So this is a pretty straightforward case. This was a lady who, good God. This is a lady who I'd seen for a very difficult ERCP a month prior because she has radiation changes from lymphoma and had developed a biliary stricture and had a very difficult cannulation. Got in, didn't do a sphincterotomy, she had a distal CBD stricture, and put in a CBD stent. And so she came back a month later for upsizing of the stents to try to treat this distal CBD stricture from radiation changes. And she has sort of portal hypertension from the liver disease as well. So you put in plastic? Sounds like plastic. I put in plastic. Not fully covered. At that first one. And then I came back. My anticipation was like, maybe I'll put a metal. I don't know what I was going to do. But there was also this question of cholangiocarcinoma, right? Because it's a distal CBD stricture, and we don't know why. We assumed it was radiation. So I left the plastic stent in. It's such a difficult visualization, I actually did a sphincteroplasty next to the existing plastic stent. And you can see, I think this is just an eight millimeter biliary sphincter balloon. So a typical biliary dilating balloon. So the reason I bring this case up is because I think it's important. Ask the fellows how they deal with this. Yeah, so I'm going to ask you a question of how you're going to deal with it in about one second. So I just dilated. All right. So now I'll ask the fellows, right? So it's, you know, it's funny, I'm like, oh, the video quality is not great here. But then I realized the video quality is not great because I cannot see anything. It's not great because it's not poor. It's just, it's just a real experience. Exactly. So when you were dilating the stricture, I mean, how often do you dilate strictures like doing a, you were doing like a sphincteroplasty. I was doing a sphincteroplasty without a sphincterotomy because I was trying to avoid the risk of a sphincterotomy in someone with portal hypertension, which I was worried about, you know, the sphincterotomy bleed. So she did have no sphincterotomy. This was purely a sphincteroplasty. Did you worry about the fact that if you're wondering if it's glandular carcinoma about bleeding or a sphincter or anything? I had a suspicion she might have had biliary varices or portal hypertension with, you know, some sort of bleeding there. I'm not sure what my real rationale was. I thought I was doing the least aggressive thing, which I still was. So since I know Matt's name, Matt, what's your mindset like right here? This is probably the moment you need to not screw up. So what's your mindset right here? So right now, my question is, where is the discomfort coming from, the sphincter itself, And so, Amitabh, you have your mic. So from a wise perspective, is there anything that you're sort of, your teaching point you would tell your fellows at this point? Don't lose the wire. That's exactly right. Take a deep breath first. Yeah. But do not lose the wire. Most of the time, it doesn't matter, right? Most of the time, you lose the wire. I would have, first of all, it's stenosed duodenum because of the radiation. So I can only have a diagnostic duodenoscope in there to begin with. I can't really see much, even in an ideal situation, and now there's just blood everywhere. This is a case where you stop worrying about what's on the screen, and you're almost like an interventional radiologist, and you're just holding the wire, and you cannot lose it because, yes, you have a stent there, but it was a lot of blood, like a shockingly large amount of blood. So don't lose the wire. So that would be my biggest teaching point here, and I've only had this happen to me twice where it's like this, both portal hypertension patients. One was a sphincterotomy, and it just, again, switched just to fluoro, made sure my scope position looked like I wasn't coming out of position, and I advanced all devices just over a wire and stopped trying to worry about what's on the endoscreen because you will sort of mess yourselves up. Anyone else have any other sort of thoughts or teaching points at that point? I think you're perfect. I've been in a similar situation once or twice, and that's exactly, that's, I don't try to take scope away from fellows, and some of our former fellows are here, but that's the point where I will take the scope, and then everything is under fluoro basically because visibility is zero. So yeah, you can see, you know, switch to, you have a picture in picture. It's continuing to do its really dramatic thing in the bottom right. Fluoro is very peaceful because there's no blood on fluoro, so you just stare at the fluoro. And again, this is a very weird case. I mean, this is like a case where I've not done, I don't ever remember just, I have a plastic stent in there still. All I