Our next speaker, Dr. Richard Kwon from University of Michigan. Rich, thank you so much for being with us and also for taking on kind of a not very easy topic. In this topic and video-based case on rendezvous is hard to come by, so I'm not going to hold you to that, but I'm sure you have a lot of great wisdom to this group of people here. Thank you very much. Thank you, Mo, for the invitation to come speak to you. I know this topic will be useless for all of you since you will all get into the respective duct of your choice, but nevertheless, I am going to show you where I was not able to do so. I have nothing to disclose. I don't work for any of the companies, unlike other people. All right. So this case is a 52-year-old female. She underwent a Whipple procedure 15 years prior for a mucinous cyst adenoma, and she was referred to our GI clinic for recurrent bouts of pancreatitis. One month before she came to us, she was evaluated in an outside ER for worsening symptoms. Her lipase at the time was elevated at 1249. Her LFTs, though, were normal, as was her lactic acid. A CT scan by report showed mild acute pancreatitis and persistent main duct dilation, though they described it as being slightly more elevated or increased from prior scans five months prior. We did not have access to those scans, so we repeated our own, and this is what we got. So since we all read our own CAT scans now, what do you guys see? A big duct, right? And so she also got an MRI, and here we see the same thing, except what you'll note in the tail of the pancreas is that it's not quite dilated, and that will come into play a little bit later. And here's another picture. So what's the differential diagnosis in this scenario? It's a pretty short one. What do you guys think? Yeah, so that's what was resected, right, an MCN. So the question is whether they got the diagnosis right, correct? So what are you thinking? Yeah, a main duct IPMN, good. What else? Yeah, an asthmatic stricture, good. What else? Anything else you guys thinking of? So she's had recurrent bouts of pancreatitis. The question is also whether she has chronic pink, right? Maybe a stone, and then God forbid she have a pancreatic cancer that's causing duct obstruction. So that's our working diagnosis, our working differential. Now we need to maybe provide therapy. So what are our options? What's on your guys' short list? Good, good, and how would you get there? Yeah, and if it's a short enough limb, you'd ideally would prefer a 1T, right? So that's what we did, and she underwent an enteroscopy. You can see we got to what we thought was the end of her afferent limb and couldn't find squat. And so this is what we saw, and you can see on fluoroscopy that the scope is in a bit of a tenuous position, but also importantly in her erigigunogram, you could see that we didn't quite get to the end. All right, so now what? That didn't work. What would you do next? That was with the Peds colonoscope. That was with all the scopes. So what's next? What's the other way we can access the pancreatic duct in this scenario? EOS, right? All right, so I'm going to talk very briefly about EOS-guided pancreatic drainage. The indications to do this include unsuccessful access to the pancreatic duct, such as those patients with native anatomy, those with obstructed anatomy, for instance like a duodenal cancer or pancreatic cancer causing duodenal obstruction, and in our case altered surgical anatomy. The contraindications mostly are coagulopathy and thrombocytopenia, and so she did not have any of those contraindications, so we proceeded with EOS. In terms of how we think about it, there's an algorithm that came out in this review article very recently that I thought was particularly helpful. If they have native anatomy here, let's see if this works. All right, so if they have native anatomy, then obviously you want to try an ERCP, and if that doesn't work, then you would like to do some sort of EOS-guided therapy. And then the big question is where your guide wire goes. So if you can get your guide wire across the papilla, then you would consider some sort of rendezvous technique, and if you could not, then you would consider some sort of transluminal drainage. In our scenario, we have post-surgical anatomy, and I failed the enteroscopy-associated procedure, so we're going to go with the EOS-guided therapy, and again, what we do next is dictated by where our guide wire goes. So if we can get it across the papilla or the surgical anastomosis, then we would consider either the rendezvous or some sort of stenting, and if we could not, then we would consider some sort of transluminal drainage. So the steps of this EOS-guided procedure, you want pre-procedure antibiotics, rectal endomethsin, you want to be very aggressive with IV fluids, you want to review the imaging to make sure you have a good sense of what the pancreatic ductal anatomy is. Obviously, you're going to want to do this under fluoroscopy, and then the key is once you're in the procedure is to identify an appropriate puncture site, and then once you do access the pancreatic duct, you will obtain a pancreatogram, often with dilute contrast, so 50-50, and then the great limiting step is the guide wire manipulation, because you want it to go across whatever obstruction you have, but that may not always occur, and then ultimately you'd like to dilate the tract in which you