from the Oregon Clinic in Portland, and she's going to be discussing cannulation and sphincterotomy techniques. Hi, everyone. Thank you so much for coming, and thanks to Uzma for inviting me. I know everyone keeps thanking the faculty for their time and everything, but it's actually really so much fun to come to these, and I enjoy every time I get to come. And on that same note, I always tell residents that rotate through with us that ERCP is the most fun you'll have in the GI tract. It is truly a fun procedure and so satisfying, and it can also be the most devastating procedure because if you don't get in. And so cannulation, of course, is the first hurdle, and hopefully we can learn some things. I think cannulating as the endoscopist, time is moving so slowly for you, when in reality, 30 minutes may have passed. And I know that for those of you who are holding the tome, time is moving very, very slowly because you look at like, when are we going to do something different or try something different? And so if you're on that end of it, cannulation can be very frustrating because you just think, you know, you got to do something different because you're not getting in. I think, you know, for me, I am always happy to listen to the other people in the room because maybe they're seeing something I don't. And hopefully, you know, if you're seeing somebody struggling, hopefully they'll be open to, you know, anything that you have to say, like, you know, could you do this or that? The other day I did a redo. Somebody had failed the day before, and then it came to me to try, and they already had a pancreatic stent in, which always makes things a little bit challenging to get in there. And we played for a little bit. And then the x-ray tech was like, why don't you just stick a little bit of wire out and see what happens, which I normally don't do. And it went right in. And I was like, Jason, you just ended our potentially long day here. So it was nice. So anyway, I have no disclosures. Biliary accumulation, as I mentioned, you know, it's the initial hurdle of ERCP. It's really not the only hurdle, obviously. And I think sometimes we are so happy to get in that we sort of just forget that, you know, there's a lot more work to be done in a lot of cases and definitely want to finish up the job. Like trying to get pregnant, this is a pass-fail situation. You're not a little bit ever, you're either in or you're not in. And so it's a stressful thing. And if cannulation is failing, you know, some things should be going through your mind, both as the endoscopist and I think as a tech, you know, what can you change? Because keep doing the same thing over and over for an hour is going to cause injury and not result in success, rarely, if ever. So really, what can you change? And when should you change it? No, when should you change things up? And really, how badly do you need to get in? Stopping and making yourself stop is the hardest thing in the world. And for those of us who do ERCP, we know this. For those of you standing there, like, please stop. Like, just accept it. It's not going to happen today. But really, I think sometimes, considering could I stop and come back tomorrow? Is this an emergent situation? Of course, this patient has pus coming out of their bile duct, so pretty emergent situation. But otherwise, maybe could stop and come back the next day. Equipment, some other people have talked about equipment. Just one thing is that it's really not as important as the endoscopist. I think, you know, we always think about, well, I don't like this tome or that tome. But really, you know, if you're decent at it, pretty much any equipment is going to be fine. There are variations of these. This, of course, is a sphincter tome, and you can bow it, which is nice. These come in kind of various designs, and some of them have a tapered tip, so they're more narrow and maybe can help with a really tiny opening. This is actually Uzma's slide from a previous talk. But I like it because it talks about all the different ways that we can cannulate. And I'll talk a little bit about the wire-guided in a minute, but most of us, I think, use wire-guided cannulation. Okay, these days, instead of just sticking it in there and shooting some contrast, all right, the odds of getting in are much higher with wire-guided versus just contrast, and the chances of pancreatitis are much lower. So using wire-guided cannulation actually came around during my tenure of ERCP, which means that I'm pretty old, but it's far superior than just using contrast. And that's not to say that if you're struggling to get in, shooting a little contrast may help you, and so that's a thing that we can do. That's something different. Guide wires come in different sizes and shorter, long. I think we've discussed that. I personally use short, but definitely trained on long, so I can do both. We typically just use the long wire if we're going to do a spyglass because it's just a little easier with the exchanges, and then you do have some angled wires that are options. Endoscope position is really the key first step, and I think especially when we're training, we're so such in a hurry to start cannulating