So basically, we're going to talk briefly about higher strictures. I think this correlates with Medtronic, what they want to try to bring into the market, and maybe will be a point of interest for you guys as well. Again, causes of more we're going to focus is higher obstruction in these cases. Again, what are the any obstructions which you're going to take a look? It could be malignant. It will be benign. For malignant, you're going to be looking at malignant biliary tumors, which is cholangiocarcinoma, secondary metastatic lesions, or sometimes the location or the anatomy of the lymphadenopathy in that area, which can cause the extrinsic compression and can cause higher obstruction as well. Again, benign causes, you can see primary sclerosing cholangitis, or in short, people call it PSC. You must have heard when you are in the ERCP rooms about PSC. This is, again, ductal etiology where you have thinning, or in common short, we call it bead-on-string appearance. You have a lot of beads on string. That means focal dilatation stricture, focal dilatation stricture, more in the intrahepatic ducts, what you're looking into. Intraoperative injuries while doing cholecystectomies, you can see it, intraarterial or other ablative therapies like TACE or other things which are done for hepatocellular carcinomas. You can see some injuries happening around that area, which we basically go and see and fix it. And again, indeterminate is always there. That means we don't know what's going on. And believe me, when we say we don't know what's going on, we really don't know what's going on. Workup, again, basic workups, these are the patients who present with abdominal pain. Normally in fall, they look like pumpkins because it's a Thanksgiving dinner. The family say, John, you look more yellow than you before. So they take him to the hospital, liver numbers are elevated, your CA99 is high, you get a diagnostic imaging. Initially in my hospital, anybody coming through those doors, CT scan is must. Even if you have a toe pain, you will get a CT of the abdomen. So CT, then followed by MRI, MRCP, again, tissue sampling, brushing, or biopsy. Biopsy through cholangioscope. Because you have to be very cognizant about it, that whether this person is a transplant candidate or a resectable candidate or not, because you will tend to shy away from doing EUS guided fine needle biopsy because risk of seeding in these patients. Cholangioscopy, which I think has been talked and butted into your minds in the earlier sessions. Again, stenting, why do we need to do? Improves the quality of life, improves the prognosis, permits oncological therapies. A lot of my oncology folks, and I think same at UT, bilirubin has to be less than three for them to go in and give them infusions for chemotherapy agents. If it is not, they are limited, they cannot give therapies, the patient does not get therapy, everything is delayed on the treatment side. And that every day for these patients is a kind of a ticker. They are like a ticking time bomb. So we have to make sure a good stenting is done so that we can help our oncologist buddies to do what they want to do. Again, endoscopic, again, multidisciplinary, we'll see more slides of these. Endoscopic approach is very important, percutaneous is your last or palliative approach in these patients, because again, risk of seeding you're looking at in these patients. So very challenging, and I think, I was talking to Dr. Stogie before as well, since he was a fellow, Dr. Chahal has been a fellow, Dr. Rain has been, and I was a fellow, there has been always, which is better? What to do? The problem is to design these studies is very hard, to randomize patients in these studies are very hard, giving heterogeneity and evolution of therapy and local expertise is very important. As you mentioned, 60 to 70% of the ERCPs is done in community. So by the time they end up in the tertiary center, they already have something done which might not be very conducive or should have been done or whatnot. Again, quick look at bismuth classification. This is a classification for higher obstruction. You look at type 1, this is that common hepatic duct. This is again the anatomy. If you look, they're a different anatomy. You have common bile duct, you have distal, mid, and upper, and then you go up into is common hepatic duct, and common, is it a pointer? There's no pointer. Okay. Yeah. So you basically look in the stricture happening in the common hepatic duct in this area. Type 2, you see this is extending into the common hepatic duct, going in the confluence. So you see the right hepatic duct left, but not completely invading them. You see 3A is that the stricture is going into the right hepatic duct system, and you see 3B, it's going into the left hepatic duct system. And then the 4, which is called Klatskin tumor basically, you see it's going into the both right and into the left segment. And this is important, again, not more for you, but for people deciding whether they will be a resectable candidate, transplant candidate, what to do, thinking in your mind with segments to drain and not. What are the general concepts in the management of hyaluronabstruction? The main, the first thing, as I said, is reviewing the cross-section imaging. Anybody who's coming to my endoscopy lab, I have a hyalur case. I want to take a look at the cross-sectional imaging to see