All right, wonderful. Thank you. So, the next fellow that's going to be presenting to us is Grace Kim from UChicago. As you can see, my video is literally 7 minutes and 59 seconds, so I'm just going to get started right away. Oh, do I start it? Oh, okay. How do I? Oh, there we go. Okay. So, a rendezvous approach for ampullary access. This is our group's disclosures. ERCP is one of the most commonly performed procedures for endoscopic biliary drainage. The successful ERCP requires identification and cannulation of the biliary orifice to achieve biliary access to the biliary tree for therapeutic intervention. In a normal anatomy, the biliary orifice is located at the ampulla of water, but in other circumstances such as post-surgical anatomy or patients with duodenal strictures, the ampulla or the biliary anastomosis may not be easily accessed. And in these patients, alternative methods may be required to achieve biliary access. So, we had a patient who initially presented at another hospital, 49-year-old man with painless jaundice. He has a history of recurrent acute pancreatitis of unclear etiology despite getting his gallbladder taken out, and he also has Crohn's enterocolitis with severe duodenal stricture that required resection about four years ago. His op report noted this duodenal stricture in the transverse duodenum, and approximately five centimeters of the duodenum was resected, but there's no mention of the ampulla or its relationship to the resection or the stricture. But since surgery, the patient has been doing well from Crohn's perspective in remission on vedolizumab. So, he undergoes his workup at the other hospital for his painless jaundice, MRCP showing this pancreatic head mass with biliary dilation. He undergoes endoscopy, which noted this small diverticular opening in the duodenal bulb, but otherwise normal, and then he underwent EUS fine needle biopsy of the pancreatic head mass, which showed this chronic inflammation and fibrosis. He underwent ERCP at the other hospital, but it was unsuccessful because they just could not find the ampulla, and his bilirubin kept on rising from 7 to 12, so he got transferred to our facility for further management. So, we underwent, or he underwent repeat endoscopy, and on our index endoscopy, we noted this duodenal enterostomy anastomosis, very patent, healthy appearing, just distal to the pylorus, and when at the level of the anastomosis, if you looked at the 10 o'clock, you could see this circular opening, and we didn't really know if this was a fistula or a diverticulum or a stricture, but we did spend a significant amount of time trying to find this ampulla. We just could not. We used both a forward-viewing scope as well as a side-viewing duodenal scope, and we just could not find it, so we speculated that the ampulla was probably distal to the circular defect, and we opted to do an EUS rendezvous for biliary access. So, before we did that, we also repeated the fine needle biopsy of the pancreatic head mass, and again, in our center, it again showed chronic inflammation with fibrosis, so we felt comfortable saying that the MRCP, noting that pancreatic head mass was probably from chronic pancreatitis and not from a malignancy standpoint. So, after we did the EUSFMB, we found the segment 3 of the liver. We punctured it with a 19-gauge needle, aspirated bile, injected contrast to get the cholangiogram, put the guide wire down, and you can see it coiling in the small bowel as depicted in the arrow, but again, on the endoscopic view, we could not find this wire, and we used both forward-viewing scope and a side-viewing scope, and our fluoroscopic image did not match our endoscopic image, so we felt that there was some sort of altered anatomy behind what we could see. So, at that point, we decided to abort the procedure and send the patient for an external internal percutaneous biliary drain for biliary decompression, and as you can see here, the internal portion of the percutaneous biliary drain is coiling at a very similar vicinity as the coiled wire from our prior rendezvous attempt as well. So, third time's the charm. We do the third endoscopy for the patient, and when we first do it, we look at it under the fluoroscopy, and we can see that the internal tip is at the level of where the circular defect is, so we're pretty comfortable that that circular defect is likely a stricture. We dilated it to 12 millimeters, and then when we went past that, the first stricture, I actually saw a second stricture, as you can see, at 2 o'clock, so then I fed another wire through that hole, and then under fluoro, we could see the wire coiling in the at the where the internal portion of the biliary drain was, as you can see here. So, then we dilated that area up to 10 millimeters, and then after that, we could see on endoscopic view the actual, the PERC biliary drain coming out of the ampulla, so then we could establish that his anatomy was actually this, where he had two strictures, and then the ampulla just took to that. And then we've fed the guide wire through the external portion of the drain. We took out the gastroscope, inserted a therapeutic scope so we can deploy a temporary, fully covered 10 millimeter by 4 centimeter stent across both of the duodenal strictures so that we can maintain a tract, and we can visualize a PERC drain better. And then we took out the therapeutic scope, inserted an XP scope so I could actually go through the metal stent, and then we can see the PERC drain much, much better now. We used the pediatric forceps to grab the PERC drain out into the duodenal lumen, and then I grabbed the wire and then pulled it out of the mouth. So now we have the wire secured from the oral side as well as the external side, and then I pulled the PERC biliary drain out, and then from the oral side of the wire, we fed the 9 to 12 balloon catheter through to get an occlusion cholangiogram, and you can see this diffusely dilated biliary tree, and then at the distal end of the main bile duct, we had a stricture there as well. So in order to stent that, we put in an XP scope back in, and then we pulled the previously placed temporary metal stent out of the duodenal strictures, and then we fed in a 10 millimeter by 8 centimeter fully covered metal stent through the oral wire, and then we had the XP scope coming next to it, so we have an endoscopic view as well. And then we deployed the fully covered metal stent across all the strictures. So you can see it getting deployed into the biliary stricture, and then we actually had it deployed through both of the duodenal strictures as well, and you can see the contrast flowing really nicely, and then on an endoscopic view, you can see the bile draining very nicely as well. So on a follow-up, the patient did great, his bili is now normal, and he's completely asymptomatic from this standpoint as well. So this is the end of the fluoro. So our video highlights the importance of having a multidisciplinary approach for biliary drainage in a patient with altered anatomy, and if possible, it's really important to review the previous op report, although sometimes it's not always helpful. And if the anatomy is unclear, it's best to stop the procedure and gather more information before trying a subsequent therapy. EOS-guided and percutaneous biliary access is very useful in delineating where the ampulla is, and for our specific case, once we saw the percutane coming out of the ampulla, we could be a lot more aggressive with our measures, dilating the strictures and putting the stent in as well. And currently, the patient is undergoing workup for the etiology of his duodenal strictures, whether that's post-surgical anastomotic stricture, or if it's a recurrent stricturing duodenal enteritis. So he's getting workup with our IBD team at the moment regarding that. So in conclusion, it's very important to have a multidisciplinary approach, and multi-modality therapy is warranted and safe and feasible in our patients with altered anatomy. Our video highlights the upper endoscopy with dilation, off-label stent placement for duodenal strictures, EOS-guided biliary access, as well as a percutaneous biliary access and drainage via IR, and then finally, ultimately, a very successful ERCP with stent placement. So it's very important to have a step-wise approach for our patients to provide the best outcomes for our patients. Thank you. Wonderful job. Thank you. Any questions, clarifications, or feedback from the faculty? With the stent-to-pure wound? Sorry? With the stent-to-pure wound that won't cover, won't stent? Uh-huh. When do you think it will? Oh, we said in three to six months we're going to repeat the ERCP and reassess the biliary stricture. Okay. Thank you.

biliary access

multidisciplinary approach

EUS-guided

duodenal strictures

anatomical changes