and get in that we maybe start with a suboptimal position, and you really don't want it to be off to the side where your angle's going to be going the wrong way. You want to take a little time and mess with your little dial, right? Once you're in front of it, the small dial moves you to the left or the right and kind of torques the end of the scope for you so that you can get the papilla sort of in the middle of the screen, okay, not off to the side. And some anatomy, of course, is challenging, and it'll be a little bit skewed just because of patient factors, but you really want to be aiming upwards and not straight in, which is almost guaranteed to get you in the pancreas. So take a little time to fiddle with that. And again, positioning, you want to stay kind of close to the papilla. You don't want to be really far away because then it's really hard to aim the thing, so your big knob, of course, is going to move you in and out of the papilla and, of course, endoscope position, just trying to be in a good stable position. If you look at a target here, you want to be in that black region, the left upper outer corner of the papilla is where the bile duct is going to be, and obviously it's one tiny little orifice. How do you make it be over there? Okay, once you're in, all right, you want to, and I'll show this on a different slide, sort of torque yourself pointing up into that position over there, 11 o'clock on a clock if you like clock faces. I never like these directions. You know, it's at 4 o'clock because then I got to think, wait, where's 4 o'clock? That's not an intuitive thing to me, but everyone says, you know, 11 o'clock is where the bile duct will be. I found these figures on someone else's talk, and they're sort of like, it's like GI porn of something. I don't know, they're really explicit GI images here. It's kind of the weirdest thing, but I thought they were nice. Is this the pointer, this top one? Okay, do I just point it? Which one do I point it? Oh, here, oh, yeah, I'm all over the place. So this is just, you know, obviously a cross-sectional view, and I just want to show, you know, where you're at if you're in the papilla, and then there's a septum right in front of you, okay? And so if you bow up, you can sort of end up in the bile duct hopefully, and if you bow down, you're in that, but this is a technique that some people use, the lift and hook, okay? So they have this here, and then they pull the endoscope back to sort of pull this apart, okay, and then get themselves in. If you bow up too much, and you're fishing with your wire, and it's not going in, you may be in this situation, or you may just be hitting the septum. Just kind of a representation of what might be going on in there when you're fishing with the wire. What are you hitting? Why is it not going in? What are you hitting? Probably the septum, you've got to bowed up too much. So those are, we'll take away the porn. All papilla are not created equally, okay? I think that second one there, I'm always dismayed when I get down, when I drive down, it's always sort of like, you know, I think Uzma's talk, talked about papilla are like a box of chocolates, you never know what you're gonna get, and I'm always sort of curious, I'm driving down there, like what's this thing gonna look like? You know, and you love it when it's this big gaping orifice with bile coming out of it, but it seems like a little gift, and just rarely do, but this is considered to be normal papillary anatomy. This is the small or stenotic papilla, opening is less than three millimeters. This is a pendulous where it's hanging down, I kind of like these because there's a lot of room to cut, and then this is kind of the ridged one, and these odds ratios are odds of a failed cannulation versus a normal anatomy, okay? So you can see these small papilla is quite more likely, they're nine times more likely to have a failed cannulation with just standard techniques, so can be, you know, the anatomy can definitely play against you, and I'll talk about duodenal diverticuli here in a minute, which are also, can be challenging. So talking a little bit more about wire-guided cannulation, okay, there are a couple of options, touch versus no touch, really nice description there, but touching it is engaging the papilla, and I'll show you a video in a minute, not just sticking it in there, but seeing it go in, okay? And it's a feel thing, but it is also a visual thing, and really, until you get it engaged, it's gonna be very hard to get in, okay? And so you really wanna make sure, first of all, you're aiming well, but once you see it go in, you're like, all right, I'm gonna be in something here, it may not be the bile duct, but I'm gonna be in something once you get that papilla engaged. The no touch technique is to not touch the papilla with the cannula, but fish with the wire only, so you have wire out, and you're just sort of poking at the orifice, and my issue with this is that really, the wire is floppy, and it's really not strong enough to go through all those folds. I mean, this is not just an open pipe. These are folds of tissue, and you're sort of trying to maneuver a floppy thing through folds of