elevated. Lipase is 5,000, amylase 4,000. So now a question to everyone, has anybody changed their fluid management for these patients after the waterfall trial? Everybody still does a change to your fluid rates? Yes. Okay, show of hands, how many have changed their resuscitation rates? So anybody for initial antibiotics? Show of hands. Yes, no, just do fluids. Okay, and roll of CAT scan. Everybody in the ED, I know even if you go with toe pain, gets a CT abdomen. So I mean I don't think that, that ship usually sails even before we are consulted, but if you were given the option, CT, you have the labs, roll of CT on day one or two of pancreatitis. They're worsening on day two. Why? Because you think about a collection or some, some complication. Right, so a patient of course got a CT in the ED before we were consulted, and of course a patient had significant peripancreatic stranding, pancreatitis, of course we knew that. Pain continues for a few more days. A week later, patient is still complaining of pain. Repeat imaging. This is what the CT is showing. What is it showing? Developing Waldorf collection. So for, you know, CAT scan, acute fluid collections in the pancreas, you know, they can be necrotic or just pure fluid. And the question is, what do we do with these and how symptomatic is the patient? So overall patient kind of turned a corner, started to do okay. So we didn't intervene because endoscopic drainage is not recommended in acute fluid collections without a proper wall. So patient was discharged, was tolerating diet, came back as an outpatient now with worsening pain. The white count had come down a bit and the labs were looking a little bit better. What do we do now? Can I stop you just to get a debate on, I don't, I agree with you on the not draining acute pancreatic fluid collections. We don't do it but obviously others do and there's been mixed data on it. Is anyone pro at two weeks draining these in an unwell patient versus sending them to IR? So draining them endoscopically at two weeks, which some people advocate, versus what we would do is send them to IR when it's an immature collection. So is anyone pro endoscopy? We're the Minnesota people. Yeah, I've not seen a lot of people who do it but no one else in the audience. So I guess that's your answer. I think the value is that IR is still your friend. So you know these are some collections which are not mature but patient is symptomatic or spiking fevers, rising white counts, there is value in percutaneous drainage to help drain that collection. So of course patient gets a repeat CAT scan four weeks later and this is when there is no sweat collecting, the fellow is starting to drool. Patient has no stomach left. Right, so you can see significant compression of the stomach on the coronal and on the sagittal. There's a larger Waldorf collection, probably Waldorf pancreatic necrosis. And now the question and the debate starts. Was there an artery at the bottom of the collection? There was, yeah, there's an artery running through the back wall. So the right where the arrow is, below that is the splenic artery running through the collection. So you should go right for it, that's a target for the Atlantic. So the question now is, is this a good candidate for endoscopic drainage? Who says no? Okay, everybody's awake. So now a question, double pigtail plastic stents versus lumen opposing metal stents. And I know this day and age of fellows have probably not even done any Seldinger techniques and double pigtail plastic stents given the advent of lambs. But I will tell you, I mean I have been trained on the Seldinger technique and putting double pigtail plastic stents in my advanced fellowship. And in purely pure fluid collections, there is value. But I would love to know the experts in the room, double pigtail versus lambs, preference? I would just say lambs because it's easier, faster. I've got, you know, days short. But I do agree that you should try to use that skill because there are other instances where you might not be able to do lambs. And so it's nice to go back, to fall back on your, another option or another technique. So very quickly, a paper just, sorry. Yeah, no, I was just gonna say the 6-Francistotome is now available in the U.S. commercially, which may bring this technique back and make it faster and a little easier. Shyam just published a randomized control trial on this exact question, just came out last week. And basically, outside of procedure time, there is no advantage of lambs for pure fluid collections. This has been our practice for two decades. When you joined us, you were seeing all cases were done with double pigtails. And unless there's necrosis or you're going through the duodenum, lambs has no particular addition other than procedure time. I guess I would argue that obviously it's a, I forgot if that study is single center or not, but the big thing for me was when we did this as sort of the cellular technique, etc., was the