what all segments are involved, like what multi-sectorial segments are involved, what I can do about this patient, which segment I need to drain, which segment I need to stay away from it. And if I'm not comfortable, not every gastroenterologist or advanced endoscopist is a good radiologist. If you have any doubts in mind, you can always go and discuss with your radiologist and say, we all have one buddies who we call and say, can I come down and look at those images with you? There's no shame in it. I think it's always to go and look and have a clear image in your mind what's your plan in this one. Again, multidisciplinary fashion, very important. Like you're taking a look in whether these are resectable, non-resectable, whether these are transplant candidate, whether you want to do brachytherapy. So these are certain things to be kept in mind, or it's just palliative we are dealing in here. Again, limit the injection of contrast. I think Dr. Lee has talked about it and other people, too. If you are going to be putting up a lot of contrast and you cannot drain it, that's going to be a problem for you because you're going to put risk of cholangitis to these patients. Avoid injection. Again, attempt the drainage of dilated bile ducts. Attempt the drainage of all the injected. Once you have injected, now you are committed. So try to see if you can drain all those. As I said, if not, that will be causing issues. The aim should be draining around 50% of the liver volume. And that corresponds to two multi-sector areas in your liver. Some people even say that should we call it 50% or we call it multi-segment drainage of the liver. Again, antibiotics is very important, considered pre and post. Again, we're going to see a little more slides upon stent-in by stent technique. And again, intraductal approach or radiofrequency or ablative therapies, which we're going to be talking more about in there. Again, quick slide, very busy slide. But this is what we're going to see is that what are we talking about today? We are talking about comparison between metal versus plastic stents. And we are looking into outcomes from survival, stent potency. We are looking at success drainage rates. We are looking at adverse events. We are looking at survival. And similarly, bilateral versus unilateral stent. Again, in this talk, we're going to be limiting endoscopic biliary drainage versus trans-hepatic biliary drainage. But again, you're going to be going to percutaneous more if you are thinking, if your surgeon says this is not resectable transplant candidate, and you say, OK, more of a palliative thing or as a salvage towards the end. Again, quick overview of the slide. Optimal malignant hyaluronabstruction. If the patient has a short life expectancy of less than three months, do not want more of the re-interventions or prefer avoiding them. You can consider doing uncovered metal stents bilaterally. If the patient wants optimal drainage, has not been decided. That means a lot of these patients come as a referral, as an open access. I have sometimes a patient coming from the community physician. And they say, OK, this is a hyaluronabstruction case, and this is the first time I'm meeting the patient. Hasn't gone through the multidisciplinary. We have imaging and everything, but nothing has been discussed about this patient. So in this case, to give all benefit or doubt of the patient, that means not to take away his or her chance of getting transplant or resection. You just go with a plastic stent, because they're easy. So you're not committing them in there. If otherwise, you can choose one over the other. Bilateral versus unilateral, again, we'll talk more data about it. Palliatively operative, again, suggest against the routine use of percutaneous trans-hepatic biliary drainage. Unresectable or palliative, you can use endoscopic biliary drainage versus percutaneous trans-hepatic biliary drainage as well. Again you can look into, this is the fluoroscopic images. This is a plastic stent. You can look into this one, and then you can see Y-shape uncovered self-expanding metal stents in here. Again, two RCTs and one prospective trial. This came into 2013. This was basically talking like, you know, again, I think this is when a lot of noise is there that you know what to do. Should we put plastic stents? Should we put metal stents? Again, if you look into here, technical success, not much of a difference between the two. But you can see the early stent dysfunction is higher in the plastic stents as compared to the self-expanding metal stents. Same as the late stent dysfunction. And low intervention rates into the metal stents. So this again led to, when the ASG came up with a guideline in 2021, they said, OK, let's see what all the data is available and what we can think about it. And I will talk about that in the next slide. And then Seng Chen came with, again, RCT. This was 108 patients, unilateral metal stent or the plastic stent insertion, intention to treat, which was a successful drainage metal stent at a higher rate of 70% to 46%. Median survival time was also higher, 126 as compared to 49 days. Overall survival in the patients were statistically significant. So this was a good data which showed up. But then the ASG in 2021, they said, let's combine all the data and see what the meta-analysis shows. Like, you know, meta-analysis, I love meta-analysis, they