tissue, outside of my case that my x-ray tech saved when I did do that technique. And there's actually data on this. The touch technique resulted in substantially more successful cannulation than the no touch. I have one partner who I know that he just does with the wire, and he does have a few failed, and in private practice, you're so rarely watching each other's scope, but sometimes I'll go in and help, and I see this, and this is just how he was taught, is to don't touch the papilla, like you'll give somebody pancreatitis, but what gives people pancreatitis are messing with the papilla for too long, because you can't get in, so just try and get that cannulatome seated in there. Now this video, and I'll confess, all of my videos are taken from the internet, and none of these are mine. We do not have good video capabilities at my institution, so I will credit somebody with this. How do I actually start my video? Do I just put, oh, I guess I just push, yeah. On this video, and it's a short one, so I'll just talk about it before, what you'll see is that this cannulatome is aiming that way, okay? Here's the papilla, and they're aiming that way, like sort of into the side wall of the papilla. They do not have it engaged, and they will not get in with this. Let's see if it starts, yeah. So see, they're aiming that way. They need to be, you know, they need to turn their little knob to the left, and that will bring them more in view, okay? And that catheter is not engaged, okay? And indeed, you know, they're not in anything. This actually was a live course in 2015 that I took this from, and their cannulation was a mess, and it was like 20 minutes, and to their credit, they put this on their live course, and I was like, man, everybody else would be like, go to a different room, because this person's struggling. But this one, okay, and I'm going to talk again before I run it. You'll see a moment where it goes in, okay? And that's what you want to do, is make sure that, and the other thing about this, I think somebody else took the scope, but you'll see that they are in a much better position for cannulating, okay? He's going to try again. It's already bleeding. See, he's on the left side of it, and watch this. You can see it go in right there, right? Do you see that? You can see the tip of it go in right there. They're engaged, okay, and they're sort of bearing it a little bit. Maybe you can stop engaging it, but so what if you're not getting in? What are some easy maneuvers that you can do that are really not too hard to do and without too much trouble? You can go into the long scope position, okay? For short scope, that maneuver that you do when you get down to the duodenum, the second portion, you turn the little knob all the way to the right and pull back, and then the papilla comes into view. What you're doing is taking this, which is a loop in the stomach, okay, out, and so now you're going straight from esophagus down to papilla. You can put that loop back in, and that'll sort of bring it just a different angle, okay? And sometimes we'll do this because it's like, you know, something's got to change. I'm not getting in. It's been five minutes. I want to change something at that point, and so sometimes that'll help. It sort of brings it into more of a pancreas-type position because it's right in front of you, but really any duct is better than no duct because getting in the pancreatic duct, although we don't want to do that when we get in the bile duct most times, at least you have a wire in the pancreatic duct, and that can help for future maneuvers. I do like changing the patient's position, mainly if they've got weird anatomy, they've got a big redundant duodenum or a bunch of ticks and you can't quite get it, you know, you can't see the papilla or you can't get into where you want to go, or somebody asked about the J-shaped stomach. Okay, if you can't get through the pylorus because their scope just like piled up in the stomach and you can't get through the pylorus, sometimes bringing them up more on their left side off the wedge, maybe somebody can push on their stomach a little bit, it can help you get through the pylorus and down to the duodenum. So these position changes can be helpful for some situations. What is difficult biliary access? This has been defined, okay, but by a couple of different guidelines, but they say more than touching the papilla more than five times, okay, so if you've tried to cannulate more than five times or five to 10 minutes you've been at it, and this goes by in a flash. If you're the one holding the scope, right? For everybody else, it's like, we've been at this a while, we're going to just like, does somebody want to break me for lunch now because this is going to be a while. So five to 10 minutes. And then I'm interested in this international expert consistent failure to access the major papilla, so they've got a stricture or something like that or a tumor blocking it. So how often is this? Okay, 20% of the time. That was actually high for me. I thought it would not be a non-standard cannulation much less time than 20%, but about 20% of the time we're going to have to use some other technique than