This is to catch you guys awake. We have some valuable ASGE prizes that we'll be handing out for correct answers. And they're all really easy, because Pat and I are going to make some up as we go. Yeah, so, yeah, there's a variety of water bottles. If you don't have a baby, I'm going to question why you're taking these, but that's okay. All right. Okay. Yeah, exactly. Schaefer, you cannot have the onesie. Okay. So I'm just sort of going back a little more to the basics, because you guys are just starting out and, you know, there's some basic things that I thought that we could talk about. And faculty, please chime in with some good questions for those valuable prizes. So this is an 82-year-old who's admitted with jaundice, right upper quadrant pain, some fevers, dilated bile duct, and gallstones in her gallbladder. So this is our ERCP that we see, and we see, what do we see in this bile duct? Choledoglathiasis. Choledoglathiasis. Very good. There were too many people who yelled out. So no prize for that. That was too easy. Okay, fine. So what should we do next? Tell me your thoughts as to what you're seeing and what would be the best approach for this. Is this going to be hard or easy? What makes this look difficult? It's a large stone. Wait, what, what, what? It's a large stone. Large stone. Okay. So what also makes it difficult if you're just looking at the cholangiogram? Why is a large stone hard to come out? Right. So the duct gets very narrow at the bottom, so this is not going to be necessarily a simple case. Okay. So you start doing your sphincterotomy and you see this. So tell me people's thoughts. You have to start giving away prizes. We're going to have to pick on some people. Okay. So, okay. So here's a question. Raise your hand. If you see pus, what are your thoughts as far as what you're going to do? Are you going to gung ho, clear the duct, do the whole thing? What are you thinking about? Yes. Put a stent and come out. I would probably, you know, I wouldn't attempt to clear the duct now, just put a stent now, let his cholangitis clear, cool down, and then come back and try to clear the duct next time with lithotripsy. Great. Good answer. Pat, give a prize. Give a prize. You can just pick. But don't give him a baby. I don't know. Or a wife who's pregnant. Okay. All right. So one of the thoughts when you're doing an ERCP and someone has this florid cholangitis and pus up there, there's a little concern that if you go in there, I mean, you could sweep the duct, but do you want to inject a lot of contrast that you could cause, you know, worsening infection? And I have seen this where we go and you start injecting and the patient's blood pressure drops and things like that. So good. Something to think about. Thanks. All right. Next. You know, again, it sort of really depends upon the situation. If someone is really sick, they're on pressers, you might just want to just stick a stent in and go. Okay. So you want to do your sphincterotomy, you know, based on the size of the stone, right? If it's a big stone, it's good to know that ahead of time so you can, you know, size your cut. So this is a great demonstration. I think this is John Martin's video that I stole. But basically, you're making this cut and sometimes the papilla, it looks really small. Like this didn't look particularly big. You think you can't do a big cut. But as you can see, John is going in, he's sort of reassessing every time. So it's not necessarily that you're just going to cut and that's it. You're going to go in, you're going to assess. Take the tome down, go into the duct, pull out. Because you really want to try and do a complete sphincterotomy. As you can see, he's reassessing and also it doesn't have to be cutting in the same direction, right? You start cutting, it opens a little, and then you're cutting this way and it opens a little more. It's sort of a back and forth sort of thing. So it's something to really think about. So the question is, how far, here's a question, raise your hand. How far do you do the sphincterotomy? What are you looking for to know that you've done a complete sphincterotomy? Yeah. No, Peter, you can't raise your hand. He wants the onesie. Do you want the onesie? What? Raising my heart in disagreement that you need to do a complete sphincterotomy. Okay. Tell me what you're going to say, Peter. Continue your thought. I mean, cholangitis is one of the predictors of delayed bleeding at sphincterotomy. And two, even with complete sphincterotomy, you won't be able to extract this stone without any ancillary maneuvers. That's probably true. It was sort of a separate case. And in the lack of any better data, still probably doing a sphincterotomy, not necessarily complete, with large balloon dilation, may be the better choice. I'm just saying that it's not established that complete sphincterotomy is unavoidable. That is true. You're right. And I will actually show you another option. So for this particular case, you're right. You may say, it doesn't matter how big my sphincterotomy is. I'm not getting that stone. So that's a good point. And it's something to think ahead, because