So, like the other presenters, just, you know, want to make sure that you guys are participating. You know, it's more inventive, exciting that way, including you guys at home. I see the camera up there, and hopefully I'm pointing at all of you, so ask questions. I'm Dr. Schaefer-Mock. I'm at Moffitt Cancer Center. I used to work with these lovely people here in Cleveland, and these are my disclosures. So, it's the middle of the night, and you get called for a patient with ascending cholangitis on vasopressors in the ICU with lactic acidosis, and unfortunately the bile duct is elevated and they're jaundiced, and you're arriving into the endoscopy unit. You activate the team. Two hours later, you're ready to do your ERCP, and you're faced with this papilla. So, not to jump the gun too much in terms of cannulation, but what would be your method of choice? Do you go for a regular sphincteratome, or do you try something different? Obviously, you saw the title of my talk. Again, it's the middle of the night, so you want to get out of there as soon as possible and fix this patient. Who's going sphincteratome right off the bat? Okay, most people. Is anybody going to go right to needle knife? Am I crazy? Okay. All right. All right. Ashley? All right. So, in this particular case- It's a good beginner fellow needle knife. Yes, exactly. But not in the middle of the night, Ashley. The middle of the night is a different part of it, right? Yeah. It's a different beast, right? So, you have a big- You can actually call this dedication on a vasopressor, so it's completely different. Right, and you actually see... So, you have a big, bulging papilla. You're actually seeing pus wiggling out there a little bit, even though you haven't done anything. And so, you can jam, jam, jam your sphincteratome in for several minutes, or you can just jump to using a needle knife. Are you doing this in the MICU or OR? So, this is being done in the endoscopy unit. Dr. Chalk has actually described several cases where it is safe to do ERCP in the ICU, and I think you guys published to that effect as well, and it's effective. It saves you the two hours that you mentioned? Yeah. It saves you time. You just roll the cart right out. You just go there and start going. Hopefully, they don't have APJ, though, right, because then who knows what you're in. Here's a question for the experts. So, we're taught, when we're fellows, that the biliary orientation is anywhere from 10 to 12 o'clock, and that the pancreatic orientation is around 2 o'clock. Do you practice, do you cut the same direction when you're doing a needle knife? Go ahead. Yes. Any other takers? Anybody feel differently? Me, too. I've found that 12 o'clock is the more fruitful orientation for these patients, and it's a little bit contrary to the way that you want to go. And then, who does fistulotomy? Who does, you know, traditional needle knife sphincterotomy, and are there benefits of one versus the other? Fistulotomy. I think this is the one case where a sphincterotomy is probably equivalent in terms of risk to a fistulotomy in terms of pancreatitis risk, because the stone is protective. Yes. That's there. But, I mean, all the data that's coming out is obsessed with fistulotomy now as a way to prevent pancreatitis. Yeah. So, for the fellows, I'm sure you, in your training, have known to kind of fear the needle knife sphincterotomy for several reasons, that earlier data suggested that there's a higher risk of pancreatitis. But, I think subsequent data where you go right to needle knife versus salvage needle knife after kind of messing around for greater than four minutes has shown that the rates are equivalent. Obviously, an important thing for you to know is that you can't take things back. Right? So, it's always good to start superficial. And so, you know, for the experts out there, what's your technique? So, are you just blindly making a big incision, or do you cut a little bit and then look, or probe, probe, probe a little bit? I mean, what are the variations in techniques from the experts out there? You go layer by layer. Little by little? Layer by layer. Probe a little bit. Always probe with a wire, if possible. And, you know, apart from the reduced pancreatitis risk, there's also the bile duct wall. The intraduinal portion of the bile duct gets more accessible with less muscle higher up. So, that's another reason to do a fistulotomy. The bile duct entrance, as it comes closer to the papilla, there's more sphincter muscle to be dealt with. So, if your aim is to get to the bile duct, it's the thinnest approach is right at the top, about a third of the way down from the duodenal wall interface. Yeah, but Vivek, you... So, the fellows know the difference in fistulotomy and traditional... You can make the argument that the bigger vessels are