give you some idea about it. So what they did is they combined all the three RCTs with the retrospective studies. And this formed a benefit towards the survival with a p-value of 0.1, 0.001, actually. That means the survival differed by 56 days in these patients. But when they quickly went in and they said, OK, let's exclude the retrospective studies and do just the RCTs, there was not much of a statistical significance noted in there. So the survival went down from 56 days to 33 days in here. The other thing which they looked into it was the stent patency, re-intervention rates, successful drainage rate, all favored metal stent over the plastic stents. The adverse events like 30-day mortality rate, cholangitis, stent occlusion, they did not differ between the two groups. So then somebody talked about cost-effective analysis. You know, we always hear from our directors, nursing side of it, that, you know, we are using a lot of metal stents, should we use metal or not, save some money for the hospital side of it. So yes, initially, when you use metal stents, they cost more. But given the data, what we have is that re-intervention rates are low, stent dysfunction is low, successful drainage rates are higher, initially cost-effective. But over the period of time, it actually evens out. So they are more cost-effective in there. But again, we don't have a strong data on it. There were two studies, but again, not much in there. So why did the ASG not went and said, okay, go for the uncovered metal stents versus the plastic stents? Like, why there was not a strong recommendation? There is a recommendation, but not very strong, is because three things in there. The plastic stents, what they looked into the RCTs were not being changed or exchanged in a way they should be in a frequent way, which could have impacted the randomized control trial results in there. Number two, ease of replacing the plastic stents in these patients. Think about when our metal stents get occluded, we have to do so many maneuvers into it to get them open, whereas in plastic stents, you remove and then you replace them, so ease is there. And then the third point is open access, which I talked to before. This patient shows up in there. You don't know what to do. So to give full benefit of doubt, you haven't discussed these patients, whether they're not transplant susceptible, not susceptible, brachytherapy, not brachytherapy. You said, okay, go ahead and let's go and just put the plastic stents in. So at this point, I think studies do favor metal stents, but again, it's at the local expertise what your thoughts are, what the multidisciplinary discussions have been happening. And again, important to be looked at different kinds of slides, different kinds of plastic stents. And I think this has been talked. You have single pigtail, double flange, double pigtail, wedge-shaped stents, again, unilateral or bilateral stents, which we'll be talking in coming slides, favor 10 French over 7 French. And the reason is because if you divide it by 3, it's barely 3 millimeters what you're looking at 10 French. So basically, there's so much of pressure from these higher strictures, 7 French tends to get occluded earlier than the 10 French. And I said easier said than done. Sometimes I have to go with 7 French because 10 French is not going through it. And if you're putting two stents, one would be 10 French and the other might be a 7 French in there because, again, we talk about because of the common bile duct diameter. Straight versus pigtail is preferred. Again, if you look into the malignant only, you're looking at unilateral to bilateral, 10 millimeter to 6 millimeter. And again, make sure never covered. They should not be covered. We have always been using word uncovered self-expanding metal stents in these ones. Again, you're looking into here is this is the unilateral. You look into the stricture. Basically, they show that this is stented into the right side of the system. Again, this is what you're looking at, flat skin, I think, in here. And then again, you're seeing is a bilateral stenting in here. So what's better, basically? It's unilateral versus bilateral. Again, question comes in. Traditionally, back in days, it was thought that if you can drain up to 25% to 30% of the volume, that's more than enough. But more data has suggested that you have to drain at least 50% or more of the volume to prevent cholangitis and have good amount of volume drainage out of these patients, which again corresponds to more than two sectors or the segments in the liver at that point of the time. Again, cholangitis risk is there. That's why we tend to do more bilateral. That's what the thought process is in there. So again, meta-analysis, what they did, ASG said, let's pull all the data and see whether the unilateral versus bilateral makes a difference. And you can take a look in here. It actually did not make a difference. So you do unilateral and bilateral, and these were the trials which they basically included in their study in 2021 paper. The P-value was 0.35, and the survival differed only by 11 days. So they said, OK, fine. Let's look at something else, like let's look at stent potency. No difference. P-value is 0.2 again in this situation. Then they said, OK, let's look at technical success rate. Technical success rate for bilateral stents was lower than the unilateral stents, and we