ability to get these through a thick stomach wall. Because I used to do it non-cautery. I used to do it with, you know, wire and then dilation. And sometimes you'd get stuck on this very thick gastric wall. I do think with the 6-Francistotome, that becomes not an issue as much anymore. And I will always try to do this for someone who has disconnected pancreas duct and it's a recurrent fluid collection. So lambs, what size? Preference? Everybody's to us, 20, 15? Can I just make a comment? So when we, you know, when we first started doing, when I first started doing pancreatic fluid collection drainage, there was no lambs and we did double pigtails. But, you know, the position could be challenging. It depends upon where you're going. When lambs came along, I mean, the nurses were stunned. I mean, our expert nurses who did it, I mean, it's two minutes done. And they were like, what? Wait, what? I mean, normally, you know, you're going in and then you put the balloon in to dilate the tract. All the fluid starts coming out. Then you can't see what you're doing. And I mean, it just was always seemed to be fraught with something happening somewhere, where something. And so I think the hard thing is, is the lambs is so easy. But it is a five to six thousand dollar stent compared to double pigtails. So it is a harder thing, you know, when it's a nice clear fluid collection without a bunch of junk in it, to say, okay, we should just do the old technique. Because honestly, our nurses, I don't, we haven't done that in so long. We're just so addicted to the one-minute lambs procedure. Right. That it's really hard to go back, I think. But I agree, Julie, and you're right about some pancreatic duct interventions and things like that. It's a good technique to know. But honestly, I, we just, I don't know. Gerard, when's the last time you did double pigtails? Two weeks ago. All right, fine. You know, that did not go very well. So anyway, Gerard's older than me by a couple years. As you can see in this presentation and the next one, five years of lambs has brought more grief than 15-20 years of plastic stenting. It's a great product, but it has to be used judiciously. So I personally use the 10 or 15 millimeter lambs if it's a pure fluid collection for necrosectomies I prefer to put the 20 because I'm gonna be going in and out quite a bit with my therapeutic gastroscope to clean up that necrosome. How long are we leaving the lambs? Removing at? Four weeks. Four weeks. So the one take-home for fellows is most of the complications have been reported after the four-week mark and that's where that magic number has come from. So we actually put this in our stent log. So we have a stent log of CBD stents, PD stents, and lambs that go in that have to be removed and the patient is made sure it's on the schedule for that. With the double pigtail, I do feel because I leave them as destination therapy in some patients where there is a high chance of recurrence of the pseudoses and so I think with the Seldinger technique you could just do that index procedure if it's a pure fluid collection and leave the double pigtail plastic stents as destination therapy. Anybody puts a double pigtail within the lambs? Show of hands? Everyone should. Yeah so now there are studies that was presented at DDW this year is it does minimize the risk of complications. I personally do, especially seeing that CT and there's a nice artery running in the back wall. I did put a double pigtail inside this. So this is a very nice video by Dr. Ken Bin-Moller. Okay so how many fellows have placed lambs yet? Show of hands? Okay good. So this goes through the steps of the 1, 2, 3, 4 in the lambs platform that's available in the US and you insert the sheath, you lure lock. You're gonna do a lot of this at the hands-on today. Know your 1, 2, 3, 4 steps. Unlock the sheath hub and the cotteries attached at this point and while putting your foot on the yellow pedal you're advancing the sheath into the fluid collection and that is a step number one. And then you puncture the cyst. These are the settings for the yellow pedal. Those were added by me inside just to drive the point home. But at this point now you're taking the security hub off, the yellow security pin, and you're gonna deploy the first flange and it auto locks. After you've done the second step it auto locks at that point and now you're gonna slowly pull the sheath back. That is step number three. I say, you know, to create like a football. You can even use the central introducer to make sure that it gets as close to one side of the flange as possible. And I'm of the school of thought, I deploy the distal flange within the scope. So this is how I do it. I know some people like to see the black mark but I have done several lambs. I do it like this. I've not had, knock on wood, a maldeployment yet. But and then you slowly move the scope away and your stent is deployed. So coming back to our patient, this is the walled off necrosis. Again