All right, so I'm going to go to the second case and then go back to the first case just to keep this sort of the theme. So this is a patient who's referred from an outside hospital with a large duct calcific chronic pancreatitis and chronic abdominal pain. And unfortunately, they did not have such a skilled endoscopist. So they kept having failed ERCPs to get basically past obstruction in the pancreas duct. And a short pancreatic duct stent was placed. I was not considering myself the skilled endoscopist, so that's talking about our panel. So this is the CT scan. So obviously, we're sort of leading them. We didn't plan anything, actually. It just happened that these cases work well together. So this is what we see in the CT scan. So any of the trainees, based on what you've heard a few times on sort of options here, you can see this very tiny pancreas stent, right? And then it sort of hangs up near the stone disease. So what would you do next in your clinic? I guess we know what Peter would do. What would we do at Rush? We're not allowed to call on fellows at Northwestern because we get fired. So we're all OK. So that's considered hazing, so I can only talk to our co-faculty. You can volunteer, though. That's allowed still. So go ahead. So yeah, I'll volunteer. I feel like Aswell is a better, I mean, you can see them. There's a PD stent that's like localizing it if there's ever a question. And given the repeated attempts before, I would try that first. Agreed? I used to worry as much as I do now. If someone is young, good surgical candidate, and they want surgery, the surgeon is on board before I even start. Because that's going to be two, three years, working every six months, changing stent, six months, yeah. So again, it's always a question of how cerebral we get during these conversations. But the data is clear that surgery is more durable than endoscopic therapy. My preference is a little bit probably similar to many of you in the audience, is that I like to prove that their pain will get better with a PD stent. And then I'll let them sort of go through the surgery or repeated endoscopic therapy. But it should be something you offer them. And I've had a couple people just say, send me straight to generally a pusto, because that's an easier surgery. But anyone else have anything else? Yeah, no, I agree. I usually like to show that the pain improved to whatever degree. And actually, I mean, literature has said those patients actually respond well to surgery too. So we actually worked actually to try to do an ERCP next to sort of see, and part of the reason for that was to try to get a sense of what the reason for failure was. Probably part of it was that I didn't look at the CT scan well enough. And so you could see, when you do the scout film on the left, that's what you want to look at, because people don't always interpret the scout films well for PD stones, because when you inject contrast, it's absence of contrast. But right beforehand, you can see that dense calcific disease right there. And you can see the pancreas stent sort of hanging out there. So this is one of those cases where you're working to get around that obstruction for a while. So can we maybe sort of our expert panel talk a little about guide wires they use in these difficult pancreas cases? So are you using the guide wire? Are you having your tech use the guide wire? Hydrophilic, not hydrophilic? Rotated, angled? Any comments? All of the above, which is what usually happens. Yeah. On any given day, I think there are a few guide wires open for these cases. But like Dr. Kohl said, I also prefer to start with the O21 in these cases and see if it navigates. Any other sort of tips and tricks from our experts? I think angled guide wires have helped over the years. I think in these cases, we'll see what Peter thinks. But the assistance, the experience of the assistant is really key. And that's what we have learned over the years. When pre-COVID, we had longstanding established teams that had been doing ERCP for two, three decades. We see certainly this in the Far East when we visit and do cases in India and China and other places. These folks are really magicians with the devices. And I think the technology takes you to a certain level. But I think the experience of the assistant is very, very important. So as you develop your programs and build your teams, invest in the nurses and technicians that will be doing these complex cases with you. Because the traveling personnel are not going to be able to help you that much. I guess the way I would disagree on this one is that, yes, in general. But in this case, I take the wire. I prefer the assistant for biliary cases. But in this one, I like to rotate the wire with my finger, get the angle that I want. You can do that with even a balloon now. You can do it with even a long wire. You can do all of this in your hands. And so my preferences for these cases where there's a complicated turn in the pancreas and or a tight stricture, I find it a lot easier to rotate the wire myself and to try to get around a turn. And I totally get that. And I think the only other nuance I'll add is that many