did was I advanced a metal stent next to the existing plastic stent because I was afraid to just mess anything up. I needed to get some tamponade. I actually do think this is probably biliary varices that bled, not from the sphincter, just because of the amount of bleeding and because it was a sphincterplasty. You can get a start, you start to get some view on that bottom right, but don't get fooled. Just keep watching. These metal stents have markers for a good reason. Just sort of keep hanging out with them. I was annoyed at how long the metal stent started to go, because it's only a six centimeter stent, but it started going up towards the intraopatic ducts, but you're in too deep. You just got to do it whatever you can. And so deployed under fluoro, if you get a little endo view, you can get that. It acts like it's slowing down. I should say one other thing I did, which you should consider too, is if it bleeds with dilation, I think everyone knows, you could also just put the dilating balloon up again. And I tried that, I waited five minutes and I let go of the dilating balloon, it was just like hemorrhaging again. I edited that for sake of just making this a quicker case, but tamponade wasn't working. But that is a reasonable thing to do when you have bleeding as well, but that didn't work here. So you can just sort of see, continue to watch. Just turn on the video so we can educate people afterwards. Right. And so that's a great idea of why you should record all of your cases this year, because you never know, especially if you're into adverse events, because we're all super into adverse events. If you want to capture adverse events, they're not the ones you're like, oh, this is going to be a great case. Like I'm going to be amazing and be a hero. It's the ones where you just capture routinely everything you do. And so, and I just show you, I'm not going to show you the entire time, but there's a long time where I'm very methodically making sure the stent doesn't go in. I would much rather have the stent be too far in the duodenum. I don't want the stent to be all in the duct. So I'm really being very careful on slowly deploying the stent, but you don't need to be that careful right now. I can just show you it's slowly coming down. And this actually did treat the bleeding, even though you could argue there are reasons why it would do a poorer job, because the plastic stent was in there. That may not be ideal to get good apposition against the whatever is bleeding. It actually did stop bleeding. She got really sick, not after the procedure, but a week later, because she got secondary peritonitis. Had to be in the ICU for a couple of days, but actually recovered. I had to bring her back a couple of months ago and took out the metal stent, just like, I said, this one, I promise you will be easy. I was like, I'm going to screw this up again. And it was fine that time. So just something to be aware of. So I think Praveen's main point is what I tell every single time we do a dilation. And 99.9% of the time, it's a useless statement, which is don't lose the wire. Don't lose the wire when you dilate, because it can be a massive bloodbath. Any other sort of teaching points from the faculty or questions from the fellows? I think the case that happened to me, it was a biliary varices. And I've noticed that when you put in a fully covered metal stent, you bring them back, just the act of gentle stent removal, they start bleeding again. So you have to be prepared for that scenario. Yeah, I waited as long as I possibly could. I see there's some potential benefit. I treated her varices, but I agree. These patients are tough. And even just working on them, and again, she's got radiation. She has a lot of reasons to have trouble. But I think that's just the biggest teaching point there for me is just don't lose the wire and try to be calm, although I was pretty annoyed at how much blood there was. I'll do this one is different from anything we've talked about so far. So this is a 20-ish-year-old very nice young lady who had an incidental 9-millimeter neuroendocrine looking lesion on CT that was sent to me for evaluation. And for unclear reasons, I said this is a critically important thing. We must evaluate this small lesion. So this is the lesion here. So those of you, obviously, you're all well into your fellowship now. The spleen is hanging out over here. This is a tail lesion right here. So I believe I measured it. And it measured 9 millimeters. And then it's got some vascularity, right? So let's see, who could I put on? Gerard? What do you think? Do you think I'm wasting my time with this 9-millimeter lesion and even evaluating it? Should we do anything for this? I still think it's worth defining because the question is, is this a neuroendocrine or is this an accessory