Next session, next talk, we reserve this to be more interactive. You know, this is just going over, listening to Dr. Vinay Chandrasekhar and Dr. Amit Rasogi, two of the busy ERCPs in the country, just hearing their perspective. How is it like spending a day in an ERCP lab when things go well and if things are not going well? And this is an opportunity for everybody. So you have listened to a lot of topics, talks on everything related to ERCP. So any questions that you have about the subject, so they are at your disposal. Thank you, Praveen. So a quick thing for the recording purposes, please, when you're asking a question, just press on the mic so that they can record it, otherwise he has to guess who's speaking. So what we thought was such a broad topic, when we thought about doing this, I guess it's very difficult to cover it with slides because these challenges, opportunities, daily practice differ with every institution, right? I mean, you could be in a small community center, big place like Mayo, a little less bigger than Mayo is KU. And you know, so the challenges, opportunities are all different. So you made it into an interactive thing that we can question each other and then you guys are more than welcome to ask any questions or we could even start with questions. We may as well start with one, there we go. I know how to ask a lot of questions in these meetings. So thank you guys for humoring me. My question is just predicated on the fact that we haven't really been in a whole lot of ERCP and we certainly haven't directly supported ERCP in most of our careers. I think it's just important. How do we best be in your room in a way that's appreciated without overstepping? How are we supportive without overstepping? That's a good question. And I'll start with that response. So don't undersell the fact that you have already built networks in the endoscopy suite, right? So ideally you work with someone who you support through your other products who also does ERCP and just haven't had a chance to be in when they're doing an ERCP. However, if you don't have that luxury, then you go to someone who you do know, a physician partner who you work with closely and say, look, you know, we're going to have some products that are going to overlap with, are going to be in the ERCP realm. Do you have a colleague or do you have someone who you would recommend that I could shadow for a day or two? And that's how you start, right? And you start to build those networks. I'm sure you have broad networks for endoscopy and for, you know, some of the things that you do, a lot of the esophagus stuff and whatnot. But if you don't have a broad ERCP network, that's where you start. You start with someone maybe who has that overlap, and if not, someone who will be willing to reach out to their colleague on your behalf. And then when you show up in that room that first day, you just zip it and just watch. Just absorb. Don't ask a million questions. That's what I tell my fellows, so that's what I can tell you. Just sit there and be a sponge. You're watching what the physician's doing, what the fellow's doing, what the nurse's was doing, what the janitor's doing in between cases. You're watching everything. Because believe it or not, I say that in jest, but sometimes that's where some of the innovation does happen. You watch and you listen. And then in between, if you have questions, you can then start asking some questions in between, just because you may not know when's the right time you can pipe in and say something and when's not. As was alluded to earlier, sometimes these are very stressful procedures, and so you don't want to be that person who pipes in and says something in the middle of a case when it's ... and then that person's not going to invite you back to their room. That's how I would start with someone who you don't have a great relationship with. And I'll stop there and see if you have any other comments. Absolutely. I mean, I echo all your points. I mean, I think all of you have relationship with gastroenterologists, and some of them are doing ERCPs and maybe some are not, but you have a standing relationship. Use that. Take advantage of that. Request it. I can tell you with my experience, Kason came up the other day, last week, actually, and said, can I be in ERCP? And I'm like, I knew why he was asking. I just wanted to just ... I'm like, why the hell do you want to be in an ERCP? What has Medronic got to do with ERCP? And he said, oh, well, you're going to teach me next week. I mean, I was just kidding, but that's the way. Even if I didn't know, even if I wasn't coming to this course, I would have said, yeah, absolutely. Again, to Vinay's point, be cautious, right? These are intense procedures. Real estate in some rooms is very limited. Now you have an extra person in that room. So sometimes it's not possible, and if someone says, no, you can't, then don't take it the wrong way. But yeah, I mean, just request and just observe, right? I mean, the first few cases you observe, and Kaysen didn't agree to