So, now we are in the duodenum, and Ajay has expertly navigated to his position in front of the papilla. When you're getting ready to cannulate, it's important, ideally, to get in a good position with the papilla situated at the middle of the screen if you can, and ideally the top half of the screen is going to give you the best angle for cannulation. Sometimes not always easy to do that, but that's the ideal. And here we have a sphincter tome and I think an 025 guide wire that he's going to be using to cannulate. Perfect. Again, like everything else we do in therapeutics, it's very important to have a really good communication with your team, be in a stable position, scope straight, monitors where you want them to be, and this might be the easiest papilla of the year. You know you jinxed yourself, right? It's like, why would he say that? The only easy RCP is the patient who has gone home, so. So I get in position. I use a little bit of a wire tip to do cannulation, but I know Dr. Fu and Dr. Maranki might have different practices. Whatever works. Are you talking about that much, maybe? Yeah. Maybe a little more? Okay. I am. This one is good. So I get in position. I kind of, most of my part is like what we call talking to the papilla, figure out which way your bile duct direction would be. There's a really good GIE video on it that you can imagine like CD discs and you can place them to track the path of the bile duct. So get in mainly 10 to 12 o'clock position. Usually catheter out a little bit, ask for a little bit of bow on the papilla and using a combination of your positions, big wheel towards you, you can easily slide in and then use your x-ray to see if the wire is advancing easily. So I'm advancing my wire here and let's see where we are. I've advanced my wire a lot, but I don't see our wire in the bile duct. So I'm going to pull back a little bit. Try this way. Nope. It's coming to this side. All right. We're making cracks in the soft tissue. Dr. Fu knew we had to change it. I know. I know. I told you, you just changed it. We'll try this again. I don't know. Just like my fellowship days. I know, right? I know, right? It's coming out the side. Keep pushing. It's going. Yeah, yeah. Keep pushing. There it is. All right. So now the camera may be able to show you our model and the way that we're pushing the wire, if you can see that, I don't know if I can lift this up or not. Does that help? But you can see I'm leading with a shepherd's hook and that's always the safest way to advance the wire because you won't be puncturing any side branches or things like that. You also won't be making a submucosal tract either. So now I'm pulling back on the wire and that will straighten out the wire because I'm trying to stay within our model. And using a knuckled advancing technique is much more important, especially if you're in the pancreas for any reason to avoid any side branch injury. And other things that you can do as you're pushing the wire is you can spin it as well to try to get in different branches. So I would say as fellows, as you're learning, when the scope has been taken away from you for whatever reason, the next step that you should ask to do is ask the tech or the nurse if you can start working the wire because it will really help you, especially as you're doing short wire and cannulating on your own, really getting a sense of how hard you should be able to push, what feels like normal and what's not normal. What about in a chronic pancreatitis case? How does that feel? And so working the wire and also having the grip strength and the tactile sensation of knowing when you think you're pushing the wire but you're really not, and also learning how to overcome a sticky catheter. Sometimes it's difficult to push the wire when that happens and you want to have wet gauze as your friend to be able to push the wire more readily. And so it's important to gain those wire skills, especially this year as you're learning. And so now Dr. Singh has successfully cannulated the bile duct and what's the next step? So we go in, unbow the catheter, go in, get our cholangiogram, make sure we're in the right place where we want to be, then come back and then get ready for a swing program. And I'm just going to change the setting on our Irby. It will be important to change the program. Um... Yep. Great. So we're on setting 17 sphincter tome on our Irby and so it's very important that you're checking those settings because before you do any cutting you want to make sure that you're on the right setting. It ultimately is the proceduralist's responsibility for any snafus that occur and so that's one of the things you always want to get in the habit of checking the settings yourself, make sure that they're accurate for what you'd like to do. And we have our electrocautery generators behind us. How about you Dr. Muranki? Do you have them in front or you also have them? Well, so our setup is patient here and then our generator is here. So I'll always make it a habit to check your settings as Dr. Muranki mentioned. And again, get in the position which is easier said than done. It really is. And this is, you know, in fact, true to life. Now, you're trying to get in. How are you trying to get it to be? What would you like to accomplish with the sphincterotomy? So again, the similar position, the papilla in the center mainly, maybe towards, a little bit towards the upper half of your scope position. You should be in a stable scope position where if you move the scope you will get a predictable movement. You don't want to be in a situation where you're trying to move to the left and the sphincterotome is cutting to the right. So always make sure you're in a