all can agree on, agree upon, because it all depends upon the size of your common bilateral diameter, how tight the higher strictures are, how you have placed the first stent in, and when you're trying to push the second stent in, the first stent is trying to come out. You're trying to save that stent. You're trying to push the other stent in, and that's a whole big struggle for anybody in this, any advanced endoscopy in this room, and higher strictures are no joke. So this is why they said even the technical success was low. Now, if you look at the success rates in drainage, which is the slide number D on the top, there was not much of a difference in the P-value, too. And they defined the success drainage rate as more than 75% of improvement as the success rate. And then you look at E slide, which is the bottom slide. This is the early adverse events, like which is cholangitis and stent occlusion, no difference. So if there's not, that is why, you know, again, very difficult question to answer is that bilateral versus unilateral, the data is all over the place, but given that there is still some improvement or some favoring towards the survival, although not statistically significant, I think it has been more favored of putting a bilateral stent over the unilateral stent. I mean, you guys do bilateral, right, in your places, try to bilateral? Correct. Yeah. A, subsect the type of high-level stricture and then the success rate from those individuals, because if it's, oh, only the right side is blocked, why would we do it bilateral and that of implicated? Yeah, I think that's a great question. I think most of these studies were type four, what they were looking into, but I think that's a great question. And again, I think that is why, if you look at these studies, none of them are very remotely new studies. Like, you know, you look at the years and everything and it has been going on, and this has been a topic of debate since Dr. Chahal, Dr. Rain, Dr. Astogi has been fellow and I have been a fellow. So we are trying to answer those questions and trying to reinvent the wheel here. But great question. Again, general guiding principle, avoid draining at atrophic portions of the liver because there's no benefit. If it's the atrophic side or necrotic side of the tumor, no matter what you do, it's not gonna help anything in there. So try to shy away from that. Minimize the injection of non-dilated ducts. Attempting the drainage of all the injector. Once you have injected, try to drain them out. Try to put the contrast tape above the stricture, because if you're above the stricture and you are trying to do it, you're already committed, you're already in there, your chances of draining would be high. But if you go from the bottom and start lighting up like a Christmas tree, then the contrast will follow where it has to follow. And sometimes you will not be able to go and drain the segments which you want to because now you have committed of the contrast present in them at this point. Again, stent-by-stent, which we talked about, and stent-in-stent, like a few of these studies by Kim and Naito, there are no difference in success rates. Higher obstruction rates and adverse event rates were noted in side-by-side stent as compared to the stent-in-stent. Again, like you know, more studies needed to be done, but this was a very limited data. I could find, just wanted to put it there. So this is what you're looking at, clad skin tumor in here. You are looking, this black thing in here is where the stricture is happening. So it's going from the confluence, going into the right and the left. And look at the common bile duct. Look at the common bile duct and look at your right intra-hepatic duct and you look at your left intra-hepatic duct. Think about trying to push two stents through these common bile ducts. So that's why the technical success was lower on this thing. It looks easy, but it's very difficult, as I said, to be done than to be said in there. You see? Yeah, and then there is unsalub. Thank you for. So this is very nice. This is also a nightmare for us if you have to do some pancreas intervention in there. Sometimes I get lucky and it straightens out. Yes. So this is an unsalub, what you're looking in a pancreatic duct. So basically this is a MRCP imaging where you are seeing common bile duct and then the pancreatic duct. Both are neighbors, right? That's why you have post-ERP pancreatitis. So in this, this is an abnormal loop happening in there called unsalub. Yeah, so that's what, and that's a nightmare for a lot of our endoscopists if you have to do some pancreatic work. So again, you look into it. This is what they are trying to show is a hyaluronic tumor, like unilateral stent. This is going into it, inflating, and then, missing something. Yeah. Yeah. And then you go and you put in stent and you can see this bent in here, how tight it is. Again, this is bilateral. You can see trying to put into the left hepatic system, then you're going to the right hepatic system, and then you are basically trying to put two stents in there, which is a bilateral. Again, look into it, like, you know, look how easy it looks and nice it looks on the picture, but when you look into how to put it on, it's not easy. Like, you're putting a wire, you put the first stent, first stent, and then you're trying to put the wire through it, because you already