up there, and cholangitis is one of the risk factors for post-sphincter organ. Absolutely correct. Absolutely correct. But, you know, the vessels will... I'll just hold comment on that, because we have an adverse event session. So, but, you know, and I have a bad luck of finding some of these vessels. But, yeah. I think... You know, not feeling like you have to do some big movement. Right. You know, there was a great video that someone gave it a course, and it was talking about regular sphincterotomy. And, you know, you feel like, oh, you start going this way, you've committed. You know, you can always change your angle. So, you start going, and you're like, ah, I kind of like it this way. You don't have to feel like you have to stay in the same position that you were going. You can kind of make changes. So, if you do small cuts, you know... So, just to add on what Vivek was saying about the sphincterotomy, right? So, you want to go layer by layer, but one of the things that people, when they start doing the sphincterotomy, is they're scared of going too deep with the knife, and then they just basically make a little mucosal incision. And then, when they don't see the duct, they just keep making that mucosal incision higher up, and higher up, and higher up. But the problem is you have not exposed the biliary orifice. And then, they make that mucosal incision thinking that it's got to be there somewhere. And now, you start probing with the tongue. And now that you've gotten rid of the mucosa, that's the mucosa that's very thin. And as you probe, you're going to start causing a bunch of tracks. So, the teaching point is when you make that sphincterotomy, yes, you've got to peel off the layers, but you've got to go deep enough. Take your time and inspect. If you see any bile, a lot of times you can actually see the sphincter itself. And that, you know, take your time. Again, get cut off. Don't take too – don't think that just because you make the cut, the bile duct is right there. And I really like an analogy that Dr. Doug Adler had said at one of these ERCP talks is for anybody who's watched Titanic, and, you know, when Jack is in handcuffs, and he asks Kate Winslet to cut the handcuffs, and he says, take a dry run first with the ax before you cut my hand. It's essentially similar is, you know, once you have a needle out, first do a dry run, how the orientation's coming in relation to your ampulla with your elevator, and then start the cut. Anybody done a needle knife yet? These are cases that are good. I mean, if it weren't, like, the ones with the big stone are kind of good. Bill, did you have a point back there? Yeah, a couple of quick points. One is, you know, I always have the tech, like, fully open the needle knife because, you know, the needle knife, you'd be surprised how long it is. And if your tech hasn't fully opened it up, one of the things that can happen, especially if they're nervous, like, and they have their hand on the handle, they may inadvertently be adjusting the length of the needle knife without realizing that. So have them open it and take their hand away, like, have them not have their hand on the handle so that the knife length is not, like, shifting on you as you're trying to cut. That's one, too. I always, you know, like, right now, for example, in this still frame, you're really close up against the ampulla. I always take a step back every once in a while to reorient myself to make sure that I'm still going in 12 o'clock, as you and Peter do, and not, like, suddenly veering off at 3 o'clock. You know, especially as an advanced fellow, I always find that early on in the year, there's a tendency to drift the scope. So, like, you know, the longer you're there, it's almost like your attending hands you the scope in one position, and then, like, two seconds later, you're kind of drifting off in a different position than your attending gave you the scope in. So just, you know, make sure that you always kind of take a step back, appreciate the orientation that you're supposed to be in. There is a question from the online audience. Sure. Asking about the difference between fistulotomy and traditional needle knife. Sure. Traditional needle knife, you start at the area where you would engage a sphincterotome, versus fistulotomy, you start above that. And the theory is that doing a fistulotomy, you're staying away from the pancreatic duct and orifice and will cause less edema and, therefore, less pancreatitis risk. Can I just make one, sorry, real quick comment? For fellows who are trying to find a time to do this, I would say that if you have a biliary stenting without a prior sphincterotomy, which you'll occasionally have for plavix or whatever, but they're now off, obviously, this is a time you could potentially advocate for, hey, can we use