of these cases require a dance between the catheter and the wire to take place. It's hard for one individual to do that. I will say this, that I will call in a senior colleague to take on the wire system. But it's still two people. It's very difficult to manipulate both the catheter and the scope and the wire with just one person. Can I ask a question? Oh, sorry. Who's doing short wire versus long wire? Who's short? These folks are being trained on short wire. Yeah. I'm still long wire. I'm still long wire. Yeah, I'm long wire too. Fellows, you guys? I think we use mostly short wire, but sometimes I've seen them transition to long wire depending on what device they want to use, like spyglass sometimes we use. And then we place Joel and stents a lot. So some of the attendings prefer long wire for that. I am generally a short wire person. And I agree with you, Raj, that the ability to control the wire to get up in there and around stones, especially with an angled wire. I like to spin it and push it myself. But I do, even though I'm generally short wire, I think there's two cases where I like a long wire system, which is, which basically I'm relying on the back tension of a very skilled tech to give me a nice straight line to get my catheters also past the stones. And that's in, you know, bad chronic pancreatitis and sometimes higher stricture cases. And so in this case, I would like to have the wire myself to navigate it up there. But then I'd like to switch to a long wire system for that active tension that they can give me in getting the rest of my catheter, the rest of my tools up there. Yeah, I completely agree with Jen. I'm traditionally short wire for everything, but for these cases, especially calcified chronic pancreatitis structures or stones, I prefer the long wires. I mean, the advantage of short, if you have a lot of staff turnover, is that you maybe don't have to train the tech as well. Yeah, that's exactly why it was developed, is for low volume ERCP centers where you didn't have the longstanding nursing. Peter? Yeah, I mean, actually, you guys are talking the same thing. The only reason for you to do the wire, Raj, is because you need experience in the system. That's the bottom line. And if you don't, then you take over. Correct. And Vivek brought something very important. I mean, I never felt as better pancreatic endoscopies as when I did cases in Bombay. Oh my gosh, I mean, I just put the tip of the catheter in the pupil and the wire is in the tail. They do the rest. Wonderful. Because the systems, I mean, they see these, like, four or five cases every single day. The short wire versus long wire, you can alternate from one to another. If you are stuck in the fellows, you probably should know that, because my favorite wire for the pancreas actually only comes in short. It doesn't come in long, the NaviPro. So then I have to exchange it, and the hydraulic exchange is the way to do it. And we can practice that in the lab once we get there. Just remind me, guys, because it's hard to explain it, but you may need a variety of wires. That's the bottom line. It's not super hard to explain. You're basically just flushing water through the catheter as you're pulling it back to exchange, as opposed to, for those who don't get to go to Peter's explanation later, it's basically, you know, just continuing to flush water through the channel as you're pulling the catheter. So it actually floats the wire as you're pulling back. Otherwise, you could actually cut the catheter and do an exchange that way as well. So if you ever need to switch, it's an option. I'm glad. I mean, obviously, I have my issues with verbalization, so thanks for pitching in. I think the point is that, you know, this is a very good case of why you really need to know all the types of equipment that's available to you and what's on the market. You know, all the different kinds of wires, all the nuances, what's the pros and benefits so that you can really, in these very specific situations where your go-to, you know, devices are not successful for you, you want to move to the next line that you will be successful for. So that's another important point for you guys to really be adept and learn all these devices. So what would you do next at this point? I mean, this is like, we get a stent across. We're sort of happy. Is there anything you would do? Do you just keep changing the stents or sort of move on, forget about the patient, move on to the next case? I think this is where I would say that I think, as well, almost has to be done if you're ever going to get durable relief and you're not going to do surgery. Probably the right thing is actually to refer the patient to surgery, given the density of disease, but I find it hard to convince patients to get surgery. So what do you think the problem is? You think it's stones in the duct? It's all stones. Yeah. It's not a... Because they kind of look scattered about, so I don't know. There's so many of them, right? But yes, so I think it's stones in the duct, but there are parenchymal stones, which will cause a secondary stricture, which is what Ashley's correctly getting at, right? Sometimes