have a wire in your second system, but you're trying to push the stent through it. So it has to go through these flanges in there, and you can see how complicated it looks like in here. So again, not an easy thing. It's very technically challenging, and again, given the data, not clear advantage, but again, favors towards it, if done in right expertise, right place, and I think most like tertiary centers. Again, have you used this system before? I have, okay, got it. Yeah, so this is like a six-fran delivery system, whereas I think you could simultaneously, you deploy two stents in there. I did not have my hands on it, but it looks nice. Again, bilateral stenting, know your differential diagnosis. Tissue sampling is important. Try to, and again, more is the endoscopic approach. We try with clengeoscopy, go and take some biopsies, do brushing. I have started doing two brushing since that paper came out. One, and do 10 times. I think the paper came from China. They were doing 20 times or something like that. No, 30 times, yeah, yeah, yeah, but I have, our material breaks after 10, so I tried to do 31 time, and it was stuck in there. I shied away just to stick it to 10, and then I said, do you guys send it for fish? Do you do two brushings? One, okay. Ours go to Mayo Clinic. We don't have the ability to do fish, so. Yeah, got it. So again, bare metals can outperform, which we have seen the data about it. If you have common peridot structure, which is type one, single stent could be fine. Two, three, four, you are obviously, minimize your contrast. You can reduce the pressure in that segment. Once you are there, you can try to aspirate. That will help you decrease the pressure. Don't manipulate and opacify the ducts that won't be drained, and this is a very important line which has been tried to hammered over and over in the slides is that do not opacify the slide, which you will not, opacify the ducts, which you will not be able to drain. Goal of stenting, again, 50% of the liver volume or two sector unilateral pacification, single stent, bilateral pacification, you do a dual stent in there. Again, going quickly to ablative therapies. We have photodynamic therapy and radiofrequency ablation. This is basically used to ablate the tumor used as a primary salvage or used for stent occlusion. Salvage therapy, as well, has replaced the photodynamic therapy in there. It's easier to be done, performed endoscopically, and does not require a photosensitizer. I have not done PDT in my lifetime. Have you guys done any PDTs? But you are not, anybody's doing PDT at this point? I have a, nobody's doing PDT, right? I had a rep come to me and he said, at some center, they were doing a PDT. I said, he was very excited. So I said, I will be, too. You can take me next time. They have good randomized control trials on PDT. But it's really tricky. You know, patient become highly photosensitive. They break out in blisters. If you are out in the sun, it's not easy. This is like those hyperbilirumia newborn jaundice, like my baby had a blue light kind of a thing. So, again, I think different catheters are available. There is an eight French catheter. Can we name them, or we are not allowed to name? So eight, yeah, eight French catheter is Habib catheter, which you are looking, and then you have endoluminal catheter from StarMed, which is a seven French catheter. So eight French catheter, which is Habib catheter, you have in five, 10, 15, 20 watts. You can go up to 60, 90 seconds, 220 seconds. And then you have endoluminal, you can do seven to 10 watts over 120 seconds from the proximal and the distal segment of it. Again, important, ablation of primary structures within the bile ducts, clearing of the obstructed biliary stents. 180 centimeter of the usable length fits over a 0.035 wire, 36 months of shell needs a RF generator. And then you have a self-expanding metal stent uncovered that if it gets obstructed, you're ablating to clear the tumor that's encroached. Yes, so basically, you're trying to do it. And I have a slide for that also. I have data on that, and I think that's a great question. I think going back early, if you see Steele and Monga in 2011, these groups went in and said, this is the extrahepatic cholangia, what you're looking at. And they tried to do a RFA therapy on this one, and this is what they found out. And then they presented 22 reported cases. They said it was simple, tumor remission with prolonged patency, no serious adverse events. So this, followed by Shiraya in 2015, they said, OK, let's see. Let's go and do a radiofrequency ablation on all the malignancy strictures, whether it's from pancreatic cancer, gallbladder cancer, metastatic disease, or cholangiocarcinoma, and see if that would make any difference. And if you see the brief, there were 45 patients in the cholangiocarcinoma group, and the mean survival was 17.7 plus minus 15.4 months. And if you look at Kaplan-Meier thing from RFA to registry, you can definitely see their p-value was very significant with the survival benefit in these patients. So this is very important. Look in their data. There are like seven studies, and data is all over the place. Some have not collected ability obstruction. Complications are there. There's some survival. And that's the problem what we face in the endoscopy world is, the heterogeneity, the local expertise, difference in collection, representation, not