a needle knife over the biliary stent? It's a great way to practice, just like the stone cases, but those are even safer and easier. And watching videos to get the orientation, I think a lot of great points have been brought up in terms of, you know, you should be a directed instrument in this case. Don't just go blindly cutting and expect the wire to go. Cut and then use the tome to kind of spread open that area. See if you can see the bile duct and either you've opened it already and just need to use the wire or you need to cut deeper. Do the experts, do you all continue your needle knife to the extent at which you need to extract that stone or do you use a bowed tome to make that orifice better in a different sort of manner? Very important question. I mean, I'll show you what we did in this case. I use a separate tome. I mean, I get in and then I use a, if I need to extend the sphincterotomy. Yeah, I do the same thing. The important thing for fellows to know is that since you started at a higher point and you've been dissecting for about five to ten minutes, you already created a fairly nice divot, so the standard sphincterotomy laws don't apply here. You're already ahead of the curve compared to a standard traction sphincterotomy when you started the papilla. So be careful when you're extending that. Now this is, of course, this is a big bulging papilla, but if you have a relatively smaller ampulla, so to speak, then the traction sphincterotomy component has to be very measured. It cannot be the same traction sphincterotomy that you would have done with a native papilla starting out. So that's a great point. Sorry, no sense. Papilla to me makes a perfect application of large balloon dilation after you have got your access in because of what we're seeing there, that bleeding part. You got your access in, you already have started the small sphincterotomy. Just go with the balloon and avoid the risk. Or maybe we can talk about the patient who's on pressers with cholangitis, and maybe the better part of valor is what? Stent and go home. Out of there. The other thing, another important point for the fellows is not to go home immediately after a case like this. So I think we've all seen that massive endotoxemia that can occur with these cholangitic patients wherein their blood pressures tank after your intervention. And people are looking to you to see what you did wrong during the case, but this does just happen. So make sure that you assess the patient after you've done one of these cholangitis cases and ensure that they're safely in the ICU and being managed appropriately, because they may get worse before they get better. But what do you do, like, so talk about contrast injection in these patients, like who are on pressers and have cholangitis. I think you want to minimize contrast. I think that's the general thought. I think we probably all will agree on that point is that there's already a very high pressure, right? You saw all of those oodles and oodles and the wave of pus coming out. That's all been inside of there. And so then do we want to, again, add a pneumatic force in there that could cause endotoxemia and worsen things? So I think the distention of the bile duct does cause that endotoxemia. And I think, you know, I've seen patients that get bet, like, they maybe relieve the obstruction, they start taking the pressers off right away. Or even the jaundice. I'm very much of a minimalist. I don't even know that I do such a big sphincterotomy. I think I just do enough. I like to sit and suck the pus out. I don't know if that really helps, but if you feel better. I mean, I feel better after I do those. I'm like, ah. And, you know. It's like pimple popping. Yeah, exactly. And then bring them back a couple days later when they're out of the ICU. Yeah, sphincter popper, MD. Yeah. Patent pending. So here's another example. This is a great fellows case. And then I'll probably skip the last case because it's kind of the same. But you're, you know, again, you have a big bulging ampulla with this. At the end, it's an impacted stone. So who would go to a sphincterotome? Couple of people. All right, cool. Who would just go right to a needle knife? A needle knife, yeah. Yeah, so I mean, I think that going, I think you can, you know, there's not a wrong answer, right? And Dr. Eisenberg's probably better than I am at ERCP, so. But, you know, I think that in this case, we went right to a needle knife and, you know. That is a really interesting looking pill there. Yeah, it's very suggestive. And the stone just pops right out. I mean, what better needle knife for the fellows? Should I let Sagarika go? Yeah, let Sagarika go. You may come back, so don't. Yeah, I have more if we need it.

needle knife

ERCP procedures

cholangitis

sphincteratome

needle knife sphincterotomy