stable, straight scope position without too much tension on the scope. I go in and then I kind of bow the, and the cutting is done by the electricity. You don't have to do any mechanical force. You can guide it, but most of the time you have to let it do it by itself. So a lot of times what you will see is either you put too much bow on the sphincterotome or you use too much pressure and you all of a sudden just fly through it and lose control over what you are doing. So I would go here, bow the tome a little bit. So I'm going to bow. And I'm not in the shortest scope position, so I apologize for that. And then when I cut, I kind of use my right hand and kind of turn to the left as I go up to cut. It's important to note about this sphincterotome that we're using, it's coded for the more like, I guess, distal two thirds of it. And the cutting wire is only kind of available for the more proximal third. But not all sphincterotomes are designed that same way. And that's really to help avoid cutting the overlying fold or things like that. You can notice this is insulated here. Sorry, I'm kind of... But what Dr. Singh is showing is that, you know, even in this low stakes game today, it's important to be, you know, very meticulous about getting your angle appropriate for cutting your sphincterotomy. And so that's something that you should not rush and take the time to get in the appropriate position. Not all sphincterotomes have that coded part, by the way, so you got to know your equipment a little bit. I'll go with this. So I'll try to... I'm not sure it'll work because this thing is padded, that chicken heart is not padded. Will it work? Sometimes the devitalized tissue doesn't cut as well. You kind of got to crank up the settings. Maybe increase the watts. Should we just go... Sure. Yeah. These are all things that happen in real life though, right? Your cautery doesn't work. Trying to figure out where the problem is. Are you working on a really big patient that needs higher energy? I think it's not cutting. Yeah. Okay. I don't think it's cutting, but the whole idea is that I'm kind of holding the scope this way and kind of trying to like kind of go like this and big wheel towards me a little bit, kind of guiding the tome into where we need to go. And that might be a little bit too much boom on my tome, so I would take the pressure off. And this much bow idly and then just keep going, going like this with my, with my tilting my body to the left side. And, and how far do you cut? Usually it depends on what you are doing your sphincterotomy for. And if you're trying to take out a stone versus you are doing a PSC patient as, as we discussed during the lectures earlier in the day. Are there any questions about cannulation, sphincterotomy? None so far in the chat. Okay. It might be postprandial napping. I think it's a really good point the idea of not having that wire too tense when you're making the cut because then you can suddenly, and it zips and sort of makes a bigger cut than you meant to so you want to be able to control it, not have too much wire, not too tense. And you know, like I was talking about earlier this morning, you know, if you start making the cut and you kind of don't like the direction you can always go in a different direction you don't have to stay in that same spot. You can move and like you're doing readjust go in, bow, come out, you know, do a little maneuvering. Yeah, I think it's, it's not uncommon that I, my initial, you know, one or two millimeters of cut is not in my ideal direction just because I couldn't get there. But a lot of times it's just by starting the cut, then I can, I have more leeway to get myself in the more ideal position. And so really just, you know, starting and going slowly if you need to, to get into the right orientation is key. And Dr. Maranki and Dr. Fu, do you have like an approach where you use like a single sphincterotome, a same sphincterotome and wire for most of your cannulations, how do you go through your selection process before the procedure? Yeah, you know, so I think your sphincterotome is like your putter, like it's just what you prefer. There's not always a rhyme or reason for it a lot of times it's just the, you know, the way that you like to use it so I, we have six therapeutic endoscopists and I think, you know, we use four different tomes routinely among us. And so I use a 44 autotome. I like the way it feels in my hands. I like the ability to rotate it. And then I, my go to wire for, you know, cases that I think are going to be more difficult is a 25, an O2-5 busy glide. For standard I'll use a short jag, but I really like the performance characteristics of the O2-5 busy glide and that's kind of my go to. If I have, you know, PD or the minor papilla, I will sometimes use the 39 autotome or I'll use the 4-5, 5-4-3 catheter, which is straight and sometimes gives me a better angle but then you have to use a tiny wire with that and that can be difficult to operate. What about you, what's your go to? So I use the autotome 39 or RX 39 for everything. It just keeps it simple. Used to have the same approach 44 for most of the cases and sometimes I would ask for 39. So now it's 39 and a 025 VZ for everything. Yeah. So I got away from asking for the 39 because they would give me a 35 wire, which doesn't fit. So what about you, Ashley? What's your go-to tome? Well, so Ajay trained where I trained and I trained Ajay and Dr. Chak trained me along with Mike Sivak. And we were not all about the very different catheters. I don't think we had a lot of choices and I just, maybe I'm not smart enough to know the difference, but I work at three different places. Some of them have the same thing, some of them don't. And so, I use a triple lumen. I don't even know that I know the difference between these autotomes and tritomes and dream tomes and all this other stuff. I'm not sure that it makes the world's biggest difference. I think having a tapered one and a regular one, and all these other little nuances are maybe important, but I could not tell you exactly what I use. I use what the nurse gives me. That's great. That means that you're flexible. 