that. He started asking questions straight away, and I'm like, okay, that's like, okay, the first ERCP, that's way too ... you're crossing the line, you know, I just didn't say that. But yeah, I mean, just observe, and when there's the right time, ask questions, right? A lot of times the questions are, can we ask at the end of the procedure? When you see there's downtime, the physician is relaxing in between procedures, you can ask that not in the heat of the moment. And then gradually you'll see, you know, your experience will build up. I mean, different types of cases, garden variety, more intense, more complicated cases, and that's basically it, I mean. So I'm sorry if this sounds like a silly question, but when you guys were talking about the room itself and how there's a lot of pieces to it, you know, we learn our space in the endoscopy suite. We learn our space in the OR room of like where to stand, because like you said, some of these rooms aren't as big as the OR, but you have a lot more stuff, everyone has to get everywhere. Do you have, like, is it appropriate to, I guess, sometimes I just ask the staff, like, where do you think would be best for me to stand so I'm out of the way, or is that something I should be asking the physician, because they might have preference of like how they want the room to flow? Do you have any perspective on that? I mean, it'll depend on the room and how big the room is, how many people are there in the room. I mean, you know, a lot of our programs have fellows, sometimes you have medical students and residents. So, you know, the best thing is to figure it out yourself and maybe just ask. Sometimes the nurses and the techs can tell you, right? They are a good resource, and you guys all, you know, work with them closely. So, I mean, just ask them, hey, listen, I've got the permission to be in this procedure. Where do you think I can stand and watch? Because I mean, you have to be in a place where you can watch something, right? There's no point standing in a corner, being in that room, not able to watch anything and learn from it. So they can tell you, yeah, this is the place where you can stand and you won't be in our way. Because, I mean, there is a lot of hectic activity going on sometimes, like, you know, you're wanting extra equipment to be brought in and stuff. So you want to be away from the movement, but yet to be able to look at the monitors and see what action is going on. I mean, so I think every room will be different. Just talk to the nurses and the techs, and they are the best people to tell you. Yeah, I think the staff in the room will guide you in the right direction, unless they don't like you. Then they'll tell you the wrong thing. You should view them very much as your ally in helping you navigate this space, since you're so new to this space, that they'll help you, you know, where to position yourself, what you should be looking at. Every now and then you'll have nurses or techs who are more enthusiastic than others. You'll figure that out. You know, you're all in these roles for a reason. So you've got the soft skills, communication skills, so you know who's going to be helpful to you. We have radiation technologists, and some of them will go out of their way to say, you know, they'll point to people, hey, look, there's that stone, here's a stricture, here's this. Here's what's going on. And I can hear them mumbling in the side, but it doesn't bother us. So you will find those allies in the rooms. I do think that, you know, you can always ask the physicians, but sometimes they may not even know where the best place is, because they're not seeing what's behind us. Like, we're looking at the patient and the monitor. I'm not seeing what's happening behind me all the time, and I don't know when nurses or techs are running to grab another scope or grab equipment going into the core, you know, getting out of the cabinet. So they'll probably tell you best. You don't need to be intimidated about going into these rooms. That's the other thing I should tell you. Don't walk away saying, oh my gosh, it's a scary room. It's not. It just, you know, I tell people from scoping, for me personally, scoping to scope out, it's we're on, you know. After the scope's out, then we can joke and do whatever we want. But scoping to scope out, it's, you know, I've got a person here to take care of. And so that's how I approach it. I think that's what someone told me, too, and that's how I learned it. So I think it's very valuable, kind of, when you're in the room as well. Every now and then you'll have people, and even me, I'll joke around, and then sometimes the fellows get annoyed, because I'm chatting with the nurses and the techs, because it's an easy case, but they're trying to focus and trying to concentrate, right? And so the person with the scope in front of that patient, that's, whatever that person wants is the most important thing, to be honest with you. And also, I mean, don't get offended if you ask a question and you don't get an answer. Maybe the physician