started, and then place some sort of stent. In terms of technical things that you guys need to keep in mind and consider, ideally, the pancreatic duct would be dilated to four millimeters or greater. That would, like, that would increase the chances of success. In terms of the puncture site and orientation, these are both very important. You don't want to be too close to where your obstruction is, because that will hinder you, but you also don't want to be too far, because that will make things more difficult, so you have to find some sort of sweet spot, and then ideally you would orient the needle towards the stricture itself. That would give you the highest chance of you overcoming whatever obstruction is in your way. Guide wire manipulation, again, is the rate limiting step. You have multiple wires you can use. People use 035s, 025s, straight, angled, so you have a multitude of choices. The dilation of the tract can be performed either with mechanical dilators and or cautery. If you do use cautery, the recommendation is to use pure cut, not a blended current. Then, in terms of stents, you don't want your traditional pancreatic stents, which have fenestrations within the shaft of the stent. Instead, you want some sort of non-fenestrated plastic stent, and or you can use small caliber fully covered metal stents. All right, so let's talk in cartoon form how this would look, and we'll do this first in native anatomy, since this will probably be more common. In any case, you get the wire into your dilated pancreatic duct, the needle, I mean, and then you pass the wire, bypass your obstruction, and loop it into the small bowel. At that point, you would exchange and pull out your EOS scope, and instead pass a duodenoscope, grab the wire, and pull it back, and then run your instrument of choice over this wire. This is what it looks like in real life with fluoroscopy. Again, you want to orient your needle towards the whatever obstruction you have, and then at that point, you're going to run the wire. You'll bypass your obstruction. In this case, these were stones, and then loop it into the small bowel, exchange the scope, and then pass a duodenoscope to grab the wire, either with forceps or a snare or whatnot. And then at that point, you can manipulate the wire. You have it in place, and then ultimately, you'd like to provide some sort of therapy, in this case, a plastic stent. All right, but for our case, the more relevant cartoon is this one, because she has altered surgical anatomy. But the same principles apply here. So again, you pass the needle into the dilated duct and advance the wire towards the anastomosis or stricture, pass it into the small bowel, and then at that point, you would exchange and then use your scope of choice to go grab the wire and provide some sort of therapy. And so what happens, though, if you do not overcome the obstruction? So in that scenario, then you would likely perform transluminal drainage. So in this scenario, this time you don't get the wire across the stone. So what you would do instead is loop it in there to really anchor it in there, and then perform whatever dilation you can, and then advance the scope, the stent, and therefore you would be left with transluminal drainage. So in this case, you'd have a stent ending in the obstructed duct, but with one end into the stomach. And this is what it looks like under real fluoroscopy. Again, you have your angle of the needle pointed towards your obstruction. In this case, the wire gets stuck amongst all these stones. And so what they did was then do a tract dilation and then advance a stent and achieve transmural drainage. So, AOS-guided pancreatic drainage is not easy, and it's not for the faint of heart. Its technical success is pretty good in that it generally is listed somewhere in the mid-80s in terms of percentage, and the clinical success is very similar in the high 80s. However, the adverse event rate is fairly high. Most of the literature says somewhere it can be as high as 25%, but in this systematic review, it was listed as 18%. So the things that we would watch out for and be very wary of include abdominal pain, acute pancreatitis, peritonitis due to some sort of pancreatic duct leak, bleeding, hematoma, peripancreatic fluid collections, and perforation. So again, this is not an easy procedure. It's a varsity procedure, and there's a steep learning curve. Dr. Teiberg, who is not in the room, but you guys will meet or have met already probably in the hands-on course, but she wrote a paper in which she describes that the learning curve is pretty steep, and again, efficiency requires like 25-27 procedures or something like that, and that proficiency wouldn't be as high as 40 procedures. So clearly not easy and a challenge to learn. All right, so let's go back to our case. So again, this is this lady's MRI. So you can see where the point of axis for me is limited because the tail end of the pancreas does not have a dilated duct. So when we go by ultrasound, so what we see here is yes, there's a dilated duct. Here's the anastomosis, and then this is the jejunum. The duct here is 6 millimeters in diameter, and the maximum I could find was roughly 10 millimeters in choice. So this is where I am going to try to start my therapy. And then I just confirmed that the tail of the pancreas, the duct was pretty tiny. So in this scenario, about one and a half millimeters. So