enough of randomized control trial. And as Dr. Rastogi was mentioning to me, it's very difficult to tell a patient that I'm going to randomize you to one unilateral stent versus bilateral stent. Think if it was your family member, there might be a gang war happening in the endoscopy outside. You might have higher security there. So again, the only purpose to show this slide is, this is where we are right now, that this is the data available now. You can do meta-analysis out of it. Meta-analysis will bring you closer to it by combining all these things. But again, I think we have more room to go and do studies on these things. Again, if you look into it, there's a strict shear bilateral. You have the wires in there. You see this RFA catheter going into it to perform the intraductal therapy. And then this is followed by plastic stents bilateral. And then in three months, they went and they replaced it with the self-expanding metal stents in there. Now, this was your question for in-growth occlusion. So Inui did a study from 2020 to 2022. I really applaud this guy, because the world was dying in COVID at that time when this guy was doing a pilot study. So must have to be a good study. So prospective study, 30 patients, technical clinical success, you can see 93% to 71%. Early to late adverse event rates were around 7% to 10%. Recurrent biliary obstruction was around 45%. But look at the median time. That's a good number of 163 days. I mean, I would take it any day in my endoscopy practice. Now, this is a very important thing, which he figured out, that basically the success depended upon how much you can re-canalyze the self-expanding metal diameter, that what the ratio of the ingrown tissue you can burn or ablate and re-canalyze, that will be determining your clinical success. And what number he came out was was 51%. So if you are able to do 51%, if you're able to open it up based on the ratio, your clinical success rates would be higher in these patients. So again, I think this is a great study. Yes. So great. So basically, your tissue has grown into the stent and has caused occlusion. So what we are trying to do is canalization. Like, canalization is a word that we are trying to cannulate in that area. Canalization is, that means we are trying to go through that obstructed mass to open it up. That is called re-canalization. The same word can be used in the cardiology world and interventional thing. If your LED is blocked, can I re-canalyze it or re-canalate it and put a stent in there? So how much you can re-canalate it. So that's where it came out, that ratio of re-canalization diameter to the self-expanding metal stent diameter. If you can open up to 51% with the RFA or a B-catheter or the endoluminal catheter, that can help you with much more clinical success. Yes. The goal in re-canalization is for the inner diameter of that SEMS to reach 5.1. At least, at least 5. A minimum of 5.1. Minimum, yeah, exactly, exactly. Thank you. You had a question? That was my question. OK, sounds good. Smart minds think alike. Stop stealing my questions. So again, who to treat these one? Early stage lesions, that means these are very early stage patients, no visible lesions, or they are towards the later part of it. That means they are non-resectable, not a transplant candidate. So this is also, again, very important, multidisciplinary meet. Talk to your people. Talk to your oncologist. Spend time in there and see what's going to be the best approach. Not everything fits every person. But you should have all these tools in your basket when you're going for your multidisciplinary talks and meetings in there. Again, good performance status is important, because you don't want somebody who is on home oxygen, like coming into it on six liters, on a wheelchair with BMI of 40. So again, 40 is new for us in the South, but again. Accessible to stenting, because it's very important. It's just not you do RFA. As Dr. Lee showed you the slides before, that he sacrificed his first son, Mr. Pig Lee, and that he had the vessels going around, and that can cause pretty much damage. So you have to see that, can you go in and put a stent in there? So this is very important. That means you need to have viral cannulation in there. Candidates for concurrent chemotherapy, radiotherapy, local regional therapy. And again, it's not a one-time thing. They should be willing to undergo multiple procedures in there. Again, we have to maintain the potency. Again, this is, again, which we have talked about, how much to pacify, pre- and procedure antibiotics, review your imaging. What is the nature of the tumor? Is it a candidate for transplant or not a candidate? What is the diameter duct? Which we have to take a look into it, because we have to push the two stents into it. Any lobe which we have to stay away from, atrophic or necrotic tumor, plastic versus self-expanding metal stents, upper limit, oh sorry, unilateral versus bilateral stents. Consideration when deploying more than one stent. How do you decide? I normally go and put a longer stent first, as long as I can, so that when I'm pushing the second one, even if it's trying to come out on me, I'm not losing my position for the first one in there. But again, balloon dilatation in these situations, and you will see a video coming up in there. Do I have time to show the video? Or I'm done? OK, so let's go on and