Next, I'd like to invite Dr. Raj Kiswani, very well-known in the world of advanced endoscopy, local Chicago-based here, from Northwestern, who will talk to us about endoscopic pancreatic interventions. Raj, you do this very well, and I've seen you give a lot of talks in the last many years, and very captivating, so I look forward to what you're going to teach us. You're supposed to undersell. So I think that this is obviously a great course. I appreciate being invited. We were chatting. I had prepared a different talk on just pancreatic videos, but then I found out Peter just did whatever he felt like doing. Peter was supposed to talk about third space endoscopy, and he decided to not do that at all. So I included some biliary videos at the beginning of this to make sure that we cover some biliary techniques as well. So for those of you who had to watch this the first time, there's some new cases. I also have a total of zero written teaching points here compared to Ann Marie, which was chock-full of information, so I apologize if you don't get as much out of this, but at least you get to watch movies. So this is something that we talked about a little bit, for those of you in the hands-on. So this is a case, kind of a miserable papilla. So you can see here that we have ticks on both sides of the papilla. The good part about when you have ticks is you kind of know where the bile duct is not. The bile duct is never going here if you have a tick, or here. It's always going to be going this way. The bad part is it can be somewhat challenging. And so what we try to do here is, obviously, in this case, we got into the PD and we have a PD stent. In general, as we talked about earlier, when you have that situation, there's a lot of ways you can approach a difficult cannulation. If I have a PD stent, my preferred approach is just to try to cannulate over the stent like we're seeing here. You try to be above the stent, bowed up, and try to basically get yourself away from the pancreas duct. In this case, as you can see, that we're just repeatedly getting into the pancreas duct. So we're clearly still really just like, you know, really close to the pancreas stent. So this is an example of what we talked about before. And some of you in the breakout is the trans-pancreatic septotomy or the GOF procedure. Most people do this when they're, you know, in the pancreas duct without a stent in. But if you have a lot of room in the pancreas duct, you can do it like this. And it's actually just as easy. So what you're doing here is you're in the pancreas duct. You can see there. And then you're cutting in the direction of the biliary orifice, right? So I'm trying to cut towards that. Like we talked about in the hands-on, I'm torquing counterclockwise using my elevator trying to cut towards that biliary orifice. And even then, I was still sort of disappointed in being unable to really figure out why I'm not getting into the bile duct. But you can see me trying to, you know, it looks, we can talk about it a lot better, but it's a lot harder to do some of these things in real life. But trying to cut towards that biliary orifice, right, over and over again. So you can see us going up here, making our way up in that orifice. And then, annoyingly, it seems like we're still not in the bile duct. But this is where I want to explain to you that not everything has to be about wires. Like our wire would not go, would not go. And I'm now 99% sure that I was in the bile duct before I had to do all this at some point. Because when you inject a little bit of contrast here, you can see how miserable some of these bile ducts are in terms of tortuosity when you have these huge diverticulums. So you see that right there? So as you can, as long as you can see here, this is basically completely distorted. So don't be so afraid to inject contrast, because I would have thought, again, oh, I'm in the PD again. I'm, you know, I'm going to keep trying doing weird things. But when you're in here, this is a big moment where you got to really try to, like, try to navigate your wire, right? So we'll show this again later. But here I would probably bow some, come back with my tome a little bit, because right now I'm just hitting the wall, right? That's stupid. I don't know why I did that. I should come back, bow a little bit, and change my angle to really follow that. So this is a point, again, that diverticula super distorts your anatomy. Don't be afraid to do, to inject a little contrast. I would have thought I was in the pancreas duct, and it's also an example of what the golf procedure would look like. And so then you can see we get into the bile duct. But as I said, I probably was in the bile duct at some other time, but assumed I was in the PD because the wire wasn't easily going. All right, I've just gotten to this case. I would not have made everyone do extra steps, so I apologize in the back office there. So here's another case. So this is a patient who had a biliroth 2. That is a big stone. That is a big duct. Biliroth 2 procedures are difficult in general. In general, I just try to go in, and there are rotatable sphincter tomes, as you all know. You can try to rotate them. I find it very confusing. I usually just try to go in with some straight canula, hope I get into some duct, and then if I get into the pancreas duct, put a stent in and then try to cannulate next to it. In this case, I at some point got into the bile duct. It was a big stone. It's a biliroth 2. I was depressed. I put in a biliroth stent, and I came back. So what I did in the next case is, just a pause there. Everyone understands biliroth 2 cannulation, right? They've all heard. The reason it's annoying is you get there, first of all, you may not be using a duodenoscope because you don't want