spleen? Yeah, good. I like it. You can defend me in court. So these lesions we see a lot. These are really tough lesions, right? These small neuroendocrine lesions, we still sample them. And so it's great to turn your flow on. I know it sounds stupid, but it's great to turn your flow on beforehand and see how vascular the lesion is. This is almost diagnostic of a neuroendocrine lesion right now. It's so vascular. Can I just make a comment? Oh, please. So again, it's sort of like, there are things you can do, but should you do them? And of course, it's easy because I know you said that's an easy lesion. But these aren't things that surgeons are going to take out. They're going to watch them. So if you could get a DOTATATE scan and it's positive, you might be able to avoid this. And so, again, just making sure. But probably all of them have done this. I've asked that myself, too. Surgeons want five minutes just because they don't like surveying people who don't have. They want to do it just to survey neuroendocrine. But I actually think I've had one of my worst pancreatitis FNAs with a neuroendocrine because you're going through normal tissue. It's not this big fibroblastoma, adenocarcinoma, and you couldn't get tissue. This was before FNB. I took seven FNAs and he had a horrible pancreatitis because you're going through normal pancreas tissue. So I think they're a little high risk for a couple of things. Yeah, so I think that's it. And maybe that's my best point of this, which is to have that discussion. Listen, sometimes I'll see some older people with these lesions. And now I'll just tell them, listen, we can just watch this. Because I'm 100% sure if I diagnose a neuroendocrine tumor, literally nothing's going to change in your life. We're going to keep following it on imaging. But that's a discussion we had. So there's a lot of vasculature around it, as well as a vasculature in it. So as I said, that's pretty diagnostic for a neuroendocrine lesion. But you've got to figure it out. So this is a 25-gauge corneal. Did some biopsies of it. What's going on? What are you guys doing this weekend? It's going to be fun. That's what we're talking about in the room. Like, today's going great. I'm going to get home. So then I look around after the pass. And so for fellows in the room, do you know what that is? You should know. Any fellows? Matt, what was that I was seeing? What's all this? It's gone now, so I'll put it back here. What's all that, Matt? That's a lot of blood, which is OK. I've seen a lot of blood after FNBs, a pancreas, tumors, and stuff like that. And it usually just stops being a lot of blood at some point. But this got really annoying. That's the tumor there, right? And now it's got this craziness. I'm really unhappy now, because it's formed like a whole thing. It's got a whole ecosystem going on. It's got what essentially looks like a big pseudoaneurysm within the tumor. And I keep watching the blood leave that pseudoaneurysm and go into the peritoneum. I'm like, this is really negative. So I've got to measure it for unclear reasons, right there. Because that's what we know how to do in the US. We can measure it and take pictures. So I stared at this for a while, trying to wait for it to stop bleeding. So were you using scope to put pressure in that area, the FNBs? I mean, people talk about that. But this is pretty deep, right, to get real pressure. So most of the blood seems to be accumulating. There's some, I thought, in the gastric wall also. Or was I mistaken? I think it's right next to the gastric wall. But if you look at this right here, and again, I mean, I don't know for sure. But if you look at this right here, it seems like it starts from the tumor. And then it's created this just free-flowing pathway into the peritoneum, as opposed to a gastric wall sort of bleed, right? All right, so what are our ideas here? I was pretty upset, because it's a young person who had an inconsequential lesion. So what do people want to do? I'll take any fellow's idea. She's still on the table right now. I actually came here to figure out what to do. And I'm going to go back and do it. So what do you guys want to do? Anyone have any thoughts, concerns, questions? Can we use the needle to push out the tissue? Yeah, what does that mean? I've heard people talk about, what tissue? What would you push out? I guess I wouldn't put the tumor back in, I don't know. That's a real, everything until that point, until you put the tumor in a free-flowing vessel to peritoneal disease, I think is good. All right, any other faculty? It's kind of cool, but actually, I wonder if you'd stop looking at it. Yeah, exactly. No, and I thought, because it becomes difficult. There's so few bleeds in FAAs and FBBs. And sometimes you see things, yeah, it's bleeding right there. But it's easy to see, and