didn't even hear you, right? They were so absorbed in what they were doing that they might not answer. So I wouldn't take it negatively that, oh, he's ignoring me or whatever. If you are talking while doing the procedure, I mean, sometimes you can, I mean, so. Do you still have questions left after the other day? Okay, just making sure it's okay. So Dr. Rastogi, I know at KU, when you, or it's Dr. Ollier, Dr. Hajazi, you guys run two rooms when you're there for advanced days. You're finishing a case, and they're rolling back to the next room, and you're back and forth. So I know time and efficiency is really important. A lot of us have other accounts where it's, okay, it's an advanced physician scoping, EOS, CRCP, three lowers, a couple uppers, then another ERCP, and then we're done. So my question is, for you guys, for ERCPs, specifically at academic institutions or large volume facilities that are doing a ton of these, how important is that efficiency? And if there's ways to make your ERCPs or cleaning gyroscopes go smoother or quicker, how much of that guides your decision making during the procedure? Yeah, I mean, efficiency is everything. And you're talking about, I was talking to Vinay that we'll have different challenges. I mean, Mayo probably doesn't have any challenges, I would guess, right? There's perfect setup. We do. So at our place, to what Jason just mentioned, is that we have space limitations, we have a decent sized lab and surgery center rooms, but the volume is such that we need more therapeutic rooms, and for some reason, the hospital system has not been able to give us what we want. So we've tried to balance the act by, you know, running two rooms at a time, so we just have one therapeutic endoscopy scoping at the main, and we run two rooms, which in a way works out because I have hardly any downtime, right? So the day has to be very, very systematically scheduled. So my schedulers, my nurse practitioner, my nurse knows how to schedule the day for me, in the sense that you don't want to have complicated patients back to back. You know, I do all kinds of procedures, I do third space, I do ESDs, POEMs, and ERCPs. So some of these cases are easier, some of them are difficult. Repeat ERCPs, although they are scheduled for an hour, take us like five, ten minutes. So they know how to juggle. So the efficiency comes in different aspects. One is how you set up the schedule, knowledge of all the patients, right? I mean, I go through every patient beforehand, I know all the records are there, everything is there so that we're not struggling to get records or information on the day off. A lot of these patients we've already talked to, so there's very limited talking, we just get the consent process, not that going into a detailed discussion of what we are going to do, unless you've never talked to them, they're inpatient, then yes, if you're seeing them for the first time, then we have to go through a detailed discussion. But the scheduling of procedures, as well as the turnaround time. So the turnaround time, the way we've worked at it is, we have two CRNAs, two rooms, one anesthesiologist, myself, my fellow. So the fellow takes the consent, I go and talk to the patients, and we try to do it in such a way that while we are pulling the scope out, or we anticipate we are going to be done, we roll the patient into the other room, right? But no patient will be intubated, or nothing would have been done to the patient till I physically talk to the patient and do a timeout. So I make sure that I do a timeout in every patient, not the fellow. So that is one of the things that I've always talked to, that no matter how. So that tells you the efficiency, right? Training of the staff, we have to have very good staff, nursing, I mean, they are integral in these procedures. I mean, if you don't have well-trained, motivated nurses and techs with you, then it's not done. So there comes the role of the industry support, like I always tell them, like, for example, for digital spyglass, we were talking over lunch, that you always hear, we used to hear, not anymore. And the moment you said, I want the spyglass, or Colangisco, whatever you call it, there would be groans in the room, because it's labor intensive, right? But I would always tell them that, you know, this is not so difficult, get the industry person, the company person to come and do training every few weeks, they will be more than happy. I mean, you guys will be more than happy to come and train the staff on your equipment, because you want them to use it, and for it to sell, right? So now over the years, it's become like a three, four minute deal that from the point I tell them that I want the spyglass. So there's your role, right, for efficiency is, it's not one and done that if you launch a new product, then you just do one in service on a Tuesday morning, like it's at our place from 7.30 to 8, or 7 to 8, and then you're done. Just be proactive, and just talk to the nurse manager. Staff is, there's a constant turnover of staff. That's the other