to perforate the patient on the way to the papilla. And once you get there, everything's upside down, and so it just is very confusing. So if you get into the bile duct, you're usually really happy. If you have a stone case, this is a time to maybe do a small sphincterotomy in the opposite direction and then do a sphincteroplasty, or just go straight to a sphincteroplasty if you're having trouble orienting well. But when you have a big stone like this, it becomes challenging because unless you have a therapeutic scope, you can't do cholangioscopy and do EHL. So in this case, it's just an example of what you can sometimes do. If you get a huge bile duct, you don't always have to reach for a cholangioscope. In this case, we do a biliary sphincteroplasty, and now you can see you get your endoscope directly into the duct. And I do this maybe a few times a year. I'm sure the other faculty do it a few times a year. It's just so much easier than using a cholangioscope when you can avoid it. You can see a nice big stone, and it gives you a good idea of how to do EHL. Everyone knows that really we have two major options here. This is EHL option, which we're putting in saline. That means you do not want the device to actually touch the stone. You want it to be right next to the stone. If you are a more wealthy hospital, I'm sure probably you have a laser, right? Yes, but you also have gigantic stones where you are all the time is what I hear. So some of us just have modest stones here, but this is an example of direct per-oral cholangioscopy, right? So we get the scope directly into the bile duct and break up the stone. It just tells you that you have to be somewhat nimble in your thinking when you have patients with biliruot2, because you end up having less devices. All right, this is a case that those of you who were here before did see, so I apologize. So this is a patient who was referred to me in the setting of chronic pancreatitis because they had some difficulty at the prior ERCP. This is a... I still... I can't see it, but can anyone see what's wrong with this picture? It's okay if you can't, because even I, when I look at the picture, I can't quite see it. But if you look really closely, if you take a scout film, there's something bad. All right, you'll see it when we zoom in more. So this patient has really bad chronic pancreatitis, had bad pancreatitis after their last ERCP when things went unwell, and you're about to zoom in, because I like to really radiate myself so I can get really zoomed in. And do you guys see what's wrong? Anyone see it? You should see it there. What do you see on the picture? I take a freeze picture right there. What's in the... You're pulling a lot of stone material out. What are you seeing in the pancreas? This is not a trick question. What is that? It's called a pancreas stent. Yes, I think you all know that now. But we did not see a pancreas stent on the... at the ampule, right? So this is what keeps most people up at night, because they can be easy or miserably difficult cases, which is a migrated pancreas stent into the bowel. This was actually pushed into the pancreas at the time of the procedure. If you do that, it's very bad, I'm sorry. But I would tell you personally, what I would say is if it's a native... it was a native case, so I'm just doing a stone case and I try to put a protective PD stent and I push into the pancreas duct, I would just put in a trans-papillary pancreas stent at this time and then take it out the next time. I think that it can get really messy to take a pancreas stent out. So a few different ways to take out pancreas stent... Oh, go ahead. It was there. Yeah. Leak? I think it was... There was not a leak. It was a lot of dilated side branches and bad chronic pancreatitis, but it could have caused a leak at some point. But no, this was early on, so not yet. So again, we talked a little bit in the earlier session about how to manage this, but I'm hoping one of our Steller fellows in the room can give us how they would manage this. So I tried to call states out and literally no one was from any of the major states of America at the time. Is there any fellow from California here? All right, there we go, California. How would you manage a migrated pancreas stent in the pancreas duct? I mean, how do you... Give me some options, you think. With the dilated... Perfect. All right, so that's probably what most people do, and that's what we'll show you an example of here, which is pancreatoscopy and either grabbing the stent with forceps or wiring the stent and trying to remove it that way. I'll show you that way. What we talked about earlier is just, I think, the easiest way when you have a stent that's migrated in, but not all the way at the end, is just passing a wire beside the stent. You take a slightly open snare around the wire, pass it to the tail, then open the stent and then pull back, if that makes sense. So you open the snare on the tail side of the stent, and then as you pull the stent snare back, it's going to be on top of the stent, you close it and pull the stent out. That doesn't work when you have no room back here. You can see they've pushed the stent, they're like, oh, I need to get it into the spleen if I can. So it's way out here, so you're not going to be able to do that, but it is another option. So this is an example of pancreatoscopy. Obviously, you're not going to do direct peripheral pancreatoscopy, PD is not that big. So you will now see a... We're cleaning out the duct. I was surprised at how well... So in sweeping, I would say almost never works. You can sweep till you're dead, it's not going to come out. It's actually quite hard to do this. We got very lucky to get really lined up with the PD stent, and as soon as I see that, my first instinct