just standard wire guided cannulation. And I didn't list all of them, I just listed the first couple. If you have a wire in the pancreatic duct, as I mentioned, that can be very beneficial. And I'll talk a little bit more about the double wire technique because I think it's helpful, but it basically just sort of straightens things out in that region and can help reduce accidental pancreatic duct cannulation. You can also put a pancreatic duct stent in to occlude it, but again, that makes it a little hard because there's not that much room in the orifice and you sort of jail yourself off and you're trying to maneuver around the stent. And so I'd like to put the stent in after I've gotten in the bile duct and then I can leave it alone and just cut the bile duct and be away from the stent, but you don't want to knock it out, obviously. But you can do that. And of course, if you're thinking about a needle knife, you want to have a stent in the pancreatic duct first, that makes it a little safer. So the double wire technique, okay, you have a wire in the pancreatic duct and you take your cannulatome out, lock that wire, have your tech or nurse load a new wire into the cannulatome and then cannulate around the wire. And I always use my fluoro for this, okay? And what you'll often see is you are going in the exact same plane every single time. And so if you look at your fluoro here, there's of course the pancreatic duct wire. And when you get it in there, sometimes you'll see my cannulatome is pointing exactly the same way as the other wire and that's why it keeps going in there. And that's why you want to manipulate it a little bit. Either torque yourself to the left a little bit or bow up, okay, and you can see that on fluoro. Now I'm in a different plane. Now maybe I'll get in the bile duct. And so really, fluoro can be very helpful for the double wire technique. It used to be thought that wire in the pancreatic duct wouldn't really cause pancreatitis because there's no contrast. And now we know that to not be true. You really want to, if you're using this technique, especially you got the wire in there for a while, place a pancreatic duct stent. If I get into the PD one time, I'll pull it out and redirect. But if I get into the PD more than once or so, I just put in a stent. They mostly fall out on their own anyway. Obviously, you have to check up on the patient later. But it's just so much preferable to have that than to deal with pancreatitis. This is a video of the double wire technique. So I think it's a nice depiction. They've got a wire there and you can kind of see they're going there, it can be hard to engage around it. You're trying to deal with the elevator. Every time you elevate, the wire elevates too. So you sort of have to get the feel for it. And now they're in. There's a tick off to the right. And we'll talk about that. Gosh, that looks so great. Right? Right there. It looks so great. But it's in the pancreatic duct again. Oh, this one. Oh, I guess, I guess it skipped a little bit. Yeah. So this one, they actually got into a different plane and got into the bowel duct. So that was good. Now, is there anything else next other than needle knife? What if you don't do needle knife? What if you never learned it? What if you're afraid to do it? Right? And these are real issues. Like needle knife should be something that we train on, but not everybody gets a lot of experience on it and then they get out and they're like, I don't know, I'm scared to do this. I'm going to get a bad reputation. I think I have a lot of complications. So what else can you do? If you have a wire in the pancreatic duct, you can just do a sphincterotomy right there. Okay. And what that does is cuts that septum on the inside that separates the bowel duct and the pancreatic duct and cuts the outer sphincter as well. Now, if you do this, you really have to place a pancreatic duct stent because this is really just equivalent to a needle knife, but you did a needle knife with a cannulatome. And I think all of us are comfortable doing a sphincterotomy. Okay. And so not all of us are comfortable doing a needle knife. So this is actually a good option. The Gough sphincterotomy, you'll hear it referred to as this, Dr. Gough first described it in like 1995. Here's a video of that. Yeah, this is the one where they kept getting to the PD and you can see his angle is exact his or her angle is exactly the same, right? Exactly the same as what that PD wire is. They're going the same spot every time. And so now they're going to cut. And what you want to do once you cut now the biliary orifice should be at the top of the cut. All right. It came over to the left, but the biliary orifice should be over there. So there they go. It's still a little scary doing this, but you know that you can protect the pancreas with a PD stent. Okay. You've got a wire in there. Just don't lose your other wire. Once I'm in the bile duct after something like this, I do my biliary sphincterotomy so I always have biliary access. I'm not going to lose that again. And then I lock my biliary wire and put in a PD stent and get rid of that wire. I know some people sort of do the whole case with two