you just need to keep stretching out the PD and you don't have to worry about the stone disease itself. But even as well in those cases, I think breaks up that stone disease and makes it easier to open. But this is not something you can just keep serially stenting and hoping, I think, that it's going to get better. So in this case, we did send the patient to ESWAL. Another reason I like to do the ERCP myself first before sending them to ESWAL is then I tell them exactly where to target it based on... So we don't do ESWAL ourselves at Northwestern. The urologist does it for us. So I just say, target this proportion of this pancreas stent to try to break it up. And so that's helpful to have done the ERCP myself, place the stent and tell them exactly where to go. And then given the density disease, the next time we did pancreatoscopy as well, because ESWAL itself didn't break up the stones enough. To be fair, this is sort of like a mix of two cases. So it's sort of cheating. But we wanted to show you sort of what pancreatoscopy and EHL looks like. Pretty easy in a large duct to do pancreatoscopy. It's just hard because, as again, Ashley correctly pointed out, sometimes these are side branch stones. And those, I'm not sure how much value you get on breaking up. Even if they're sticking in, you have to do a little bit of shaving of them. Obviously, you want to be somewhat conservative in the amount of saline. But most of the time, we aren't because the pancreas is so beat up, you're not going to hurt them. Most of these patients do fine. This is the one where I turn the generator up as high as I can right from the start. We don't have laser, so we have to do EHL. But you can just sort of see that you're lining up the probe next to the stone. These are very hard stones to break up. But you just basically keep shocking it over and over again, trying to break up the stone disease the best you can. And my experience with ESWAL, even though we've had very good success with our urologists, it's never, for me, been a complete cure-all to where I haven't had to do adjunctive things as well. There is at least one European trial where ESWAL alone was the therapy for chronic pancreatitis, I think as Peter alluded to earlier. But in general, my preference has been to add ESWAL as a component of all the endoscopic therapy that you're seeing here. So you're putting this saline in here, and are you worried about too much overfill, chronic pancreatitis, maybe not, versus the bile duct? Is there anything you do differently? I think I just get obsessed with the view and want to keep going. I don't think about it as much as I should. I probably am not fighting as much about it, but I'm curious what others, when they do EHL from our expert panel here, your EHL in the pancreas, any tips that I'm not demonstrating that you use to break up stones better? I think the one thing is, even though it's chronic pancreatitis, you always want to be mindful that the proof doesn't touch the wall of the duct. And the bile duct's a little more forgiving in that sense. Psychologically, I feel better if I have done a good sphincter on me and I could see the flow coming out. I don't know if it makes sense, but okay. And I think also attaching suction to the cholangioscope to make sure that you're getting some degree of suction back. I do it even for the bile duct. I attach the suction. Right. So for EHL to work, it has to be completely submerged in fluid and saline. So that's what we're talking about here. I would say the only other thing for pancreatoscopy EHL is that it can be challenging when you're trying to remove stones in the head because if it's somewhere close to the ampulla, you're not going to have enough purchase into the duct because all of the equipment's very heavy. It's always going to want to fall out. So that's one technical thing that you might have to think about or encounter when you're doing these particular stones in the head. This patient did very well with therapy. But these are tough cases. Was there a decision that I'll do my other quick case real quick? We'll make that one quick so we make sure we have time for some thoughts. Antibiotics, Raj, or no antibiotics? I don't. Sorry, it's a lie. All pancreatoscopies, we give antibiotics. I don't know how valuable it is for pancreatoscopy. Obviously, for cholangioscopy, there's good reasons. But for all cholangioscopy, pancreatoscopy cases, we give antibiotics. Agreed. Agreed. For the fellows, the initial ERCP, and you had to try to put the PD stand in. I'm sure it was difficult. It was miserable. What are your tricks? What tools can you go to to facilitate that? Yeah, I mean, I think that's the hardest part. It's on the stone disease. I think that what I've found for these cases is I can sometimes get the wire across. Navigating that dense stone disease, but it's really hard to get other things across because it's going to keep catching on the stone. I've found the passage dilator, once the wires are crossed, can sort of move the stones aside even better than a typical, you know, dilating balloon. So that's my preference, is a wire, then a passage dilator after that. And I