Thank you for all those important points. I think definitely fluoroscopy is a skill that we probably can spend a whole day talking about, particularly good practices of it. And I think we actually probably don't do as much education as we should. So that's something that you should definitely focus on during your year to learn good fluoroscopy practice. So we're going to shift gears and talk about the pancreas. These are my disclosures. I'm going to talk about two cases, but we're going to sort of flip-flop. But these are real-life cases, and the first one we're going to talk about is Petey-Stones. I think it's probably up there in terms of satisfaction, right after a really oozy cholangitis pus-draining kind of case. So this is another one that's really satisfying for a syndoscopist. So this is a 34-year-old woman. She had every comorbidity, sickle cell, diabetes, end-stage renal, pulmonary hypertension, which we fear, CHF with a terrible ejection fraction, and complications related. And she comes to our service for acute recurrent pancreatitis. I would say that during that year, she had maybe three to four episodes, pretty mild interstitial. She never had any complications like collections. So she just came in, but it was a recurrent theme that we didn't really understand what was going on. I think one of the differential diagnoses, you guys can sort of shout it out. You guys see these consults every day. What do you think? What are you already starting to think? You have to rule out malignancy, I think. Okay. 34, but it's always on the list. Oh, 34, yeah. Divism. Divism. That's a good one. 34. Okay. Anything else you're thinking about? I always read, and that's more a cerebral question for the smart people in the audience. I've always read that chronic renal failure is its independent risk factor for chronic pancreatitis, but I don't know how good the data is on that, because of the crossing of people who smoke and have renal failure. And so I don't know if you have any comments on that, and is that a good enough independent risk factor for you not to look for more? Well, that's actually a very good question. I don't know the answer to that, but this case talks about that. Could it be like calciflaxis from the ESRD causing secondary calcification of the pancreas? That's part of the reason that people think that chronic renal failure is associated. Like calciflaxis, you mean? Yeah. What about sickle cell disease? Anybody care about that? Recurrent gallstones from the sickle cell disease causing chronic pancreatitis. Right. I would think about that. So her LFTs have always been normal, but definitely that would be the most common thing, right? I guess there's also that idea- Additory component mutations. Ischemic. Ischemic. Yeah. That's the other thing too. So basically in a young person with lots of comorbidities who comes in with recurrent pancreatitis, you have to really keep your differential wide. Think of most common things like stones that you see in sicklers, but also theoretical things. Ischemia related to sickle cell crisis. Does the calciflaxis occur? And most of these patients are on a whole list of medications, so you just have to review that also with a fine-tooth comb. So really putting on your medicine hat there. To be cynical, she drinks alcohol to kill the pain, most common reason for acute recurrent Very jaded. Is that what you say about interventional endoscopists or about the patient drinking alcohol to kill the pain? Very jaded. So all of those things you just have to keep in mind, but the good news is we're going to change our thoughts because we have imaging, and imaging shows that she has new pancreatic duct dilation up to the head due to what we see are filling defects. And interestingly enough, when she came in before and we were doing a pancreatitis workup, of course she had an EOS, and at that time, and I would say that was only two, three months prior to her, this presentation, her pancreatic duct was normal and she had no obstructing stones. So that sort of goes to say, like, is this something like calciflaxis or something related to the end-stage renal that rapidly developed in such a short period of time? I've actually never seen it. I don't know if anybody else in the audience has seen this before. You know, it sort of makes you go back and say, who did that EOS? So here's a CAT scan so you can see for yourself how impressive the PD dilation is. It's measured to be about seven millimeters, and you'll see some small stones, calcifications in the head that are parenchymal but also within the duct. It can be hard to tell whether they're parenchymal or vascular in some of these patients with that kind of history, but obviously. Very important point. Even with EOS, you sometimes cannot tell and don't rely on it because EOS is 2D and so is CT. Yes. So we weren't sure, especially because the EOS before was normal. And before we want to think about doing anything interventional, we really want to make sure that we're doing the right thing. So we wanted more anatomy, and MRCP can help you in this way. And so it confirmed that there was a small pancreatic duct stone and that there was upstream dilation. So the next question, let's repeat that EOS. I have to give a shout out to my fellow Yusuf who's here, who did this excellent video. I was going to say, yeah. You're off in the end here. I don't like any of this. No, this would have taken me like forever to do. Okay. So you guys want to shout it out in the room, fellows, attendings, what do you see? Filling defects, casting shadow. What organ is this? It's a baby. The point, so when you learn EOS- Dr. Khol is getting a separate hands-on. Yeah, I should probably go to a different course. But I will comment on this. I think ERCP is difficult, but EOS is even more tricky. get- what do you think, Peter? Do you have any comments on image interpretation on EOS, especially cases like these that are complex, that are altered anatomy? I mean, they're difficult. And the other problem with EOS is quite obvious, which is we don't have films to be reviewing later. So you rely on what is reported at that time, and that's it. So were they not there, were they not seen, we'll never have that answer. So I mean, I think