challenge that we face, that there's a constant, it's very tough to retain good nurses and techs. After COVID, there's this new demon that has come about, which is travel. So we've lost like good nurses, good techs, because they can make a whole lot of money by doing travel jobs or whatever, if they're not committed to stay in a place. So there's a constant turnover, which you might not realize. And that's where your role comes in, is to come and do constant training and help with their future, especially if it's a new product. Yeah, fair. I would say that the other thing about just a day in the, through the lens, a day in the ERCP world. So most of us will review all of our cases either the night before or the morning of, right? So we know what's going on. ERCP, unlike other cases where, we have a shared system in our unit so that if I'm done at my cases at three and someone's got three more cases to do, I'll pick up their colonoscopy and I'll say, okay, what's the case? Diarrhea, biopsies. Okay, fine, great. Like no other thought about it and just meet the patient and consent and just talk to them on any issues, right? They'll tell me if they had colonoscopy before, was it difficult? Not, I can figure that out. ERCP in particular requires a lot more careful review. You need to review it. You know, if they've had imaging, review the imaging. I don't just look at the report. I actually look at the imaging because oftentimes what the radiologist is commenting on is not what I want to look at or is not consistent with me. Look what I want to see. Two is I need to know if they've had, you know, if there's someone who has a condition that they're coming back for ERCPs frequently, I need to look through those prior ERCPs. What worked? What failed? What didn't work? I need to know if they've had a prior ERCP is that they have a sphincterotomy. It changes what I'm going to start with. I'm going to use a balloon catheter or a cannulotome, not a sphincterotome. So it changes what equipment we have. So I like to do all mine the day before. I don't like to walk in the morning of. And then what we do, and I'm sure you probably do this, is we have a huddle in the morning where we go over all the cases for the day. What's the equipment that we need? What's the plan with anesthesia? Is this a Mac? Is it a general? You know, what are the anticipated sort of things? That way the team, everyone on board will say, okay, this is a stent exchange. You had a 10 French, seven centimeter length stent. Okay, I'm going to have pull one of those and not open it, but just pull it so that that's probably going to be the stent we're going to replace it with. We're going to replace the stent. So everyone in the room knows at the beginning of the day, okay, you know what? This case was scheduled for an hour. It's just a stent change. It's probably going to be quicker. This case was scheduled for an hour, but it's actually way more complex and it's going to need cholangioscopy and this, that's going to take an hour and a half. So that level sets everyone in the room about what the day is going to look like and how it's going to go. Now, the day can go to hell. And then, you know, what you thought was an easy case, turns out to be a nightmare. But I think that's very, very different than servicing an EGD in a colonoscopy room where you could basically take any patient within three minutes, know exactly what you're going to do and be confident. So that's number one. Number two is many of the practices like his practice sounded like my former practice where I was doing 14, 15 cases bouncing between rooms. It could be a EGD colonoscopy, US ERCP, you know, EMR, this, this, this. At our facility, we're very unique in that I have a, I'm in the ERCP room tomorrow. I have six ERCPs. They've already emailed me to add on a seventh and there's an inpatient to add on an eighth. So, you know, so there, I already know what my day is going to potentially look like. And I already know kind of what, what it is, but mine is just an ERCP day. And the turnover, I work out of one room in those days, which I used to, I used to like working out of two rooms, but I did double the work almost. Now I do, you know, I do, I do eight, eight, six to eight cases in one room and we're scheduled six, six is full. But what happens is, as this is, this is the other thing that you need to be aware of is that, you know, this is just one of the hats. And many of us have many, many, many hats, right? So I don't get time to do all the other stuff. I manage my fellows. I run the pancreas group. I run this, I run that. On a given day, I'll get anywhere from 100 to 200 emails of which at least 50, I need to respond to. And so during that downtime is my, that's my time to like get stuff done, just knock out stuff. And so you may think in between cases may be a good time to catch the physician, but maybe you have to look and read, you know, read that person and say, look, they're doing a ton of other stuff right now. Sometimes actually in the procedure, when it's an easy