I've got a quick question. So can you talk more, for large stone cases, can you talk a little bit more about balloon dilation assisted ERCP versus cholangioscopy? And is there a clear division of when one is appropriate versus the other? Or is that based upon physician preference, experience, that type of thing? So there is some physician preference that's involved in that. But there are proposed algorithms for how to manage that. So if it's distal, common bile duct, stone and stricture, not no stricture, but stone in a dilated duct, the preference is going to be to do a small sphincter, or do a sphincterotomy and then large papillary balloon dilation to pull that stone out. The reason being, seeding that cholangioscope into the distal duct, just sitting there is somewhat challenging. And you can probably accomplish it with other tools. I think anything above that becomes a little bit more in that gray zone. So if you have a big stone that's in that main duct, but a little bit higher up, then it's somewhat dealer's choice. Now if there's a stricture down below, or a narrowing down below, then you need to fragment that stone. No matter how much you dilate that stricture or narrowing, that's not advisable, first of all. But if there's a stricture down below, then you have an outlet problem. You're going to need to fragment that stone to get the pieces out. Just a quick clarifying question, when we say distal, about how many centimeters, give or take, into the bile duct are we talking here? Yeah, I mean, generally, the distal, two centimeters, roughly. I mean, there's no hard cutoff. I don't know if you guys have a similar thing. Yeah. I don't think there's any rule to that. I mean, you can have stricture, like for example, post liver transplant patient, right? They can have stricture right at the anastomosis in the middle of the duct. And the stones can be above it. Sometimes we have seen livers being transplanted, they had the stone in the bile duct, and now they have in this patient, and they have anastomotic stricture. So stricture can be anywhere. You know, even the papillary stricture, right at the orifice is too tight. You cannot bring the stone out. So generally, you know, if you have a stricture, it doesn't matter where, you have multiple faceted stones, stones more than two centimeters, they are the indications for cholangioscopy and won't work well with balloon dilation alone. Yeah, I think generally, though, I think with cholangioscopy becoming easier compared to the initial sort of cholangioscopy where you have a separate fiber, there is a trend, I think, over time for people to switch sooner. But I think in that process, we are also losing some of the benefits of other devices such as baskets. I think Dr. Lee mentioned this earlier, lithotripsy is so much faster if you can do it with a basket than with a cholangioscope. So if you have the space, the algorithm based, and everybody is going to be slightly different, but in my mind is, if you have the space, open the basket before a cholangioscope. It's okay to burn a basket because the time that you will save in terms of breaking it up and getting it out will be much more than the time you spend doing cholangioscopy and breaking it, you know, fragmenting it, because it's not like you blast them away very quickly with cholangioscopy. And then all these other factors such as the length of the stricture, the location, the size of the duct, you know, play into it too. I think for those of us who have done mechanical lithotripsy or with a basket, you get PTSD if you have a case of trapped basket, which is not that uncommon. So you wrap the basket around the stone, and especially if it's a high Hounsfield unit stone, really thick calcified stone, you kind of crush them with the basket, and now you have a trapped basket. So that just, so I'm sure most of us, we have had cases like this. I've had cases though, I still, again, they're so rare overall that I feel that, and this is a separate topic now. I feel that our trainees are losing the skill of using a basket. That's my concern. And I'm all for new technology and cholangioscopy taking over, but I do think there's a role for baskets that's going to be sort of probably be even less in the next sort of 10, 15 years, partly because people just won't know how to use these baskets. That's my concern. So I just had a case three weeks ago where I had a large stone. I tried to fragment it with a mechanical lithotriptor. I actually had senior nurses in the room with me, broke the device, we got the rescue device, we broke the rescue device, and then I had a basket stuck in a patient for a huge stone. And then we did, pulled it out, pulled the wires out of the mouth, and then I went back with the scope and then did cholangioscopy and EHL until I freed it and then pulled it out. I had the video, but I didn't think I had the time to present that, and that was more fitting for your talk anyway, so. Yeah, and those are the situations where you're saying, why didn't I just use cholangioscopy? Yeah, exactly. Yeah, yeah. Absolutely. Good question. We have time for one more question. I have a question, if that's okay. Hi. Hi. This is for Dr. Chandra Zakara. My question is, in those patients with the main duct IPMN, what is your, you might have mentioned this, what is your intervention with those patients? Yeah. So for us... So the intervention, because they're high risk for cancer, high, high risk for cancer, the number one intervention all the time is going to be surgery, okay? So it's going to be surgery if the patient's fit for surgery. Our role is just risk stratification in that. Identifying. Identifying, right? With that being said, I've seen a few cases where people say someone's not fit for surgery. Well, how do you, what can you potentially do? And this is really way out there and not ready for prime time. But what they're doing is, my colleague even did a case a couple weeks ago where they do pancreatoscopy and then they use laser to kind of destroy those papillary fronds. I'm not saying that's advocated at all. Surgery, surgery, surgery, but, you know, but there's some, you know, can we do something ablative in those patients who are not surgical candidates to help prolong their lifespan? Sure. Or the development of the pancreas. Yeah. And prevent, or prevent cancer, correct? Could I ask one more question? This is actually related to the anastomotic strictures that are in those post-liver transplant patients. So since like 80% of those strictures are anastomotic, do those patients just keep returning to have their stones removed or how does, how, in your practice, what do you see? So most of these strictures resolve. So over time, you know, with repeated ERCP stent placement, they will resolve and then you get the stones out. So the likelihood of a patient having a sort of refractory stricture that just does not respond to surgery is partly dependent on where it is. In the full duct to duct anastomosis where you have the full liver, it's a much bigger main bile duct. Those strictures have a very high resolution rate, over 95%. So the living donors can be tricky, but there too, the surgeons will reoperate to do a different type of anastomosis in very refractory cases, but almost all other strictures will resolve. Okay. Thank you. So, I mean, when you talk about strictures, you're talking about one chronic pancreatitis related stricture in the distal bile duct, right? Sure. A lot of data shows that using fully covered metal stent or multiple plastic stents, it introduced, leads to 80% resolution and we have now data showing up to five year follow up that they stay resolved. So they don't reoccur. So we have a five year follow up. And the other type of strictures would be, you know, like post transplant where you can have a stricture right at the hilum, the bifurcation. Those are usually ischemic and they are the harder ones. They don't really, the response rate is less and oftentimes those other patients, they may need repeat surgery. And as Dr. Ryan mentioned, post living donor liver transplant, because there are multiple duct anastomosis, there are multiple areas of ischemia and then there are strictures higher up where endoscopy is less successful compared to duct to duct, which where we are successful. Okay, great. Thank you. Thank you so much.

bile duct stones

ERCP

balloon dilation

cholangioscopy

mechanical lithotripsy