these are very challenging cases especially if it's completely filled with necrosome. To even see which is the cyst wall, what is misentery. So take your time, spend the time to identify it. Here you can see, again heavily edited video, that to find the actual cyst collection and it's huge to identify the site where you want to go in. The one other thing I do is I endoscopically also check where my puncture is gonna come because when I'm gonna go do the necrosectomy I want to have a good access point for the scope to go through the lambs. And there was brilliant material coming out. Anybody dilate at the index? I was just gonna emphasize one point you made because again we've seen everything that could go wrong. I've seen it go through the esophagus. Even just too close to the GE Junction, your aspiration risk. So in a collection like this you have your pick of places to place it. So you know try to find that right spot. So in the interest of time we go to the necrosectomy. Choice of tools? Panel? Quickly? Choice of scope or tool? I like the cold snare that you're doing. I personally, yeah Raj. Oh same, yes. I guess in Congress, agree. So yeah my personal favorite is the therapeutic gastroscope with the 20 millimeter braided snare. I feel like that works the best. I know there are rotating oscillating devices available, rod nets and everything but I think the therapeutic gastroscope with the 20 millimeter snare has sold me well. Anybody lavage with hydrogen peroxide? Yeah it's very effective. And do you suction it all back once you, or do you leave it in? I wait for the bubbles to dissipate, kind of like what Prabhleen describes, and then after the bubbles have dissipated then you can lavage the rest out. Yeah that's the enzymes working is what is in for anyway yeah eating away the bad stuff. And when do you bring them for the index necrosectomy after the LAMs goes in? I would say their clinical course, what it looked like. I mean you saw that pus, you could think about putting a nasocystic drain in for a little bit depending upon how they are. I don't know, bring them back in a week. I I don't, if I brought it back in a week I wouldn't take the LAMs out, it would just keep it in. It kind of depends I guess how much junk's in there. I usually bring them within a week. Julie? To go back to the lavage point, if it's not so bulky and you have a cavity that you can assess, I like to lavage whether you do it with peroxide or not, just to assess what the wall looks like and if that necrotic junk is soft and it's going to come off, or if it's really adherent and you know you're gonna have a tough time really taking it out. So I think that lavage aspect is, can tell you a lot about what you're dealing with in terms of the necrosis. In terms of when you bring back, I don't think we really know what the sweet time is, but the point is is that you really want to keep them on a short stick and you don't want them to disappear on you because of all the bad things that can happen. So just watch them very closely. I would bring them probably back in two days for this because of the amount of necrosis and one very boring point that if you, there's a technique to removing the necrosis that I didn't realize until recently is really just slowly working your scope and your snare back and rather than pulling too hard and it's it starts to slowly pull more and more necrosis and you can get really big pieces compared to just grabbing a snare and grabbing it and trying to pull. So you're almost like slowly working it out and you'll get these gigantic pieces coming out which makes us a lot faster. Peeling it off. And how much time do we allocate? I mean we can keep going. I actually only allocate 60 and I just try to get as much as I can out and and then you know bring them back again but that's me. Yeah usually 60 to 120 again we we have issues. Yes Peter. I just wanted to add to the devices discussion. Certainly snare works very well. Rotnet totally does not work. I will not even waste time and the device but actually my preferred device is a three centimeter Dormier basket, stone extraction basket. And it tends to grab better than the snare and you tend to lose less material. importantly what Raj said is you work the scope and the basket as a unit and you go slowly and some torquing can help to get it through the orifice. And it's crucial your assistant to be on the same page. Obviously you don't want to close the snare or the basket completely because the wires will just cut through it and that will be the end. So you want to close tight enough, lose it, but not too tight so it cuts into the necrotic tissue. So there is some coordination that is required during that removal, but this has got to be one of the most painful procedures that we do. I agree. This is right up there with the double balloon. People like to put the lambs in and then put the necrosectomy on the partner's schedule. That has been my strategy for years. We've actually