wires, but I don't like to leave the pancreas undrained for any length of time. And there's always a risk you're going to lose your PD wire if you don't go ahead and put a stent in right then. So cut your bile duct open once you have that and then deal with the pancreas and then deal with the rest of the case. So how good is this? There's data on this. There are actually two pretty big meta-analyses. And transpancreatic sphincterotomy or the golf sphincterotomy actually outperformed all the other adjunctive methods. Early needle knife was second, so really meta-analysis data, you sort of have to say, you know, where's the truth lie? But it's at least equivalent, if not a little better than a needle knife, okay? So a nice option. The golf sphincterotomy and early needle knife both resulted in less pancreatitis than just continuing to try, okay? So keep poking at it. You'll definitely cause some issues. Do something else. And so that's good data. Now what about needle knife, okay? If you have a PD access and you can have a PD stent in, that's always a little more comfortable or you can do this freehand. Fiscalotomy is sort of a more advanced kind of technique. Definitely want to be very proficient with a needle knife before you try something like that. Maybe get some extra training on that if you haven't done it or don't do it, right? This is why there are expert centers that help us when we fail and then they can do that. Needle knife, and so you want to put the tip into the orifice and cut in the direction of the bile duct. Again, we're trying to find a tiny little structure in that mound of papilla. And so it's, you know, it can be a challenging thing. But again, lower risk than just continuing to poke at it. So fewer complications with pre-cut, then keep trying. Here is a pre-cut over a pancreatic. Whoops. I don't know what I'm doing. That's not what I wanted to do. I don't know if this is not going to... How do I go back? Oh, here we go. I don't know if... You're just going to get a preview of the entire rest of the talk. I don't know how to make this video play. Oh, there you go. Thank you. I, you know, I like these videos where it's really messy because I feel like we see lots of videos where it's just perfect. And I actually tried on... I had multiple cases one day and I tried to have the nurse video even just using an iPhone and it was so nerve wracking. And I was like, this is a terrible video. I'm all over the place. And I think you end up realizing how edited these videos are. But like, look at this. It's kind of a mess. It's like bleeding and there's just a bunch of tissue. But they've basically just cut in the direction of the bile duct and nicely were able to get in. When it's bleeding, you know, it can be disturbing. Perforations bleed. This can bleed. So it can be a little nerve wracking to pull that out. But it's a good technique. I might have to have you start this one too. I think it's a weird video. Maybe. There we go, thanks. This is that one where you're going to cut. I think, you know, having an impacted stone in there would be a good one to practice on. You can see the stone, but you can't get in. Here they are trying again to get in. It's not going. And now they're just going to cut that big mound from the top down towards the orifice. I don't know, definitely got to have some bravery. Really no risk of pancreatitis with this because you're not coming into the, or hardly any, but obviously you probably poked around it a while. Nicely, they're seeing some biliary contents, which is always reassuring. Got in there. All right. Now what about sphincterotomy technique? Over a wire standard, obviously you have to know which duct you're in. And you just want to put some tension on the orifice. You can either do that with a scope maneuver. And that would be elevating your tome a little bit. We usually use a little bit of bow at least. How big do you make the cut? Okay, as big as you need to. Don't make it too big, obviously. And I think a far bigger crime that people tend to do is making a wimpy sphincterotomy. And it makes the whole rest of the case challenging. And it can result in inadequate drainage at the ends. They get cholangitis. So you really have to make a complete sphincterotomy, right? And so cut the whole thing. There's an inner area you can cut too if you really want to go nuts. But just make sure you make a decent sphincterotomy. If you have big stones, which I think Dr. Rogo is going to talk about later on, if you have not made a big enough cut, you're going to fail. The terminal fold above the papilla is the limit, which I'll talk about. And this is another messy video. I think this is that same case of that where we started off and I was showing you how to engage the papilla. And I think they finally got in. This is at like the 20-minute mark. But you'll see kind of how big they can make it. And again, this is such a nice video because it's like real, you know, the bowel is contracting and you can't see and it keeps coming towards you. You can almost see that inner area where the bile duct is that you can sometimes cut. But you'll see just how big you can make it. And the terminal fold is like way up here. Let's