procedure, that's the best time you have them captive to talk about things. So there's never a set rule about like, you know, this is the best time to reach someone. This is the best time not. You just got to read the person, even ask them, hey, when's the best time? Or, you know, like you seem really busy today. Do you have five minutes to talk about this, you know, and then just kind of carve that out. That's another strategy to use. And not to go any further on it, but kind of put my sales hat on, but not put it on. It sounds like with the workload that you guys have and how busy you are during and in between saving those 15, 20, potentially 30 minutes in a given case could be crucial to your day to day. Absolutely. So I can tell you, I mean, some of the company folks, when they want to talk to me about it, they know that during endoscopy days, I mean, like I think you're talking about pen is busy, right? So I mean, there are two rooms. I have no time to talk during those days, especially if you have to have a decent discussion, like constructive discussion. So I just set up a time later. I mean, the best day to meet me is, everyone knows is the clinic day. So I have clinic, which is away from the campus, so away from the crazy place that I work at usually. So that is a remote, like, you know, a peripheral KU Midwest, right? So I know when the fellow is seeing patients with me, I have downtime and then I can sit down and give undivided attention to whoever comes and meets me. So I mean, like every place is different, right? Like he's so busy in between procedures. I try, I can't do what Vinay is doing in between procedures. I have some other time during the day or whatever to do those. So, you know, you have to figure out your own place, right? And have, you know, some kind of a judgment is involved in that, that how do you get the maximum out of your conversation with the physician? Absolutely. Hi, I'm gonna switch gears a little bit. What are both of your preferred cannulation techniques and why, and when, and if your first option doesn't work, what do you normally go to, or is that patient specific? Yeah, it's shifted over time. And so I think the one thing that I try not, yes, everyone has their own preferred modality, but I think you also have to change your practice based on what the data shows and what your own outcomes are, right? So I think if someone is coming to you for the first time, I think universally people will start with a sphincter tome. So just a sphincter tome with a wire, wire guided cannulation. And that's where you start to see some divergence. You'll see people who will persist with that same device and that same wire for 20 minutes. And you'll see people try it three times and say, oh, this is not gonna work. I'm gonna move on to the next thing, right? Some of that comes with experience. You know, you go down and you see a small papilla, or it's angled the wrong way, or it has a favorable anatomical features like a bulging intraduodenal bile duct that you can see. So that may change your approach. So my next approach, it depends on what's happening during the case. So if I am in getting the pancreas and I wanna go into the bile duct, okay, let's say that's the scenario. I used to get in the pancreas, get in the pancreas, get in the pancreas, and then, you know, maybe do a golf maneuver, which I've done it several times. Now it's changed. The data shows get in the pancreas and you're trying to get in the bile duct, put a pancreatic duct stent. So I put a PD stent in now, like almost up the first, if not the first time, the second time I'm in the pancreas. Why? Because it's gonna help reduce posterior speed pancreatitis and then straighten out that duct so now I know the anatomy to get into the bile duct. Then I'll try to go in with the sphincter tome and a wire. If I can't get it, then I'll cut over, do a cut over that pancreatic duct. So that has changed over time. I don't know what your preference is. Yeah, so very similar. I mean, if it's a native papilla, we all start with a sphincter tome. And a good day is when you get into the bile duct the first couple of attempts and you just get deep canalation. I don't use the wire guided canalation. I wasn't trained with it. I do it as a second step. The first step is to just engage the papillary orifice in the orientation of the bile duct, which is at 11 o'clock going upwards. You have to assess the papilla. You can see the hump of the bile duct, the interdural segment, so you direct it. And if you get in, that's the smoothest way. And you don't want to push it. You know, it's just like we used to call it the cotton kissing technique, I guess. I don't know what it's called now. You put the catheter out a little bit, engage the papilla, and you bring your big dial of the scope towards you so that the entire thing goes up. So that's the least, you know, it doesn't alter the anatomy of the bile duct as much as just if you push it. Because if you push the catheter a little forcefully, then it'll angulate the distal bile duct and you'll