invented a device, hopefully Microtech will put it out on the market. I like a cap on it, but you suction it up with a cap and then you try snaring it and it falls off. So we got Microtech to put a snare, fix the snare on the cap. They're going to try to market it if they ever get it out through FDA. They wanted it as an ESD device, but the idea was suction this up and then snare, colt, snare, suction, colt, snare, suction, colt. So Endotech actually makes that now for foreign bodies. Oh, really? Oh, you mean a basket? No. It's called Endotech. It's an e-suction device. Yes. Oh, damn it. How did Microtech not figure out the IP? There's a pink band around it, so it'll be different. Anybody use the Ovesco device? It's a plastic cloth. It's a plastic cloth, Ovesco. Ovesco has a device as well. No. I have not used it, but. Yeah. Excavator maybe? Excavator, yeah. It's a plastic thing. Is it good? Yeah. It looks like Super Puck, man. Yeah. Yeah. Does it work? Is Ovesco in the room? No. I feel like it doesn't grab as much as you think it would. It does not. And does it get gunky? Yeah. And then the jaws are hard plastic, so you just have to be careful with the tension and things like that. But it doesn't grab as much as you would expect it to with big cups like that. Just on the safety component, there's occasionally times where you're not sure if it's necrosis or actual stuff you don't want to be removing. So I'll close the snare and then look for vascular changes before I pull too hard. So you can get confused, and you can be very depressed then. Vascular changes? What do you mean? Necrosis has no vessels, so if you see anything... Like that first CT scan. Yeah. Yeah. You don't want to snare a splenic artery. Yes. It's considered bad form. Yeah. Expert tips. When do you do an ERCP to see if the patient would need an indefinite double pigtail or something? So when do experts do an ERCP in these cases as well of pancreatic collection? That's a great question. So usually when these are in the body tail areas, there is some degree of disconnected duct. I would get an MRCP once the cyst is completely collapsed and right when I'm ready about decision making for removing the stents versus doing a double pigtail. I don't do a diagnostic ERCP in these patients. I don't know if the panel does anything differently. All right. So interest of time, we'll keep going. So this is after two, three hours of work. Their goal is to get to this point and get all the necrosome out. Practice pearls. Decide between double pigtail and LAMPs. There is a role for both. And I usually bring them within a week to do the necrosectomy. Confirm resolution with imaging, a multidisciplinary and close follow-up is key. And teamwork. This was a large collection. Patient actually got percutaneous drains by IR. And then endoscopic necrosectomy was also performed in collaboration with IR. And you can see the IR drain in the cavity. So they are your friends. And finally, this is the goal and the resolution that you want. I would just say that in general, I would get an MR with secretin in these patients to make sure there's, to that question, the stricture, disconnected duct, because it's easier than to leave double pigtails in permanently if there's going to be a disconnected duct than having to deal with it later. Does anybody practice differently on their initial approach if there's extension into the pericolic gutter, like asking IR as well as you doing endoscopic drainage right from the get-go? Yes. Yeah. Okay. So, quickly, since we all love LAMPs, this is something that we all should be acutely aware of. I'll go through the case quickly. Patient was a 66-year-old male. This is Dr. Call's patient. And I was involved in the patient's care with him. You did the necrosectomy part after you did the LAMPs, though. Everything good is her. Everything that went wrong is him, is what she's saying. Yeah. Yeah. Everything that went wrong was mine. No. So, patient was managed out. Dr. Call, any comments? No. You have learned well. So, keep going. So, the course, patient had pancreatitis. Course was complicated by pancreatic fluid collection. Now, this was at an outside hospital. So, they decided to do percutaneous drainage, which was complicated by a PD, injury, and leak by IR. They had reaccumulation of the cysts, was sent to surgery, had a surgical cyst gastrostomy. And patient came back with, four months later, with pain and was finally sent to us for evaluation. Amazing back story this patient had. For two years, multiple entities tried to deal with him. Except GI. Except GI. This is happening from within a few miles from where we are. So, it just reminds you that America is a very big country. So, CT showed an 8.5 centimeter pseudocyst, causing extrinsic compression of the distal stomach. The patient was symptomatic. And the question is, anybody says, drain, do not drain. At this point, the U.S. should come in. They've had every intervention known to man for a