think I learned from him was sometimes using a strand retrieval, a Sohindra strand. Oh yes, yeah, which is a which is really committed. I'm gonna grab a glass of water. That's a last resort. I was just going to say, after using DHL, is your strategy to then put one single PD stent in or then you aiming to put in multiple PD stents on the second session? What do you guys think? I mean, I think it depends on what you're putting the stent in for, right? So if you have a stricture, then yeah, you want to serially dilate. You might need multiple stents or larger diameter stents. If you're just leaving a stent in just to make sure that the pancreas is drained and there's no stricture and it's just a disease, then I think you're okay with just one stent. I would say that, you know, the other important discussion is what kind of PD stent would you put in, you know? There's all different kinds on the market. You know, I usually pick different stents, like more stiffer plastic stents for PD work, for chronic pain, versus if I'm using just for prophylaxis, I'll use a softer plastic stent. So other things to think about. Good points. Also for the younger generation, Dr. Eisenberg will agree that this is an unmet need to develop a pancreatic wall stent, fully covered, right? We have been waiting for almost 25 years now. We still don't have a workable one, especially be particularly nice if it's a biodegradable one. So get on it with Boston and everybody and let's have it at the next course. Let's go do that right now. I will try to make this quick because I want to make sure we get a lot of content, but we wanted to just sort of, unfortunately I don't think it'll be as quick as we want it to be because these are always long discussions, but 43 year old female comes with IRAP, or I shouldn't say IRAP, recurrent acute pancreatitis, and then she's had three total episodes of pancreatitis, all interstitial, ten years, four years, and six months prior to clinic visit. She's had some outside MRs initially that were negative, you know, obviously outside scans that didn't show anything, but most recent scan performed in your clinic with secretin identifies pancreas divisum. So you're in your first month of practice out of fellowship, you're high-fiving yourself that you've solved this. What are you gonna do next in this 43 year old with three episodes of acute pancreatitis and divisum? One answer, there you go. Is she smoking or any other risk factors? She is not smoking and she doesn't drink. You apparently don't. Trust me, I think I was supposed to add that in, but it's been a long week, Ash. So there's two parts of this as we sort of got to. One is, is the divisum causing the pancreatitis, which is why that question about smoking and drinking are important, or is the divisum a bystander of the pancreatitis? Is the divisum causing the pancreatitis is a reasonable question, but as in this case, everything else is excluded. We should probably get genetic testing on these patients to figure out, as everyone knows, the CFTR mutations associated with divisum and it is probably a co-factor. The question of the SHARP trial I was brought up was, even though we know that divisum is associated with pancreatitis, it's not actually based on solid evidence that endoscopically treating the divisum will actually long-term improve the disease course, right? So it's really easy to do this when you have chronic pancreatitis and divisum and you know that it's the right thing to do because it's the access to the chronic pancreatitis. It's a little unclear, just like we know when you do a biliary sphincterotomy in an 18-year-old, long-term that's going to scar down and have issues, you know, whether it's the right thing to do to a minor papillotomy. But in this case... Also the tangent is, is it divisum? Do you buy your MRCP report? Right. So in general, before you do an ERCP, as Amitabh was getting at, you should do an EUS, ideally same session, because you can see most of these. Always review the films yourself. I guess the other question I asked about the MRCP is, is there, does it look like, you know, you have some dilated duct in the, you know, region where the ducts can... I didn't have Yousef make my videos or my slides, so this is like, oh, really great, you guys. This is like midnight. Plenty of cancers that have been missed and called pancreatic pancreas divisum. It's a good throwback to Yousef, I'd say. All right, so I think we switched to a Mac, so I don't actually know if my video will play as I intended, but this is an example of, so what's wrong with this cannulation here? This, this is, what's wrong with this minor, first of all? It's like very major-y looking. Yeah. And what else is wrong? It's never like that, just so. Yeah, exactly. What else is wrong with this cannulation? I mean, it's not wrong, it's what had to be. It's a very straight position. Short position. For whatever reason in this patient I could not, for the life of me, get this minor into the long position, so this is not the typical way a minor looks, nor is it the typical, the approach to a minor, because this is a very miserable approach, because if you get