with large balloon, we don't want to do a complete sphincterotomy. Yes, Motib. Probably a gush of bile. Or you can stop at the linear transverse fold of the duodenum. Right. So you're going to see bile when you cut, typically. But you don't want to go past the transverse fold. But Peter is right. And it sort of brings me to my next point, I think. I'm wondering if I get nothing. OK. Oh. Peter gets a water bottle. Peter, you get a water bottle. All right. You got to stay hydrated. OK. So here's one of the devices. And I don't have video for this. I was actually begging people at the end, the last two weeks, to just take a video, even if they didn't need to use a lithotriptor just to do it. So here's a device that you all need to know how to use. This is a rescue lithotriptor. So if you go in and you're thinking, big stone, you're going to have to crush it, there is one that, if you think ahead of time that my basket will not get stuck, you can use to do lithotripsy with the basket. But if you are feeling like you've done that complete sphincterotomy and you're going to get the stone out, you just put the basket around and go for it. And suddenly your basket is stuck at the end of the bile duct with the stone in it. So you guys get the dilemma that you're in, right? So you go up in the duct and you try and shake it out. But it will not come out. So you have to learn how to use this rescue lithotriptor. Has anybody used this before? Yes, okay. So, yeah. All the faculty, yes? I think it's been used less and less than we did. I have a lot of them. So basically this device, you actually have to cut the handle of the basket and take the scope out. And then you're going to thread this device. And then you're going to put the wires through the end here, bring them all the way through. Through here, there's a little hole there. You're going to stick the wire through there and crank it. And you're going to crank it. And you're going to watch under fluoro as this thing goes. So the cable is going in the patient's mouth. Your scope is out, right? Down, you can watch under fluoro. It goes in. And then it crushes, it closes the basket. Basically the metal, as you can see here, is right up against the basket. And as you crank it, it meets up at the end of the thing. And then you pull the whole thing out. Also, it could just burst the basket wires. That's true. It could burst the basket wires. But hopefully after all that, you've crushed the stone. So this is always one of those things that when you're in it, you're just like, wait, what am I doing? Wait, am I taking out the scope? It's a little bit stressful. You don't want to send someone home with a basket in their mouth. That generally doesn't go well. So you're going to take the whole thing out. And then you go back down and see what disaster you have waiting for you when you get there. It's a little beat up generally. And hopefully get the rest of the stone out. So this is really something important that hopefully you'll learn how to use. Although you're right, Pat, we now have this lithotriptor. We have mechanical lithotriptors. So this is the mechanical type lithotriptor here. Ashley. What? Go back to the previous slide. Did you tell the name of that lithotriptor already? I don't know how to do that. Oh, this is the Sohendra lithotriptor. What else? Sohendra contributed to endoscopy. Oh, tell us. Raise your hands for a prize. Other devices. Yes, Katie. Because I know which prize I want to give you. Go. Sohendra Stent Retriever. Give her the thing. See, it pays to be a woman in GI. All right. What else? Stendalator. You don't get a prize, though. Right. Sure, Sohendra Dilators. What about like... What? I don't know, what about like... All right, so this is a bonus question. There is a device developed by Dr. Chalk. And if anybody can come up with the name of it and you guys be quiet, and Peter too, back there, you guys, they get a prize. Yes? Podigy Traction Wire? What? Podigy Traction Wire? Or no? Did you invent that on the top? Something else? Oh, no. No, this is Dr. Chalk's invention, and Katie, you can't answer either. Nobody knows? All right, you guys think about it. Everybody's going to Google you now, Amitabh. Damn it. You guys should know what you're dealing with here. It's serious. Okay. He rang the bell at Wall Street. Yeah, exactly. On the New York Stock Exchange. Okay. So this is the elective type one, where basically you know it's going to be a big stone, you want to go and you don't want your basket to get stuck. This is a device that you can use that you put, you know, you capture the stone, and then you can manually crush it. You can reuse this. So it's a pretty great device. Okay. So another option is Peter brought up was if you have a big stone and you're thinking you're not going to be able to, I think this is your video shaper, you're not going to be able to get it out. You want to do, this is a great technique that's relatively new over the last, I don't know, six, seven years, where you do a small sphincterotomy, and then you do a large balloon dilation of the papilla, and you can sweep out the stones that