99% of the time I'd say it works, but I was always impressed going to these meetings where people will be talking about exactly what they use here and there and whatever. But I do like the VisiGlide 025 because it's sort of multi-purpose and those for bile ducts, I mean, other than like a very hydrophilic, like the Acrobat or the GlideWire that you occasionally want to pull out, that's always a pain in the butt for everybody to use and is not striped and 5 million other issues with it. I just usually use a triple lumen catheter with the 025 VisiGlide and that's kind of it. And some places I don't have that many choices and I think it's a little more the endoscanist than the tome. Particularly. Great. Well, that's all we have for demonstration today. Thanks very much to the participants for hanging in there with us. And if you have any questions, please don't hesitate to reach out. Even after the course is over, I'm happy to answer any questions or help guide you with your equipment selection. Thanks, you guys. We really appreciate it. I think that was great. Nice little session. Learned a lot here. The cord for sphincterotomy? Oh, great. Oh, hey, Ashley, we were just informed. We figured it out how we can perform a sphincterotomy. Yay, all right, let's do it. We're gonna go back to it. But I think it is really important to, you know, learn, know how to troubleshoot things, right? When things don't work. We have had issues where cords are no good. And so we've had to go find another cord from another room. We've had issues with just generators. I don't know why they won't work. We've got to emulate again. We've got to make sure that the pedal is set up to be the right pedal on the program. So you kind of need to understand a little bit how these generators work, but it is kind of nice. Now we have buttons that say hot axios and soft coag and sphincterotomy. And, you know, it's sort of dummy proof, but you kind of have to have a little understanding of the circuit so that you can troubleshoot if there's a problem. Well, you know, that's a great point that you bring up that we have all these presets and they're great to be used, but you have to really be aware of what the setting is, especially when you're using a partner setting. So for example, at our institution, we have an EMR setting for, you know, mainly for colonoscopy and EMR, where the yellow pedal is perfect for EMR, but the blue pedal is snare tip soft coag. And so if you didn't know that, frequently people who aren't that familiar with it will try to take off a pedunculated polyp using the blue pedal, using that EMR setting. And that's really not the most appropriate thing. And so it's really important that you know what your settings should be and what you'd like to have for your settings before you go ahead and use them. All right, so now we're back in the bile duct and we have sphincterotomy capabilities. And so Dr. Singh is going to get in position. This is all connected. Oh yeah, we need the... This one? Okay. Again, getting in position and I would ideally like to go to the 11 o'clock towards position towards, but I start with whatever I can get and see if I can change my angle. This tome is not rotatable, but some of the tomes you can rotate a little bit to help you guide too. Have you found that useful? I've never used that, but I'm sort of sitting and watching you struggle and I'm like, yeah, I've been in this position, right? You kind of want your whole tome shifting left. Just get your sphincterotomy going closer to 11 o'clock, but you just can't get there. I think more than that is sometimes just unbowing, going into the duct and pulling it out and then bowing again helps more than that. But... I think that also helps when you think, oh, this papilla is so small, I'm not sure how much I can cut. So you go in, you dilate your tome, you pull back and it sort of maybe helps reveal the papilla. I don't know if you want it. So usually I would not have to use that much. I just hold it and it would go like this and keep turning my angle to the left. Here I'm using a lot more cautery than usual. And how is your approach? I usually tend to like cut and then reassess and then cut more. And I see some people just... Again, every papilla is different. Cut a little bit, resize yourself and then go again. I feel like if I've gotten it in a perfect position and my cuts are keeping me aligned and I'm happy with my 11 o'clock positioning then I just keep going. But more commonly I reposition and realign after a few cuts. This is kind of a good example of you did your first cut and you're like, eh, it's not quite in... So you're kind of moving a little bit. Now we are more towards the 11 o'clock position we wanted. And here I would go a little bit more because I have more and see if it would... I don't see any bile. All right. And then a lot of times, see a lot of smoke. I use a lot of sphinctroplasty in my practice as well for stone cases. So, and that's when we had to make a decision before you are doing sphinctroplasty. How much sphinctroplasty, what do you want? Do you want a big sphinctroplasty and then sphinctroplasty, which I try to avoid. So a medium size sphinctroplasty and a sphinctroplasty. How do you approach those