into the PD, that's literally when your scope will fall out of position, because you're really at a very bad position, but this was what needed to be. So what's, this is why it's going to be a tough thing. I want to make sure we finish on time, but for our panel, oh, go ahead. You got time. No, we have a few more cases. Oh, okay, sorry. What's your approach to divism? What's, what's your tome, your wire, for both of you? Your cannulon wire, I don't want to do this. Yeah, so same thing, a straight catheter with an O21 wire, or sometimes I've used a 543, like real tapered catheter with the O18 wire, but again, I think the day your minor looks like this, you should have bought in the lotto, because normally it's, you're spending a few hours giving secret in trying to look for the opening, and when it's really that, that small, then you're, I'm really going with the 543. Yeah, I start actually with the 39 tome and a O25, because I like to, I like the bow capability, and then if I can't get in, or if the papilla is really tiny, I'll switch to a tapered catheter, tapered tip catheter. Yeah, that's my preference, is I am a long wire person, but for these, I do short wire again, and I do 39 with a 25 isoglide, and try to just do physician-controlled bar guide cannulation. So you can see here, you're getting the wire out. But Raj, it's interesting you're saying about scope position, because remember, you're not going up, like you're going kind of straight out, I mean the duct is going to go straight, so the shorter position isn't always, you have to remember, if you go long, the angle of, you're not going, the PD's not going up and around, it's kind of going straight a little bit. It's just hard to face up right here, right, so my wire seems like it's going to face down. Oh yeah, secretin for all, or some secretin? Ashley, yes, no, before you cannulate? Not necessarily, I mean, I think. I'm a secretin for all person, but you're probably, but for this one, I don't think you have to. I think for the searching of the papilla maybe, a little methylene blue. And we'll show, this is really cool how it looks like a computer, this nice font you have on this Mac. All right, so I secretin sometimes for Ashley, cannulation we talked about. Any of the fellows know who Kramer was? Not from Seinfeld. In the old days, pieces of plastic used to be named after people, that's not done anymore. Michel Kramer actually developed a catheter that had a little wire at the end of it to help for minor papilla cannulation. But that Kramer catheter was crazy. Amundowitz used it all the time when I was a fellow, and it was the craziest thing I've ever seen, because you spend forever to get in. It was just a needle tip, and you couldn't do anything with it. You just get in, you do a pancreatogram, and then you have to switch to another device. I'm like, well, this is like a, I didn't want to say it, but this is dumb. We used it in Michigan too, but I switched now to the 39. This is an example of a very easy cannulation, so you're seeing a little bit, I use the tip of the guide wire in this case to try to engage. I like the way you set it up that it's a horrible position or whatever, and then you're like, and I wired in. I'm not going to tell you a case where it's like I don't succeed. No, I mean, those videos hit the cutting room floor. So basically, in this case, you're sort of probing, probing with the wire, trying to get in. We'll assume I get in at some point. For, again, our experts on the panel, are you a traction sphincterotomy or a needle knife over a guide wire? I'll tell you, I'm a traction papillotomy, but anyone else in the audience who, those third space people love using knives for everything, so is that what you just, you just knife the whole thing? Go ahead, tell us. I think I do traction for this particular one, yeah. So there are certain minor papillae where the traction sphincterotome doesn't enter. Yes. So the best, not to fight it, just get a stent in and then needle knife it. I think there were some minor pilots done on comparing the two. I think the traction had a little bit more problems, but that's older data, so. Yeah, I mean, you feel good when you're in with the wire and you cannot, for the life of you, push your tome in because you know you might be helping the patient in those cases. You can keep the wire there and do what's called the needle knife over a guide wire to give you a little access. I've also actually just taken like a four millimeter dilating balloon and just use it as a passage dilator over that guide wire to give me some opening and then gone back with a sphincterotome as an option. Also, another caveat, notwithstanding this papilla is like more majorly minor, but the typical minor papilla doesn't have the same heft as a major papilla. So your sphincterotomies need to be more conservative, although not so conservative that they're back next week with stenosis. So it's a very fine balance. And that's the next question, which is, I never know how far you can cut it. Nobody knows. I've been doing this for a long time and I don't understand it. Major, it's so obvious. For these, it can be challenged. So