is not to grab it with the forceps, because I think I'm going to lose my position right away. I had a wire ready until I get there, and now you've wired the stent. Once you've wired the stent, everything's great. You can pat yourself on the back and you're happy. You can do it a few different ways. You can just put a Sohendros stent retriever into it, and then pull it out. That's how normal people would do it. I just took a dilating balloon inside of it, because it's very low profile, and if you inflate the dilating balloon inside of it, then you can pull back, and then you can pull the stent out, if that all makes sense. So a lot of different ways to approach this. Sweeping, it never works, but it's what we always do first. I'm sure everyone has examples where it's worked a couple of times, but it doesn't work well. A basket could work, but it's very hard, and some of these PDs are small. But in general, my favorite way is either a snare pulling back or this way. It's why you have to be very careful when you're putting your pancreas stents in, because it's just much, much different than a migrated biliary stent. I think in the interest of time, I'll try to do one more case at least. Any questions on what we've talked about so far, or we have a discussion section potentially, so I'll just keep going. This was a patient with a walled off necrosis in the head from alcohol, really severe disease. The first time I cannulated the major papilla, had no idea what was going on. The ventral duct seemed to just go into straightened extravasation, ultimately went into the minor, and had a massive leak in the head, and I couldn't see any of the body or tail. This is what all of you know would be considered internal drainage of a pseudocyst or walled off necrosis. It's basically getting your wire coiled inside the collection, placing a trans-papillary stent, this time through the minor, and letting that collection decompress, and then I'm coming back this next time now to try to treat the underlying issue, because I couldn't even see the duct before. Usually, as you know, when you're doing minor cannulations, you're in the long position, but in this case, I was able to get a stable short position, and this is something we talked about a little bit in the hands-on, and I just want to sort of show you how important it is for you to become really savvy, like you're one of these IR people, the IR people are always the people we look up to, they're so much cooler than us, and they're always playing with their wires and using like 80,000 different wires, and so this is a patient who I need to get my wire to go like, this is where the leak was, I'm not going to over-inject it now to show you, but the leak is in this area, this is going down towards the ventral duct here, and this is the dorsal duct. I need to get my wire to come around this way, and then come back up here, okay? And so I want to just sort of give you a sense of when you're trying to do these cases, what you need to do. And the first thing you need to do is, you can see here, if I keep my balloon facing this way, I'm not going to get where I want to get. So this is where we talked about when cannulation and sphincterotomy, you've got to change your scope position, right? So if I change my scope position and push it in more, you're going to see how my balloon position changes its trajectory. It's going to be less vertical, it's going to go more horizontal. So I'm doing this over and over again for no clear reason, but you know, got to keep doing it, you'll see me push the scope in more, now you see I'm more horizontal, that's your first step. My next step is to try to get the wire to come down this way, and then flip back up. So this is where you have an angled wire, and you're basically trying to manipulate that wire to come down here, and this works for these post-transplant strictures that you'll all see a lot of, all this stuff. You got to figure out how to hold that wire and make it turn. So I kind of want to do something like that, but what I really want to do is have the wire come this way, and then once you see it come down this way, you'll see me flip it up. So now you see me have it down there, and what I'll do is I'll start to rotate the wire again in my hand, and you'll see it start to act crazy, and eventually it actually flips into where I want it to be, right? So it's not that I'm pushing, pushing, pushing always, I'm trying to get it where I think it needs to be, and then rotating it and flipping up into a direction that I think will be beneficial to me. And so then, the key next part is to make sure you have enough of the stiff portion of the wire across, you can see the leak is starting to fill up there, so I'm not going to overdo that, get the, so the wire was going up the leak there, I've made it around it, get enough of the stiff part of the wire in, and then you're home free. So again, another example of why it's helpful to understand how to control these angled wires and move forward. And then we'll get the stent across it, and we're heroes for a day. I think, well, we can stop there, I'll just show you that what, I'll show you this, which is what Peter was not supposed to show because it had nothing to do with his talk, is a great example of an anomalous pancreatic biliary junction, which I can guarantee you has zero to do with third space endoscopy, which is what Peter was supposed to talk about, but I know he talked about it, so I will not show you another case, but I did show you anyway. Perhaps a better anomalous pancreatic biliary junction than even Peter had. All right. In the interest of time, I'll stop there, thank you.

endoscopic pancreatic interventions

pancreatic duct stents

biliary techniques

trans-pancreatic septotomy

pancreatoscopy