Any questions to either Mark or Rich? Yes. I have a question. How do you choose the size of the grain when you're doing the dilation-assisted stone extraction? So let's say, if you're right, that you have a 7mm dot, and then a 15mm stone with a 15mm proximal dilation of the dot. So how would you choose your size of dilating bloom there? Yeah, it's a good question. So number one, if you have a stone towards the bottom in the terminal bile duct, what I do is I put the dilating balloon in, partially inflate, and then I push the stone up a little bit so that you're not dilating alongside the stone, so that you don't cause either a shelf, an embedded stone, or a defect in the terminal bile duct. And you really have to see whether the bottom narrowing is the inter-sphincteric segment, or whether it's actually distal bile duct that the stone has settled, or like a stricture that the stone has settled above. But in your scenario, if the distal bile duct is 7mm, I think that you could go 8 or 10mm, depending on how it looks, and if you have a waistline, etc. But you don't want to use the same dilating balloon for every duct. So you don't want to do a 10 through 12 CRE balloon for every single DACE that you do, because that will probably get you in trouble. The other thing I would add is you would more than likely intervene on the stone first to break it into something more reasonable, which would avoid problems. In that scenario, then you could dilate, as mentioned, with a little more chance of success. The other question I had is, where do you put the golf procedure relative to needle knife when you're trying to decide what to do in terms of cannulation, or facilitate biliary cannulation? What is the golf procedure? Like the trans-pancreatic septotomy? I think that's kind of a dealer's choice. Number one, I don't do two guide wire cannulations. If I am in the pancreas, I'm leaving a pancreatic duct stent in. And so in that situation, if I'm still having trouble getting in the bile duct, if there's a reasonable intraduodenal segment of the ampula or of the biliary duct, then I just do a needle knife over the protective pancreatic duct stent. And that tends to be better for me. Different people do it different ways, and that's been well described. I very rarely do the trans-pancreatic sphincterotomy to get into the bile duct. But at the same time, I'm usually putting protective pancreatic duct stents in early if I'm spending much time in the pancreas and I don't want to. Good questions. Keep them coming. What else do you guys have in mind? I'll ask you guys. Go ahead, David. I had one more question. So we do double wire, and we do put a pancreatic duct stent, but we put it after we've done all the biliary interventions. But do you usually—I mean, it sounds like you try and put the pancreatic duct stent, and then you try it, and then you reattempt biliary cannulation. It just seems like sometimes the pancreatic stent falls out, but it may be my own manipulation of the scope. Good question. So I always put a pancreatic duct stent that's small in caliber. So usually if I'm using a 025 wire, a 4 French stent that does not have an internal flap, that goes beyond the genu of the pancreas, because I don't want the pancreas stent to go up and cause trouble at the genu. That generally gives you enough leeway to do what you need to do at the bile duct. If you do an adequate biliary sphincterotomy, you can generally sweep and do what you want to do without having the pancreatic duct stent removed. If in the very rare circumstance that you're not able to get beyond the genu or there's a stricture or there's something else, then sometimes I will leave an internal flap in to prevent it from coming back, or I'll put the stent in at the end of the case. Great questions. To the faculty here, Rich, Mark, probably, and Mary, what do you guys think? You know, we have a wonderful cohort. They're very skilled, but now also training at high-caliber centers. They'll be on their own here in a year or two. As far as the risk-taking part of this, because you'll face these complex cases, sometimes from day one, depending on where you are, what words of wisdom or advice do you have in terms of tackling a case of this type without a lot of support in terms of expertise in managing either on the surgical side, on the interventional radiology side, or maybe colleagues who do interventional endoscopy as well? I think we heard several questions in the morning during the hands-on session, like when should I get into this or should I wait a year or two or should I maybe not do this at all and refer? And this is something we'll come up probably later today with the next round of talks about interventional EUS, but you can potentially get in trouble from these, right? I mean, you can really cause a lot of harm if you don't know, if you don't have a strategy to manage what you got yourself into in the first place. So sometimes not doing something you can't finish or not starting that is probably better than getting halfway through and getting stuck and not having a backup strategy. This is more of a high-level theoretical kind of conversation or discussion, but I'm interested in your thoughts next few minutes on what would be the threshold to get into that. Do you wait for yourself to have gotten through some cases? What level of support you might need and what would you look for before you tackle your first rendezvous, for example, or integrate pancreatic stenting if you're on your own out there? Rick, do you want to take a stab at this? Sure. I mean, I think it depends on the procedure, what you're talking about. My first bit of advice to every fellow is to go to, your first job should be somewhere where you have senior mentorship. It's helpful from a career standpoint, but it's really helpful for these challenging cases to have someone around who has seen the ropes and can walk you through it and sort of tell you when enough is enough and whatnot. So that would be my first piece of advice. Don't go somewhere straight out of this fellowship where you're the guy or the girl or the woman because it just would make your life harder. But I think in certain scenarios, I think you can quote-unquote practice during the course of your fourth year or at least be exposed to it. Like the case that Dr. Gromsky mentioned about the impacted stone, my first thought always is to let the fourth year do a needle knife so that they can practice it in a very controlled environment rather than some stressful, like I can't get into the duct and this guy's cholangitic and on pressers sort of scenario. Hopefully over the course of your fourth year, I'm sure you're going to see all of these challenging cases, and it's really important even if you're not hands-on with the scope that you're actively engaged in the procedure, like thinking about, well, why is Dr. Lennon doing this? Why is Dr. Gromsky doing