not get in. So first, couple of attempts to do that. If you get in smoothly, that's great. Then you pass the wire up, inject contrast to confirm. If I don't get in, then I start getting into that area and start asking my, we have the long wire, I don't know whether you guys use the wire. So the nurse, and we have decent experienced nurses, so they try to pass the wire and then you see. During that time, if I get into the pancreatic duct, I leave the wire in the pancreatic duct. And that is good because you know the configuration, you have not injected contrast. I mean, if it's going straight into the pancreatic duct, there's no reason to inject even contrast. And that also decreases the risk of pancreatitis further. So then I remove the sphincter, don't get another wire, and then do the double wire technique. Majority of the times, that is successful. If it doesn't succeed, if let's say it's successful, we do the bile duct therapy, whatever, stone or stretch or whatever, but put a stent in the pancreatic duct at the end. And if the double wire technique also does not succeed, then that's a bad day. So then now you're 10, 15 minutes into the procedure minimum. So then you put a stent in the pancreatic duct and then a couple of attempts again. But once you have a stent in the pancreatic duct, dilating over it can be a little more tricky because the space is already limited. You know, the real estate is already taken up by the stent. So then you have to do pre-cut. And that's how it evolves. And the last is, luckily it doesn't happen that often, but it does happen. I wouldn't say it never happens. It happens that even after pre-cut, you can't get in. And usually these are cases where there's some problem, like a big mass or something. Then you have to think of either you bring the patient back another day when the edema and all has subsided, or you do some other technique, which is EOS guided or what have you. Yeah, so I would say that there's no standard second maneuver, right? And I think the more experience the individual has, whether they articulate it or not, they have said, okay, what is the thing that I'm running into? Is it because it's a small papilla and I just can't find where the bile duct is? Is it because I keep going into the pancreas? Am I not sure of the orientation? All of these different things that's leading to unsuccessful initial attempt at biliary cannulation. For those, you have different algorithms in our head that we're doing, right? So if we get into the pancreas, he leaves a wire, I leave a stent, and then that's the next thing. But the approach would be extremely different if I wasn't getting into the pancreas and I'm not getting into the bile duct, I'm just getting nowhere. So then my approach would be very different based on the way it looks and the way the orientation is. What's the indication? Is this something where I've been struggling for 20, 30 minutes and this needs to get done today? Then I may be more prone to switching to an EOS guided technique earlier. Whereas if it's, hey, this patient's got a stone but they're doing okay, come back to fight another day. It's already swollen, it's edematous, and there's diminishing returns by trying to keep, trying to cannulate. I think the last point, Vinay, is very important. I mean, you know, so ERCP is probably the most gratifying procedures that we do and probably the most humbling also. And when you can't get into the bile duct, for me personally, I do all kinds of procedures. Nothing is more frustrating than that because you're like, I've been doing this for 20 years and still, and there will be failures. So you have to be, to his point, you have to see what the patient needs. I mean, is it necessary, really necessary to get in today, right? I mean, if the patient's doing well, come another day or ask another partner to take a crack at it. So, you know, not every ERCP has to be done the same day, right? I mean, it's like patient is doing okay. Even for malignancy, I mean, the patient's been jaundiced for weeks. Waiting another couple of days if you can't get in today is not going to matter much, right, in the big scheme of things. So yes, mentally, it is a little annoying and it hurts your ego, so to speak, but you have to take a step back and say, yeah, I did my best. This is not the day. We have to have another plan. Can you explain patients doing okay? Like what would be the... Like, so let's say someone has a stone, right? And comes in with pain, no fever, no white count elevation, you know, giving him antibiotics, the patient's not gonna crash with cholangitis all of a sudden, right? So there is time. Whereas other cases where, you know, septic shock, this is, you know, this needs to be done. You have to source control. Well, as much as we would love to continue with our question and answer session, guys, we have to stick with the time. So we have 10 minutes break and then you guys head on to the Bioscale Lab.

ERCP lab

patient history

cannulation techniques

collaboration

contingency plans

medical team networks