I would like to introduce the next speaker, Dr. Mark Gromsky. Mark will present to us – he's Associate Professor of Medicine and also Director of Advanced Endoscopy, very well-versed in many things, including ERCP, but also bariatric endoscopy. So, although the focus of his talk will be tricks and tips for you guys on ERCP, Mark, thank you for joining us. Thanks so much, Mo. Appreciate the invitation. We had a great group at lunch. Ken Cheng and I talked with a group of you, and a lot of the discussion was about, you know, your first job next year and what to expect, how to think about starting, et cetera. And so, that's kind of the focus around this talk as well, is what are some of the key takeaways that you guys can take from this year for when you start and you're independent on your own doing ERCP in just nine months, maybe you can fall back on and think of. I'm a strong proponent of a one-year advanced fellowship. You should be very, not only proficient, but towards expert level at the end of your one year in both ERCP and EUS, because the vast majority of advanced endoscopy jobs, that'll be the vast majority of the procedures. These are my disclosures here. I'm from Indiana, and so is this guy, David Letterman. He was born and raised in Indianapolis, and he was known for having a top 10 list every episode. I don't know if anybody remembers this show, so I'm going to try and emulate him with this talk here. So number 10 on the top 10 list is you should have a very clear indication for ERCP. So the number one, probably the number one reason for a lawsuit and for a one lawsuit by the patient against an advanced endoscopy doctor is in ERCP and not necessarily having a clear indication where you have a bad complication. And so these days we have pretty clear guidelines on when there's an indication for ERCP, and just know those indications inside and out. And there are some roadblocks you can get. Sometimes referring doctors will refer patients to you, pushing for an ERCP, or even a radiologist suggesting an ERCP, even though they haven't seen the patient. Some of those common ones are suspected biliary pancreatitis, but they're in a low or a moderate risk of colodocal lithiasis. Another roadblock is potential functional biliary type pain without any other evidence of a need for an ERCP. And so just keep that in mind. Number nine is going off of what Dr. Dragunov said, becoming an expert in interpreting pancreatic biliary images. This year and for the rest of your life, before you do every ERCP procedure, I would highly recommend that you review all of the images yourself, whether that's a CT scan, an MRI, or an endoscopic ultrasound. The reason being is that, like Dr. Dragunov said, you will be better than many of the referring or local radiologists in interpreting these images. You just have to put yourself into the position of being the radiologist that's reading all the scans from the emergency room, from looking for a stroke to looking for a left pinky fracture to looking for, you know, pneumonia, et cetera. And you're looking at pancreatic biliary endoscopy or images every day in your career. You will get very good and you need to be an expert in reading these scans yourself. Number eight is having a great working knowledge of the tools in your endoscopy lab. And so it's pretty easy now when you're attending is suggesting a certain tool or your nurse is handing you a certain tool that they think is going to be right. But next year, you'll probably be working on Thanksgiving. You'll probably have three ERCPs that you'll need to do and the tech or the nurse working is probably the lowest on the totem pole. And so you need to know that, you know, that a stent can't be pushed with that tool or, you know, this device will not fit, et cetera. And so I recommend taking a tour of the cabinets in your ERCP or in your endoscopy suite and looking at the tools and every time that you're and have a working relationship with your technician and have them remind you of what the catheter French is and what how big the balloon goes to, how many tour the pressure of the dilation balloon needs to go to, et cetera. Because ultimately you're responsible for what you put in the patient's body. Also, secondly, you know, for post-surgical anatomy and for instance, post-whipple patients, not all of the tools will go down a pediatric colonoscope if you need a colonoscope to get to the biliary anastomosis, et cetera. And so that's very helpful to know ahead of time. Number seven on the top 10 is use liberally dilation-assisted stone extraction. And so the number one indication across the United States for ERCP is a common bile duct stone removal. And so this is very helpful when you have a stone that's not tiny but not super huge, which a lot of the stones are, if the biliary orifice is in a diverticulum, et cetera. And you do a moderate-sized biliary sphincterotomy and then you do a liberal dilation of that biliary orifice to just at or above the diameter of the distal bile duct. And many of the stones that you think going in you may need lithotripsy for, you'll find will come out after you do this quick and easy procedure. And also, even if you have to do lithotripsy, the fragments will come out easier as well. And so you'll find that this will be a great friend of yours. Number six on the list is that the needle knife is your friend. It's a friend that you need to respect, but it's a very, very useful tool. And by the end of this year, you should be proficient in the use of the needle knife for biliary access in particular. For instance, this is what I call a birthing stone with a stone that's coming out of the biliary orifice. This is a perfect case where actually the initial cannulation approach should probably be using a needle knife just to do a five or six millimeter sphincterotomy over that stone. It'll fall out and the pus or the bile will come flowing afterwards. It'll be very easy to get into. One of the problems is if you don't feel comfortable using the needle knife with somebody over your shoulder, when