way. So for a prize, how long should you keep the balloon up based on data in the literature? One minute. Very good. You get a prize. Water bottle? Book? I have a baby. Wait. Wait. How old's the baby? Because this is newborn. Oh, no. He's not a newborn. Yeah. One year old. Oh, is that a newborn? As a mother, I would know that that was a bad idea. As a father. Okay. No. Yeah, my wife would have given me shit. So there were some studies looking at this, and it looks like one minute is the sweet spot. I think less than that, and actually patients have more pancreatitis, which is probably because it doesn't actually do the thing that it's supposed to do, which is dilate the entire channel, and so you struggle getting stones out. So this is a beautiful thing when you can do this, because it really makes life easier. What kind of size of balloon do you use? So how do you pick the size of the balloon? Does anybody have any thoughts on that? Way in the back. That's a good answer. That's my thought. I told him that. Oh, shit. All right. Give him a... Well, he's a good listener, so he gets a prize. All right. So it's important not to put a balloon in that's too... Sorry to interrupt. So I think in terms of how long do you keep the balloon inflated, I think there's a huge variation in practice. A lot of people, I personally follow that. We just inflate it until the waste is effaced. So once you notice that the balloon is fully inflated, you can just let it down. The reason people, they keep it longer is to reduce the risk of bleeding. But I think you'll be okay just... You can deflate it once the waste is effaced. It works. Okay. Under floral. So you'd see the face under floral. Right. This is also, Schaefer was saying, a good technique if you're worried about doing a sphincterotomy. I mean, we know there's some risk of pancreatitis, but obviously risk-benefit analysis. So I typically do a minute, but the other important thing is make sure you keep your wire up there, because if there is massive bleeding, you can think about putting in a fully covered metal stent or something like that. All right. Okay. So this was just showing the anatomy of the sphincter and how when we do sphincterotomy, we're basically cutting more of the distal tunnel, and that's why the balloon helps with the proximal tunnel. Okay. So here's another option, which is EHL. And have any of you guys done this so far? Yeah. Okay. It's pretty cool, right? It can take a fair amount of time if you have multiple stones, but it's very gratifying. You can see these stones getting broken up. In the duct here. All right. So for a prize, I don't know, Pat, what's a good question? What are potential complications in doing EHL? Yeah. From? Okay. That's good. I think this is my last slide, so we have to give away prizes. All right. So this is only for the fellow who has a newborn or pregnant spouse, or if there's a woman pregnant. Anybody? Shoot. Does anybody want to have a small child? What's that? You are? You didn't want to tell anybody your wife's pregnant? This is the new announcement? Okay. He just wants the baby clothes. I don't know. What's another good question, Pat? Schaefer? Good question for EHL. If you're not getting a good spark, what's a good one? Oh, that's a good question. So if you're not getting a good spark, what's a good one? You need to instill saline. What's that? You need to instill saline. You don't have enough liquid in the, you don't have enough fluid in the vial. I don't know if that's a good enough answer. You need an aqueous medium. Right. Okay. All right. Excellent. What else? Right. What else can you do? Yep. Sure. Sure. Yeah, sometimes you burn through a couple of those. You can also turn up the heat. It's always the answer. Okay. Excellent. All right. I think that's all I have. What? Go ahead, Pat. And also, EHL would say always go longer. I always stop too soon. I go back and look at it. And then you have to go, yeah. This is a longer case. Keep on going and shooting and shooting and shooting. Because you go back in and there's still a big still in there. It's usually a long case. Right. So you realize after you decide, okay, we've done enough. You take the whole scope out. Then you go in with the basket. And if you have to do more, then you've got to take all that out and go back in. So you're right. I mean, it tends to be a pretty long procedure. So all right. Well, that was it. So you should be a grandmother there. Oh. Yeah. I think another thing that very simple, easy, available for management of stones is don't forget there are a lot of studies showing if you just even leave a seven French stent in and, of course, fully covered metal stent in, the chances of breaking that stone and removing it successfully next time around is 60 to 80 percent in studies. So have that in your back pocket. And also, when you're doing EHL, stay about a millimeter distance from the stone. If you're touching the stone, that's when the probe burns faster. So you're going to be burning more of those if you're in direct contact.

ERCP procedure

choledocholithiasis

stone removal

sphincterotomy

stone management