the point is that this patient's pancreas is so abnormal that you kind of say, what organ am I looking at? But what is nice is that you've had all the cross-sectional imaging beforehand, so you get an idea of what to expect. And that's really why it's really important to look at your own imaging and look at it like 10 times, have it even up in the room so that you can go back to it while you're doing the EOS if you get lost. But this is a nice case where that stone, and rightfully so, showed shadowing. And so you can see it was really in the ducts, so it was kind of nice to see and confirm what you thought. So what are you going to do? What's your choices? These are also board questions. So prior to this, we were doing conservative management, right? Because it's mild interstitial pancreatitis. She did well. She didn't have a complication. So we did conservative management before she came in the other times. So she's in pain. So do you just call pain management and say, bye? Do you do, oh, I can do plexus block, should I do that for her pain? Should I do ERCP? Or should I say, you know, I don't know about this, this EOS looks terrible, I don't have a block time during this week, I'm going to call my friendly surgeon. So who wants to chime in? Actually, there is one more choice, which is quite reasonable in this case, which is sex or corporeal. True. Which will be my first choice, but if this board was in the Far East, that would be the answer. We don't have that many machines here, not that much expertise. So who votes for endoscopy? Who votes for do nothing? Who votes for surgery? They do most of the time. We'll put the as well category with endoscopy, let me clump it together. Any takers? You got to vote. Conservative? Endoscopy. Surgery. Okay. The surgery is a very good answer, except in this patient. Yes, who has multiple medical problems and likely they're not going to call you back. But it makes you feel good, Julie, that there's like a stone and then upstream of that is dilated and it's in the head. That's right. And it's a prime problem. You know what the solution could potentially be. You have to address the obstruction and potentially have her not have pancreatitis anymore. So this is one of those ideal situations where you want to think the endotherapy is going to help. Can I just pause you? Yeah. I was excited for that because when you want the PDs, when you get the CBD. Yes. And vice versa. Or to get the wire past a stone that's causing obstruction of the duct. I mean, oftentimes that was pretty slick looking unless it's highly edited video. Highly edited. Highly edited. She's not going to lie. This was a very challenging case. I think we used like, I don't know, every tome that we had. Ultimately, what got me in was a taper tip catheter, single lumen, can you believe we had that? And I used a Vizzy. That's Omtop's favorite catheter. This is the only one that got me in. We used everything. See? After this case, I was like, we need to order 10. So anyway, you have some choices. Oh, no, it's fine. There's so much has happened already this week. I know. Stop. Stop. Patients already back for the repeat ERCT. Oh, because you did reverse double guide wire, which I've done when I'm struggling and depressed, but I'm actually not sure it helps. I'm curious from the experts if they actually think the reverse, I don't know what the right term is. Reverse double guide wire helps. Is it reverse because you're in the bile duct? Yes. And you're in the PD. I've done it because I can't get into the PD and I just try to do this, but do people think it actually works just as well? I don't think we have conscious. The bile duct's so much bigger. It's like the wire in the PD makes more sense and it maybe straightens out the bladder. I would say for this case, the part that was challenging, I mean, there's a lot of things that were challenging. We were in here for hours, okay? Very nicely edited, but it was hours and lots of sweat. But first of all, it's the stone that's right there. So you know that that's always going to be your challenge to try to wiggle a wire through there. And two, I just feel like chronic pancreatitis is, it's always going to be a challenge no matter what, whether there's a stone or not. It's always going to up your level of complexity. But this person's anatomy, I think the reverse double wire helped because her ampulla was actually floppy. So on top of that, it was swinging all around. So to take away that portion or that factor, I left it there to anchor myself. But I'd love to know if anyone else does reverse double wire. Yeah. So I mean, I have done that, but again, that's when you're depressed and using it at the last resort. But for my pancreatic cases, I actually prefer to start with a straight catheter and the busy... Yeah. That's been our standard. The proforma catheter and the 21 guide wire is usually the way we go, because the bow introduces a default upwards angle, which is contradictory to the pancreatic axis approach. But anyway, this is a great case. Can I also just ask a question? How many people are doing lithotripsy, ESWL preferably, before even going to UACP? I didn't see the... So I used to do as well in Philadelphia, and we would get referred cases to do it. And it was really easy to learn how to do. And you just have OR block time, you'd wheel the machine in, the patients would be intubated. And it took a good bit of time. But I had great success even breaking up 12 millimeter stones. And the ESGE guidelines don't actually recommend that you need to do an ERCP with PD stent placement in advance. Correct. Correct. The stuff turns to sand and falls out, and you can do ERCP after if it's needed. But since moving to Penn State, we have regulatory issues where the hospital is not willing to lease the device for off-label use. And so I haven't been able to do ESWL there, and so now we send them to Hopkins. But it's a really easy thing to do, to learn how to do, if your institution will let you rent the device, the big lithotriptor. It does make life easier if you can see it and target it. Is there any value, though, guys who go to ESWL first, of putting in a PD stent to see if patients have improved symptoms? Because we know that you can take the