it's not easy to see things, yeah, it's bleeding right there. But is this going to be consequential? And I 100% agree with you. I watched it thinking it was eventually going to stop, and it was so much blood. Like, it was shocking. You can see that vessel. It's created, like I said, it's meant to be there, that blood vessel now. So I think, I mean, the good thing, go ahead, everybody. I was going to say, balloon up and try to tampon it. I know it's deep, but I will be doing that. Yeah, I will be doing that, too, while you're watching. I'm going to push it, and then be calling our colleagues from IR, if you're really seeing this. Right, but you're against that wall, and a transducer can press on that. I think what you can do is, I'm sorry. Yeah, I know. I would agree with both of them. I guess we have the same training. OK. I mean, while you're watching it, it doesn't hurt to inflate the balloon large, and press on your big wheel down to press as much tampon as you're doing, while you're watching it anyways, and thinking of what you're going to do, including, obviously, coiling, if you want to do coiling, injecting blood in the track to make a clot in there, and calling IR. That's the last backup. I think other simple thing, it looks like what you're showing is, this is intratumoral bleed, because it was highly vascular. One other great teaching point that you showed, Raj, was you went with a 25 gauge, which is what everybody would have done instead of 22. But the simplest thing that also can be done, it looks like it's coming deeper, not surface. Balloon may not work that well. You can go in and inject saline. That has been shown, especially in the cystic literature. And even in this, again, act as a tamponade. You're not going with any other higher ablative agents, like glue or anything like that. But those would be other things. I did not. I was pub meddling a little bit while I was doing it. I did not see that saline. That's a good idea. So it did not stop. It just did not stop. Trust me on that. So I went with, it stops if you turn off flow, which is nice. So if you want to not stress your ass out about it. So I went with a coil. And so I went into that sort of, I don't know, this is probably still like the pseudoaneurysm that's formed from just my aggressive biopsy, because I was going to defecate tissue. And I just put in a single coil into it. It didn't, I had to put a 19 gauge into it, because I used a real. And so I put the coil into that. It didn't completely stop after that, not that I would expect it to. But it then basically really reduced. This worked way better than it should have, because I have trouble coiling gastric varices sometimes. So I got lucky here where it worked well. You can see the coil is in the right area. And there's some bleeding there, but it starts to slow down more and more and more over time. And it actually then stopped after five minutes or so. So this was, tissue was positive for neuroendocrine tumor. So that was the other key. But this is an example. So this is another one where you want to try to do something. I actually did a hybrid. I called IR and did the coiling. So they came in the room and they're like, you can do it. And I'm like, yes, I can do it. Mostly because they didn't want to do it, right? Because it's not an easy IR case either. It's not a super straightforward one. So I always watch and look out for bleeding. But most of the time, it stops on its own. But I get a little nervous with some of these core needles, especially these neuroendocrine lesions. I did, and the coils are in the right area, not like in a ring. Oh, there was a lot of blood. Yeah. Yeah, lots of retroperitoneal blood, a lot of blood. She had a decent amount of pain, but she's doing OK now. She was able to go home after a couple of days. And she goes, why does everything bad happen to me? I said, I feel the same way right now. Assuming she doesn't have an aspirin allergy, would you give indomethacin for something like this? Oh, for the pancreatitis? It's an interesting thing. Because she's a young lady, and you stuck a healthy pancreas, too. Yeah, I guess I wouldn't, because I would be barred to bleed more with the NSAIDs. But yeah, I have given, when I have intracystic bleeds, I have given indomethacin to try to reduce their sphincteritis. Or if you're doing an FNA, and you go through normal PD, or obstructed PD, everyone knows when you're doing an FNA or FNB, you don't want to hit the upstream obstructed PD, because that's where they get these PD leaks and get pancreatitis. So I will give indomethacin in those cases. In this case, I was trying to do everything to avoid bleeding. Sorry, I went over time. So I'm going to stop there, and why don't we go ahead? Thank you.

biliary stricture

metal stent

bleeding

neuroendocrine lesion

biopsy