you go into practice and you don't have that person every case, you won't get into the habit of using it routinely and then it'll be out of your toolbox. It's really essential for rescue cannulation attempts, but also it's been proven in good studies to be a relatively low risk approach to primary biliary cannulation as well. Number five on the list is indeterminate biliary strictures more is more. So my philosophy is, you know, traditionally the policy cellular nature of cholangiocarcinoma and hyaluronic strictures, et cetera, has led to low performance of intraductal sampling. And so when I'm getting a patient where I see on the imaging that I suspect this will be a biliary hyaluronic type of stricture or something that looks like a cholangiocarcinoma or a gallbladder cancer, up front I do multimodal therapy. So I'll start with an endoscopic ultrasound, I'll look for any liver mets, I'll look for any lymph nodes that I may be able to biopsy with FNA, FNB. On the first case, I don't generally go for a biliary tumor that's near the hilum or near the liver for seeding cases, but lymph node or metastasis, that's a good option. If there's nothing on onsite there that's helpful to you, then I go in with cytology brush, fluorescence in situ hybridization, I do intraductal fluoroscopy guided biopsies, and oftentimes on the first case, I'll do cholangioscopy with spy bites as well. The reason being is you don't want to delay that patient getting to see surgery, getting to see oncology, getting on chemotherapy, getting on immunotherapy. Because we know that by the time that we get the biopsies back, by the time we interpret the biopsies, by the time we talk to the patient, by the time that we get them back in for another ERCP for a lack of getting a clear diagnosis, that can be four, six, eight weeks sometimes. For that reason, I go big up front on these cases. Number four of the top 10 list is things will go wrong, unfortunately things happen, right? We can do things in the best possible way and things happen. You should practice what you're going to do when that does happen. So at some point in your career, you'll encounter a pancreatic duct stent that's been migrated up into the duct. At some point in your career, somebody will refer you a patient where they put an uncovered metal stent in a benign biliary stricture. At some point in your career, you're going to have a sphincterotomy and everything turns red. At some point in your career, there's going to be a hole from a perforation. At some point, you'll have a basket that's around a stone and you can't get it out. All of these have endoscopic options. You can salvage these, the patient will do fine, but you need to have a game plan going into it of what every step is going to be and you'll improve their patient's outcomes and you'll prevent needing these patients to go to surgery. There's more than one way to cannulate a bile duct. This is just kind of a three-dimensional view of an ampulla here. You could achieve biliary access in many, many different ways here. You could do kind of the most popular guidewire-first cannulation. You could do cannula-based cannulation. You could do a pre-cut sphincterotomy with a needle knife. You could do a pre-cut fistulotomy from the top down. There's a lot of different ways to go here. Once you get very comfortable, if you're not getting in in the initial few times despite being lined up very well and thinking you're doing things right, don't be afraid to mix things up. Also, don't be afraid to manipulate your tools to get into where you want to go. Sometimes you'll have a diverticulum and it looks like you need to go directly to the left. Well, you can do that. Sometimes you just take a catheter and you use your fingernail and you turn it to the left a little bit and then it'll drive you right in. And so just think outside the box sometimes and oftentimes something that looks like a difficult cannulation you can almost always get in. Number two, appreciate the incredible value of mentors. I've been very fortunate to have a number of really good mentors and that's important. That's what takes you to the next step in your career, to the next step technically. One thing I like to say is that you tend to make yourself close to these mentors because there's something drawing you to them. What I would encourage you is make sure that they're technically excellent. Make sure that they're academically excellent, but also make sure that their character is excellent because that oftentimes what I've found is the people in medicine that have the strongest character are the happiest in their life, but they're also the ones that are going to look out for you in the long run. And so that's a word of advice about mentorship. And then finally, number one on the list is support your team because they will support you. So advanced endoscopy is a team sport. For instance, at our institution every morning at 7.30, everybody, all the docs get together, the charge nurse gets together, the research lead gets together, the APP gets together and we go through every patient and we say what the position will be, what the anesthesia will be, if there's any special tools we need, if they're a research candidate, et cetera. That gets everybody on the same page. They have a clear expectation of what they need to do for that day and they feel like they're a team. And so I think it's a very important point to make that the job of your team should be something that they want to go to every day and the job that you go to is something that you want to be in every day. Because if you have that mutual respect, when dirt hits the road and you need them to do something very quickly, you know, and follow your lead, they'll do it every time. And so that's all that I have, Mo. I have finished one minute ahead of time. And so list of my top ten tips here. I'm happy to take any questions. And thanks everybody for being at this excellent course. Appreciate it.

advanced endoscopy

ERCP tips

biliary access

dilation-assisted extraction

cannulation techniques