stones out, and they still don't feel good. That's a great point, Ashley. I think we use that pretty consistently as a therapeutic trial initially, before we embark on too many other aggressive maneuvers. And most patients will not have any significant benefit from PD stenting, because their disease is far gone, and the retro-pancreatic nerves are involved, and there's a complex mechanism of pain. For the offbeat patient who gets pain relief with PD stenting, those are good candidates for definitive management. So these are all good questions, because when you get to this situation, you sort of have to already have an idea of what your plan A, B, and C is, right? So usually, ESWL is good, and that's if you can coordinate it. And so that's going to be institution-dependent in what your availability is. Most of the time, at least from my experience, we don't have good coordination. And so most of the time, we have to go in with a plan that we're going to try to take care of everything. And just getting into the pancreas is already 99% of your battle. So getting in there was good. And so the questions now are, how are you going to manage the stone? And we're going to tag-team this. But this is a case where we were able to do it without anything more than just simple stone extraction techniques. But you dilated. So we did a big sphincter on me, because we knew that the PD was about 7, 8 millimeters. So we cut to the size of the duct. We did the cholangiogram you saw before, but there was a filling defect within the head, which was that big stone, and then upstream dilation. We passed a balloon a couple of times, and of course, they always break, right? These PD stones are like diamonds. They just break everything. So once you realize that you may not be able to sweep, which is something that you should expect because it's very common, the next point is, can you get away with just doing standard sphincteroplasty in the PD and then stone extraction? Or you go straight to EHL with pancreatoscopy? So in this case, because the PD was so huge, and I was able to liberally cut, and I knew on EUS and on MR that the stones were small, less than 5 millimeters, I thought I had a chance with doing it with conservative measures without having to do all the extra work. And so we were lucky and was able to remove all those stones that you can see. And then the best part was, is after we do a pancreatogram, there was no filling defects anymore, and the duct drained beautifully. So at that point, we decided not to leave a stent, look like she was draining pretty well, and let her be. Quick comment on your video for your fellow, PHI, bad. So make sure when you submit, you guys know you have to submit videos, right, after this course, right? Okay. By tomorrow. But don't have PHI. Oh. Well, by tomorrow, but we would like, you know, when we first started this course, you know, if you were invited and taken care of, which we take care of you a little less than we used to, due to financial constraints, the expectation was that you would submit a video to Gerard's committee, which he's, are you still, no, okay, but submit a video for DDW. Just one quick comment that I think everyone knows, except in the chance that one person doesn't know, you're dilating to the level of the distal duct, or the duct, downstream duct as I prefer to call it. So I was surprised, but actually the duct is dilated to the very edge of the papilla. So if it wasn't, you would really, really hurt the patient, because that, in my experience, it's mostly been like a one millimeter duct for a little while, and then a stone, and you cannot do this then. Right. I mean, that's why this case was so exciting, because the duct was dilated all the way down to the ampula, so you could get away with a streptoplasty, but that's a very good point. Whether you're in the bile duct or the PD, you should always dilate only to where the duct allows you to, the duct size. So most of the time, you're right, there'll be strictures. You won't be able to have this as an option. You have to deal with the stricture first. But for this case, it was very sweet. It was no strictures, completely, diffusely dilated, just stones there that were able to be extracted. So then you have to wonder if this is really going to help, because it's harder to deal with it, but the better scenario to explain pain would be stone causing upstream dilation, But I think the stone was at the very, very, which is why it was difficult for you to get in. To get in. It was a very downstream duct, so maybe the patient just was nice to you. So just quickly going over predictive factors for long-term success, this is what we know, short-term disease duration, non-severe pain, absence or cessation of smoking and alcohol, which is sort of something that you can figure out for yourself in your practice. I actually like to, for the chronic pangs who have stones that are not maybe as acute as this patient, but really talk to them in the office because it's not, most of the time, it's not a one-time deal. It's not like you do one paper ad at QRCP and you say, bye, I'll see you later. It's usually a relationship that you're going to have to build with them and they have to be reliable enough. So in my practice, I've decided not to try to go down that route in people who are still drinking actively, and they have to just be honest with me and I'm honest with them. But that's my own practice. I don't know what you guys decide to do and if that even factors into why, if you decide to do endotherapy for patients. So we can talk about that at the break. Location of obstructing stones under the head are easier because you don't have to drag it all the way out if you're in the body or a tail. Complete removal is really what you want. You don't want to leave partial stones because you're not going to relieve the pain if that's really what this is all from. And then obviously you have to deal with strictures first before you do anything. So under other therapies, which Raj is going to pick up now, but as well as for stones that are large, and then he's going to talk about pancreatoscopy.

recurrent pancreatitis

differential diagnosis

pancreatic duct dilation

stone extraction

endotherapy

pancreatoscopy