fluid. Including surgical cyst gastrostomy, twice that failed. Twice. Those tend to fail more than the cyst jejunostomies, is what I understand, right? Because of just the, and the wall tends to close up a lot more. I think it suffers from the same problem, right? They don't leave a destination hole there, so. But anyway. So, we. So, here's the, here's the important slide. So, this was a real conversation during the procedure. And we see a pure fluid collection. And the, the lambs lover that I am, I was like, yeah, let's just put a 10 millimeter lambs and we can put a double pig tail inside. And then we're talking whether we should do the cell linger technique with the cystotome was not available yet. And my, you know, the discussion was whether we will be able to get the dilation balloon across. So, we're doing the surgery in this area. And also, it was a tough location. This was very close to the antrum, actually. So, we are dealing in the distal body and atrial area. And the scope is unstable. And has, cyst has recurred, so we want to establish a robust drainage. Patient is symptomatic. And both he and me are going back and forth in the room. So, you know, Dr. Kothari has a, has a lamb's radar, so. She left her colonoscopy, EMR, and joined me here. And then we entered this debate. So, this is exactly what we were talking about 15 minutes ago, right? Pure fluid collection. And you know, I said, let's just put a double pig tail, get out of dodge, he'll be fine. You know, relatively easy case. And then we, let's go with that. Okay. So, we put the lambs. We, of course, put a double pig tail inside it to, for our due diligence. And patient does really well, wakes up, he's feeling great. He presents five days later with hematomasis. Hemoglobin went from 11 to 8. And of course, he got initial transfusion. Again, this is at an outside hospital. And I'm out of town. And he's traveling, so. And this is not even four weeks, notice, it's five days. Yeah. So, in five days, he comes in and gets a CT in the ED. There is large amount of presumed blood products within the stomach. They didn't see any active extravasation. The CT was done with contrast, but it was a regular CT with contrast. The lambs and double pig tail were in place. So, at this point, they didn't see any active extravasation. But the patient continued to have melanin hematomasis. So, role of endoscopy? EOS? I mean, the cyst has decompressed. I think you're saying EOS for vascular. For Doppler. That's the advanced fellows course. That's a... That's 2.0. Exactly. No, it's great, but a lot of these tend to be huge vessels. But yeah. So, we did do an EGD in the ICU. And there was a fresh oozing seen from within the lambs, but not amenable to endoscopic therapy. So, at this point, what do we do? IR. IR. One problem, right? You go in and... What options do exist? Well, I was going to say, I think you do the EGD to make sure it's nothing besides what you just did, which you're pretty sure is what you just did. Right. That's the problem. I'm not sure you go into a cavity and start... Yeah. Well, but, Ashley, you make a good point. It could be one of two things. One, it could be a pseudoaneurysm, where obviously you cannot do much about that endoscopically, but it could be at the puncture side that you have bleeding, and you may be able to do something about it with EGD. Right. Yeah. So, that was the goal, is to see the puncture side. But the bleeding was, of course, coming through the lambs and from the cavity. So, we sent the patient to IR, and lo and behold, there was a pseudoaneurysm of the GDA, which was not there on all the prior 10,000 CTs he'd had leading up to this point. And he underwent successful coil embolization. Everybody's high-fying. You know, patient is stable. But of course, as nature would have it, he's traveling. I put the lambs, so patient continues to have melanoma. And ongoing bleeding, despite the coils, and we suspected that there is still some degree of bleeding going on, required transfusions. What do we do now? Again. What do we do next? Yeah. Oh, you had left the lambs in? Mm-hmm. Are you sure? The lambs did not get removed at the time of bleeding? At the time. It was five days old. Five days old. Remember? I mean, you can do it, right? At five days, you can remove it. Yeah, but I mean, that's like, who knows what will happen when you pull it. The artery might come with it, so. No, no. I'm just, I'm not. I'm just kidding. I don't know the right answer. I mean, you can remove a lambs after a few days when it's in this, when it's in this retroperitoneal space, right? Right. I guess we also kept it as, you know, maintaining the patency of that site for what might follow next. So what do you do? Scope again. I'd call IR again. I mean, you're not going to, I wouldn't scope them again. Reasonable. Reasonable. IR is going to tell us to scope again. Yeah. That's what IR did. That's what we did and that's what IR did. So we said IR and IR said GI. So. Meanwhile, he's