you want to make a generous enough papillotomy, but you prefer not to give a patient a perforation. We've seen some major bleeds from minor sphincterotomies. I edited that bleed out of this case. In the interest of time, I just want to show you, okay, that's a papillotomy. And we should, probably this is a good one to use, pure cut, if you're going to use it. And this is too much coagulation there. That's a disappointing cut. And a study is just coming out or came out showing at least equivalent safety of a pure cut essentially versus the sort of blended cut and reduction in pancreatitis risk for biliary sphincterotomy. This is a place where it'd be reasonable to try to use that more pure cutting current to reduce the risk of stricture reformation, because that's too much coagulation there. In the interest of time, I want to, oh, this is the bonus video. Interest of time is the bonus video to show you that they're not all easy. So the major is, I want this bonus video to play, let's see how I make it play. I think another important point about the cautery effect on the sphincterotomy, sometimes you think that your knife is in good apposition and splaying the tissue, but sometimes your view is not good. And so you're actually, the knife is not really on the tissue. And so you're stepping on the pedal and you're getting more cautery and less cut. So you just have to make sure that, I like to just really sit on the air at this point when I'm doing sphincterotomy, really blow up the intestinal wall and just make the tissue spread out. And so that you can really see well and that the knife is right opposed onto the tissue so that it's really like a cleaner cut. But that's what sometimes what happens is you're stepping on that pedal and you're like, wow, I'm not cutting. And it's usually because you're not on the tissue. There's not enough tension. Amitabh, you're the wisest of us all. So I'm assuming because I'm showing you an image, you can tell where the minor is in this, right? But it's frustrating. These can be super frustrating. It's easier. It's like the whole AI debate. Once I've shown you where it probably is, you can say, oh, I know where it is, but would you have seen it otherwise? These are hard. I'm not a methylene blue person. That is one of the ways you can spray the duodenum with methylene blue and then wait for it to wash away. If you give secretin, you'll see a nice demonstration of why secretin can be helpful. I kind of suspected it was here because you can see why. It's completely without merit. There's just not an opening that you see. So when you give some secretin right about probably now in the video, you'll see that you can sort of see this little washing. Actually, what I do is I've suctioned it a little bit, and then you're seeing that fluid come out, and it's sort of winking at you. These are exciting but also daunting because you know that as soon as you touch it, it's going to get edematous, and you have a couple of shots to get in. So there you go. Really trying to get it open with the suctioning the fluid down and the secretin, and then you know that's the minor. Same approach, which is to use your guide. I use my guide wire. You don't want too much guide wire out like that because then it's all floppy and not stiff at all. But remember, if you have a very small amount of guide wire, it's like a knife itself. It can dissect through tissue. So in this case, it's a little too far away. I don't like what I'm doing. I'm a little closer here, and still I'm just trying to probe a little bit. Where is that? Would anyone have needle knifed that right there without even going to cannulation? No, not in America. Yeah, people do, but I've never needle knifed a failed minor cannulation to be honest with you. I find that's very daunting to me. So in this case, I'm engaging where I think the orifice is and then trying to probe a little bit closer with the guide wire. But every time I touch it and don't succeed, I'm reducing my chance of success like dramatically. But in this case, I'm able to lift up and get the guide wire in. And so it's more of an example that all minors are mostly like this, I feel like. So you would needle knife? So if it's a failed cannulation and I've seen it there, I would think about doing needle knife because I know I'll get in after the needle knife. I know I will not. Know your limits is probably the point because I should. It's the right thing to do, but it's... Because if you make that edematous and don't see it again, you're going to kick yourself. Yeah, I would just come back the next time, but that's me. Anyone else in the audience for... I'm with Raj. I think once you needle knife a papilla like that, you're obliged to stent it. And also the other thing is there's a higher risk for retroperitoneal perforation in these minor papillae with that anatomy right there. So if you get away with it, great. Nothing succeeds like success, but if you fail, failure could be quite miserable. We'll see how correct you are. Shafer, would you needle knife this? No.

pancreatitis

chronic pancreatitis

ERCP

calcific obstruction

surgery

endoscopic therapy

pancreas divisum