situations? Yeah, I'll get, you know, it depends. I generally start with a small to medium sphincterotomy if I'm planning to do sphinctroplasty. So, you know, dilation assisted stone extraction or things like that. But otherwise I aim to do a complete sphincterotomy. And so that doesn't always include, you know, cutting up until the duodenal reflection, but just making sure that the papilla itself, the muscular area is cut completely is important. So can you guys talk about, like, when you're doing sphinctroplasty, what sort of how you decide, you know, what size balloon you might use and what things you just think about when you're doing that? Yeah, you know, I think that the size of the balloon is determined, you know, in some part by the size of the stone that you're trying to extract. And the limit is you cannot really dilate larger than the distal aspect of the, of the bile duct. So if the bile duct is only 10 millimeters and you've got a 10 millimeter stone, then you can dilate to 10 millimeters, but not really beyond it. And so that's one of the rate limiting steps for me. Yeah, size of the duct, you don't wanna go. Yeah, I mean, so on the other hand, if the duct is two centimeters big, then I can dilate to 20 millimeters, you know, without getting into too much trouble. And it's been shown that DACE is, you know, very safe, certainly up to 18 millimeters, but even up to 20 millimeters, it's safe and effective. And also, as far as how long you hold the balloon up, there is some data suggests that one minute actually, there is some data, unlike esophageal balloon dilation, that, you know, if you don't hold it long enough, there's an increased risk of pancreatitis, which may be related to the fact that you then struggle to get all those stones out because you didn't leave it up long enough. You know, because if you leave it up for a while, you know, stones can just, after a minute, you know, you take it down and stones can sometimes fall out, which is always ideal. Yeah, I generally leave it up for about a minute. And then, you know, the other thing that happens with DACE is it's not uncommon to get, it starts to bleed quite a bit. Usually it's self-limited, but if it's not, then you have your balloon right there that can act to tamponade. And sometimes I've had to hold the balloon up there for, you know, upwards of a few minutes to tamponade it, but it's usually effective treatment. And you have the wire up, so as long as you don't lose your wire, if it doesn't stop, you can always put in a fully covered metal stent, so. Right. Yeah, it's always the moment of, you know, excitement when you're like, okay, take the balloon down. And then you see his bile and not too much blood. You're right, a little bit at the beginning and you're like, oh, hopefully that's it. But it is a great tool. It just makes life so much easier. So, you know, watching it on floor, you put some contrast in the balloon so you can see the waist. And after the waist sort of, you know, falls up. Yeah, you know, I think it's important, you know, just a point about doing DACE versus, you know, cholangioscopy with EHL. I don't do them both at the same time, right? Because it's either one or the other. So either the duct is very big and I'm going to DACE it or I'm going to do SPI with the EHL. But if you have a big boggy duct, sometimes, and the papilla is wide open, it's sometimes difficult to keep all that liquid in there to be able to do EHL and see what you're doing. And, you know, the more contrast you have to put in there to identify the stones or see what you're doing, the stickier it gets. And so I usually choose at the start of the case, I'm either going to do DACE or I'm going to do SPI, but not both. What about you? It's just such a quick and easy thing to do, the dilation, you know, I just think that, you know, it's way cheaper than EHL, cholangioscopy with EHL. Also depends on the time of the day, I guess. True. And it is something you want to think about. Like you guys were saying, you don't want to do the world's largest sphincterotomy. And then, I mean, typically that's not how we're taught. We do a small one and then do the balloon. So it's just something to think about first is, you know, you're in there and you're struggling. I mean, we don't really do on-demand cholangioscopy. I mean, we have the device, but we don't use it a ton. So the nurses don't love setting it up and yeah, it takes a long time. So it's something to think about when you first get your cholangiogram and you see big stones, you know, be smart, think about it, think about using it. And I'm sort of more of a, you know, electromechanical lithotripsy person for the first round. If I can't get it out, then I'll go to cholangioscopy. Because cholangioscopy is really expensive and you really don't get reimbursed. So it's something you don't want to overuse, I would say. Or at least that's what they've told me at my institution. All right, well, thanks you guys. I really appreciate it. This was really awesome. And there are some participants. And one of the fellows says, when your mentor Amitabh gives lectures by writing on a board, does he call it a chalk talk? See? That's a good one. I'll mention that. Maybe we can come up with something, you know? He's going to be president of the ASG soon. So we're going to keep that. We might have to patent that idea. Great, thanks for that. Thanks everybody. Thank you so much. All right, thanks guys. Bye. Thank you all. I hope you enjoyed it. And please send in your evaluations. I think we'll be sending you, tell us what you think of the virtual platform. Bye guys. Thanks.

cannulation

sphincterotomy

duodenum

papilla positioning

sphincterotome

wire tip