getting, he's getting two or three units every day. I'd do what Raj said. Take out the lambs and put in double pigtails. Yeah. So we brought him for an EGD and there was actually active bleeding coming out through the lambs. I tried to suction all this clot burden, this huge clot burden within the cyst and you can't even suction it out or get a view of the cavity. So I'm like, here, that's me suctioning. And then what we did was actually pour Puristad or this hemostatic gel into the cavity. And lo and behold, the bleeding slowed down. This is again on fluoride injected some dye to see if I could clear off or saline wash the clots and go into the cavity. I couldn't because the clot burden and the bleeding was pretty significant. So again, under fluoro, I just poured a bunch of Puristad into the cavity and I did pull the lambs out. I didn't want to pull the lambs out first because I wanted to keep the access. I didn't know in all that clot I would lose access to the cavity. And after the lambs, again, you can see the bleeding had stopped and I put a double pigtail because I wanted the cavity to not shut down and now you have a blood clot filled cavity not draining. So the double pigtail was left in and the patient actually stabilized after this. And two days later, we were able to send him home and the key is multimodality therapy needed. We actually are presenting this case at ACG in Vancouver in a few weeks. It is accepted for presentation. And the main goal is keep your patients safe, identify the complications early, know that IR surgery, are your friends when complications like this happen. As cool as lambs is, you know, there are, you will hear about bleeding and perforation and all those complications. Be ready, prepared to manage them. We had to make a call to London to make sure it's okay to put it in the pancreas. Sorry. Go ahead. Yeah. That too. Do you dilate lambs at the index procedure or? I usually personally don't like to unless I'm going to do index necrosectomy, which actually Dr. Vardhajulu's team recently published a paper on index necrosectomy and great outcomes from that. I like the lambs to settle for a few days before I go in. I personally don't dilate. I don't. Gerard. I wonder if we're going to get a case report of embolization of gel at some point. I hope not. Yeah. I mean, there's a, people have talked about the spray and its safety in the retroperitoneal space and because it's such high pressure, obviously the gel is not under that high pressure. But if you have an actively bleeding artery, there is a chance that some of that gel gets into the artery. It's just amino acids, right? Yeah. It is. So it's just amino acids. So we actually made a call to the industry and see whether there were any such cases reported and there is actually in this ACG another case of an intrasystic bleeding where the gel was applied to achieve hemostasis. And the feedback, I mean, the reply we got from industry was that it's just amino acid. So ours was the same concern. I mean, it's still off label. Like I think Dennis presented this morning, it's very important to speak to the off label nature of interventions. And these will come up medical legally if things go wrong and you will not be able to defend it much. It's also just amino acids. So keep that in mind. But in this case- It's hard to know which intervention of yours made the whole thing. I mean, maybe it stopped the bleeding. Maybe it was just clotting and then you pulled out the lambs and put in double pigtails. So maybe that was more helpful than anything else. You just assume the back cyst wall was oozing. Correct. Correct. Because you don't think it's an aneurysm anymore. Yes. You think it's just like the stent was aired here. Correct. I just want to make one quick comment, which is that throwing back to the initial discussion, if you're ever going to put double pigtails in, this is the case to do it. Because my experience for these recurrent pseudocysts is as soon as that collection collapses, you'll never get- I try to get two double pigtails in, you'll never get them in. If I have to do a lambs, I'll pack it with multiple double pigtails to create the space around the double pigtails. And that way, when I pull the lambs, there's some space to put the double pigtails back. These collapse so quickly that you can't get back in to put the double pigtails to permanently drain that collection. Yeah. And that's what I also actually do in those cases. I don't- and I know I'm going to leave the double pigtail as destination. I actually grab the lambs with a rat tooth and I just leave it over the double pigtail and I leave the double pigtail. I always pull the double pigtail. By accident, I pull the double pigtail if I try to do it. This guy is going to run around with that pigtail for a long time. Yeah. I'm not touching it. All right.

pancreatic fluid collections

fluid management

CT scans

LAMS

interventional radiology

bleeding

multimodality therapy