincterotomy is very small. Then you're tensing it. You're creating unnecessary compression of the pancreatic orifice, so on and so forth. So those are the things, the size of the duct, size of the stone, the size of the duct below the stone. What do I have to dilate or not? And we can even go up with a CRE balloon now because the ability dilation balloons go up to 10 millimeters, right? But I usually, I don't know what Jeff and Harsh feel, I don't dilate beyond the size of the distal duct. I mean, that is one thing that I really worry about is, especially with the availability of EHL and mechanical lithotripsy, my usual extent of dilation is whatever is the size of the distal duct. So if it's going up to 15, I'm comfortable going up to 13 to 15 millimeters and then pulling out the stone. And by and large, majority of the stones will come out that way. Once in a while, once in a week or once in a month, you'll have a stone that will be resistant. And then you can use accessory modalities like the Sohendra or you have the lithotripsy, mechanical lithotripsy basket that can crank and cut or EHL. To add to that, I think all good points. I agree with what Amit said. I think every case is different. To specifically answer your question for the stone master, you almost have to have everything right. You almost need to know upfront how big the stone is. If you have an MRCP that shows that you have a massive stone with a massive duct and the distal duct big enough, then yes, you could go with that. But if you already opened a sphincterotome, and now you do a cholangiogram and realize the stone's bigger than the duct, using the stone master, then it's a mute point because now you're adding double the cost. Now we just use a dilation balloon. So there are cases where I know it's a big stone. I know it's a big duct that's going to let me dilate. Then I'll go with that combination device. It saves time. There is cost savings with that as well. As Amit mentioned, I think 90% of the times we're able to get that out with a good papillary dilation as long as the distal duct allows. The other part is cholangioscopy has become so much easier now. It's plug and play. It's not as onerous as it used to be. But you've got to put in the sheet at almost like this sigh of, oh my god, you need a cholangioscope. It's not that anymore. We have the cholangioscope processor right in the room. So we just bring the scope, plug it in, and you're good to go. It saves a lot of grief instead of trying and mucking around and getting a basket stuck with the wires coming out. Just go with the cholangioscope. So try a dilation. See if the stone comes. Don't get it wedged down and then try to rescue it. If you know it's not going to come, just going to cholangioscope in EHL does save long term time. And if you don't have it, just throw a stent in and bring them back another day. You don't have to solve everything right then and there. The primary goal is drainage. So if you get a stent in, get drainage in, and then you fight it another day. Gen Z. Thank you so much.

bile duct stents

post-operative bile leaks

large bile duct stones

covered metal stents

cholangioscopy