look at this video, because this is a good video. Again, this is not my video. This was given to me at Curtsy of ASGE. A 54-year-old woman with adenocortical cancer, large liver mats. Performance status is good. TB here means total bilirubin, alkaline phosphatase. Numbers are there. And then you basically see the video. So this is a common bile duct, what you are looking in here. They are trying to go in and try to cannulate. You can see how tight these strictures could be, that they are trying to push the wire in there. And because of time's sake, I'll just show you. And you can see, OK, now it has gone into the left hepatic system, most likely segment 2, 3, 4, what we are looking. And they have gone as far as they can, because I was told the cardinal sin in this situation is losing a wire. As a fellow, the scope is taken out of your hands after that. Now they're trying to go and push the cannula through it. Again, going. And now you can see they're trying to basically fill up the segment. Again, they did not try to inject the contrast here. They went above the stricture and tried to inject the contrast so that they are committed now. And they already have an access to that area. Because if they do it here, although the contrast will go there, but it might also go into this segment into the right side, which they might not be planning to drain in this situation. Again, this is a balloon. This is a hurricane balloon coming up. Like you can see, these are the two dots. They are trying to go into the segment, which is strictured. And I'll show you. It's going to be. So you can see it is, you can see they're trying to now inflate the balloon and this helps to open up the stricture. This helps you basically go in and help us to put the stent in too because the stricture is tight, balloon dilatation always helps in this situation. And they're trying to make sure that the whole pathway is open. And as you can see this waste coming up in here a little bit here, I think it then goes away. I think so, I think it will be very difficult. Think about the wire, think about wire is 0.035 inch, right? That was not able to, or sometimes 0.025, sometimes even we are doing 0.021. That is also difficult to go into it. And then you are trying to push in at least, I'll say 3 French, 10 French is 3 millimeters stent through that area. So that will be tough. Again you can see that they are doing, yes. So that is why you have to go slow. You cannot, you have to like be very careful what you're doing. So go with the smallest diameter, like as a four millimeter is I think the smallest what you can go. Take a look into it, see what you are doing, be cognizant. And if you think there's a room, you can sequentially go up to six millimeter, be very conservative. That's what I was told. And I think it's the same approach still, like be very conservative, whether it's a high-risk obstruction, whether it's a primary sclerosing cholangitis, chances of perforating are high if you go very aggressive in this patient. The same like esophagus, but this is even more dangerous because, because, exactly. Again I think this is a right-sided tumor in this case, and the surgeons wanted to basically go and stent the left side. You can see the left stent in there. This is additional imaging, bilateral. You can see this is going into the, I think, right anterior, and this is the left hepatic system. This is right, going to right anterior. This is right posterior going in there. Looks very fancy, but, yeah. Again, last slide to conclude, where rubber meets the road is important. High-risk stenting is substantial, more complex than what we think as compared to the common bile duct. Planning is very important. Like, you know, you have to plan it, discuss it in multidisciplinary meeting. You need to have a game plan when going in. What's going to, I'm going to go, what is my plan B if plan A is not successful? What are we going to do in this situation? What type of stents are available? What's in your bucket in there? Address, what can be drained? What can be done? What cannot be done? And this has to be done to the surgeon. You know, sometimes surgeons can be, why didn't you do this and not? So pick up a phone if the surgeon is not in your hospital, is somewhere else, or pick up a call to your surgeon or to a referring gastroenterologist or anybody, like, you know, just to make sure, just let them know, hey, listen, we were planning on this, but this did not happen because of this, this reason, and this is what we did. I think this is very important in patient care and making sure that we are trying to help them, not creating more roadblocks for them. Again, plan to draw what you specify, low threshold, again, this is very important point which we see, but not very common, low threshold to transfer to a tertiary center, if in doubt, for better outcomes. Leave them alone, send them. Do not do a half-hearted thing. Do not put a one stent, which is hanging in the confluence, and it's a clad skin or a type IV hyaluronic acid, and now patient comes with cholangitis, is on two pressers, and now you get a consult, what to do next in this situation. Well, I will finish my slide with this one. Thank you for bearing me.

biliary obstructions

cholangiocarcinoma

primary sclerosing cholangitis

stenting

transplantation

radiofrequency ablation

diagnostic imaging

multi-disciplinary collaboration