under fluoroscopy, you can see I have my scope here. This is what I'm looking at. My needle is, I hope you guys can see that, is right there. Again, it's angled towards the stricture itself. You can see we do a pancreatogram here, and initially, I'm a little worried because I'm awful close to the anastomosis. Thankfully though, what I see is a blush of contrast going through the stricture and into the small bowel. So I aimed my needle and the wire there, and then I'm able to loop a wire into there. Across the anastomosis, into the jejunum. And then at that point, I exchanged the scope and then advanced the colonoscope to this spot. You can see I've grabbed the wire, and I'm able to show some contrast. But this confirms what we saw earlier in the air jejunogram. There's a bit of distance between me and the anastomosis. And what this doesn't show you is that it was actually, the scope is torqued at a very funny angle so that while this looks like it's a straight shot, it's actually, the wire goes across and then goes down this cliff. And so I couldn't actually really see much. And so I did a lot of this in terms of trying to do a dilation purely under fluoro, and made the wire a bit tenuous. But I was able to get a five, five and a half French catheter across with some difficulty, but that was all I was able to get across. I couldn't get a balloon catheter to negotiate that bend. And I tried stenting, and as you can see, it goes, the stent goes off this cliff. But in trying to advance instruments, I ultimately lost the wire because the wire flipped back and out. And so rather than proceed, I just, because I was able to do at least a little itty-bitty dilation, I left her alone. So she mercifully tolerated the procedure very well and has been symptom-free for roughly a year. And so there was success. How much time do I have left? Okay, all right, so I'll just real quickly. So she did well. This is actually now questions geared to you guys, and I've asked the faculty at the first morning session. But after a year, she actually started developing symptoms again, and so she came back for a second EOS-guided procedure at the recommendation of our multidisciplinary pancreas conference. And unfortunately, I was not able to pass any instruments, any mechanical instruments, like a mechanical dilator or balloon catheter, across the transgastric tract into the pancreas. And so I ended up losing wire there again, and so we are, thankfully, she's back to being asymptomatic, but her symptoms are starting to come back. So what would you guys recommend for her now? Yeah, except, like I just said, I couldn't get any instruments into the duct. So the big question is, how do I get into the pancreas? Mo, do you have any suggestions? I could use some. So I haven't done anything yet because the patient is still pretty asymptomatic. She did meet with surgeons who, our surgeons said that this would require a total pancreatectomy. I think another outside hospital also said the same. I think the limitation being that her duct is not dilated all the way out to the tail, so there's not a lot of real estate to work with. We had a similar case just a couple weeks ago where we didn't have to resort to this, but like we went all the way to the PJ and asthma. So it was like a stricture that was concerning. And as a backup, we thought of using like a secretin test. So basically try to stimulate pancreatic juice like during the procedure to see if you can see potentially an opening. Especially like when they're not having active pancreatitis because then like, you know, you're hopefully not going to invoke acute pancreatitis with a secretin simulation, but that's like one possibility. It's like just trying again and see where maybe on floor where you think the PJ might be and then secretly hope something comes out. Yeah, the only limitation is I can't get around that part of it. You can't get around that part of it. That's a good thought. Yeah, you know, the only thing I don't understand about the case is why there's segmental dilation. You know, usually a mechanical PJ and asthmatic stricture you see dilation throughout the entire duct. And so, you know, I think that's the only, I think that's the only concern for me is why would the tail necessarily be spared? That's a good question. You asked it twice and don't see anything sinister, but I totally agree. I mean, it may be that I have to wait for that tail duct to blow out. I don't know. I think I have time. Anyways, Chris? Yeah, I remember fondly. Would you guys use heat? Like there was a suggestion at the last session to sacrifice a Axios and drill your way in. Well, not right now, but like if push came to shove, would you? Yeah, that would require a lot of counseling and hand-holding, and she'd have to be comfortable with that. Yep. That was suggested as well. Yes. The short answer is yes. The long answer is it would be such a royal pain at our hospital that I would almost rather do anything else. Yeah, that's a good thought too. The only other thing I thought of was maybe I'd have to use a double balloon or some sort of balloon, but then my choice of instruments really drastically gets limited. So I don't know. All right. If I come back next year, I'll tell you what happened. All right. Thanks.

endoscopic ultrasound

pancreatic drainage

Whipple procedure

EUS-guided intervention

pancreatic disorders

complications