that? Why, you know, which wire and why, and this, that sort of stuff. And as long as you are able to glean lessons from this, I think, and you don't have some, like, god-awful god complex, like when you're out in the real world, like I think my guess is you will be fine. You guys are all at super fine institutions and going to be super well-trained. So that would be the big thing. And then at some point, you know, like you can never hurt someone, almost never hurt someone by, like, pulling back and coming back another day to get into whatever duct you want, but you can certainly do a boatload of damage just trying to keep going and going and going, you know, especially, like, the later on in the evening you go and, you know, like everyone's... At some point, you guys should pay attention to when your attendings say enough is enough and maybe do it a little earlier, early in your career, and then as you get more skills and more experience, then you can sort of push it longer and longer. Thanks, Rich. Dr. Lennon. I just have a few comments. One is I would echo very strongly what Rich said about being in a great place where you've got support. So when your future depends on your reputation, so I'm sure you all know who are good doctors that you go to, and it's based on their reputation, it's extremely easy to lose your reputation by making the wrong decision and having your patient spend two or three weeks in the ICU or have a worse outcome. When you're training, remember, you may see people doing poem and stuff like that and it looks really easy and you do it when they're standing directly behind you. Just when you're going out in your first year, be sensible about what you do, and I think one of the most important things about a good doctor is recognising what you can actually do and being reasonable about what you do. If it's a highly complex procedure and you've never done it, don't do it on 3 a.m. in the OR with no support. If you're going to do something for the first time, do it during the weekday with somebody beside you who can step in and help you if you need to. I would just say be careful and then take it easy in your first year. It's not a sign. I think the best doctors are the people who can raise their hands and say, you know what, actually maybe I could do this, but I think the best thing for you is actually I'm going to refer you on. It's a sign of maturity. Great conversation. Yeah, one comment I would make is forge positive relationships with your surgeons as well. And along the same lines, especially when you start, talk with them early and often about a plan. If you think it's kind of an out-there type of plan. The pancreatic rendezvous is not like a month one in attendingship case certainly, but that's certainly an option to strive to. But what you don't want is you don't want, as you mentioned, in month one, month three, month five of your starting, you don't want people, particularly that aren't in your department, to say, did you hear what happened? This, that, and the other thing. Did you see what this cowboy or cowgirl is doing? And so I would say that I completely echo those comments. Now, with that being said, it is a good opportunity, particularly if you're in a setting where you have senior mentors by your side, to buddy up in a case with a senior person. And so, you know, to basically, you run the whole show, but you're both in the room and basically they're only making a comment if they disagree with a management. And so the tough job is the job where you're the only person there. And then the important thing is to forge a good relationship with other resources in your area to run something by them. Do you think, what do you think about this? Do you, should I refer to you, et cetera? Because reputation is very important in this field. One more question. I was just going to ask, you know, with a lot of these things, they're not necessarily FDA approved. So in the consent process with the patient, like how do you approach it? Because I'm sometimes afraid, like if I tell them too much, I'm going to scare them. But at the same time, I want them to be aware that what we're doing isn't necessarily conventional and does have its risks. Who wants to take that? Actually, I would first make a comment on the previous question as well. One additional comment I would make, apart from everything that was discussed, is early on, I don't think we know all about the scopes, equipment compatibility, wires, everything that's out there. So it's hard to come up with plan A, B, C. If A is not working, then you switch to plan B. If you're switching the scopes, what are the compatible equipment? What else needs to happen? So I think it takes some time. Pancreatic rendezvous, antigrade, it's an extremely rare procedure to come by, even in high volume centers. I did a total of two last year. So that's why there's not enough literature. So if you go type, try to find literature on this. There are just case series, five cases, three cases, four, 20 cases was the largest one. So this is extremely rare, and therefore, for multiple reasons, it's something that you reserve after you have become really comfortable with. You know all the tools that are made by different device companies, what the compatibilities are, and you know what the different steps are. If A doesn't work, then you can switch to B, C. For example, Axios was brought up as a device to gain access. I've done that on one case. But, you know, that takes, again, some time to think about it or know about these troubleshooting tips and tricks. So have that plan, I think, early on. A senior person is a good idea. So to answer your question about FDA, most of the procedures that we do and the devices that we utilize, they are not FDA approved. Do I always make it a point to address this with the patient? I actually don't. But I do make it a point, especially if I'm doing an interventional procedure, try to sit down. If I have the option, they're not in the hospital, and it's an outpatient in an office setting where they are there and the family is there and discuss all the alternatives. This is endoscopic. This is what will happen. This is what I can probably encounter during the endoscopic procedure. These are the alternatives if there's IR or surgery. Have them see a surgeon if that is an alternative so they are fully informed. But when they are in the hospital setting, I also make sure that they have had the discussion with the alternative. So surgeons have seen them, they have had an IR consult, and then they come down, and it's my bit to discuss it with them. So, yeah. Well, I'm sure we'll have more of these conversations at the end of next session. For now, we'll have a 22-minute break. We'll come back at 3 o'clock. Thank you again so much. Thank you.

dilation-assisted stone extraction

biliary cannulation

medical training

patient consent

non-FDA-approved equipment