see, they're just going to keep going, keep putting tension on it. They're having to move the scope in and out to keep tension on the wire. They're cutting a little bit far to the right more than I would like. I would like to go a little bit more to the left. And you can always size it. You know, this doesn't quite look like a complete vignette, sort of falls open when it's complete. Here's the terminal fold up there. That looks complete. I'm hearing comments on the sphincterotomy deck there. This is one where they had to manipulate, whoops, go back, manipulate the scope a little. You might have to play that one too for me, I don't know why my videos aren't playing. And this one, huh? Because I'm a Mac, it's because I'm a Mac. Can you play my video for me? Oh, I see. I don't know how to do that. That's far too advanced for me. But in this one, okay, they couldn't quite get a good lineup. They want to go more to the left, the tomes heading off to the right. And they can't quite get it where they want to be. I don't know, their wire's not very tense either. But on this one, they're going to go into the long position. This is a nice view of the long position. They just push scope in and adjust themselves a little bit with the little knob, okay? And that's how the long position looks. They're a little far away from the papilla still. I need to bring that in a little bit. But that's how it would look to be in the long position. Sometimes can help you actually cannulate if you're not getting in otherwise. And they can just start the cut here with being in the long position. They're a little far away from the papilla. I don't really feel like that's great control. But at least starting the cut, and that's perfect. It's going in exactly the right direction now. And then they bring it back up. Okay, and then finally, I wanted to talk about duodenal diverticulum as the, you know, everyone like sighs when they get down there, and there's a bunch of ticks because you're like, oh no, this is scary now, and I'm not going to be able to find the papilla. Duodenal diverticula can be quite challenging even to find the papilla, okay? It's usually between 4 o'clock and 8 o'clock. There I go with my clock rim. So just the lower half of the clock face is where they are, and it's on the lower rim of the papilla. There's often kind of an isthmus in between the two. I'll just run this because it's a longer video, but you can see it there. You know, they've kind of found it there right in the middle, and again, 4 o'clock, between 4 o'clock and 8 o'clock. That's sort of like right at 8 o'clock. They're using the cannula tome to push away the folds, try and get in. And a lot of times, again, there's this isthmus between the two, and that's kind of where the bile duct is running. This one's a little bit far away from the isthmus, and it's going straight off to the right. So it's a little bit scary, like, gosh, can I cut that? The other thing to know about a duodenal diverticulum, often it is quite easy to get into the bile duct on these. That's why I don't mind them so much, because usually cannulation is pretty easy. It's often not as acutely angulated up like a normal papilla. It goes quite up to go to the bile duct. It's often more straight in, and that's just an anatomic thing that can be found. In this case, they make a small little cut and then use balloon dilation to make the orifice bigger, which is a very safe method if you're not sure how big you can cut because you're not sure where it's actually going or if there's some fold there that you're going to cut through and you're worried about cutting through. So they make a tiny little cut here and then use balloon dilation, which I think the difficult stone talk will undoubtedly mention. I know I want to keep watching the video because I'm like, everyone's just fascinated by watching endoscopy and I am too, but I know this is kind of a longer case, but they just kind of make a small little one and then go for that. So in conclusion, cannulation is achieved in the majority of cases that initial ERCP. Eighty percent of the time it is a simple cannulation. If your hospital or clinic isn't one that kind of monitors quality data, this is becoming a thing. You know, some people in the audience here are writing papers and criteria about quality indicators in ERCP, and this is fairly new. I think Doug wrote the initial iteration of it back in 2015, but our hospital, community hospital, they're starting to monitor these things and complications, which they had not been doing before. But I think it's a good thing to know your cannulation rate to make sure. Just like we monitor our ADR, adenoma detection rate, we really want to know, am I doing good quality work? So I think, you know, monitoring your cannulation rate and how often you have to pull out, you know, advanced techniques is a good thing to know. Maneuvers that you can do to facilitate access, okay, double guide wire, trans-pancreatic sphincterotomy, needle knife, and don't forget about stopping and coming back another day because 50% of success is the next day try, okay? Don't be afraid of diverticuli and make the sphincterotomy big enough, but not too big, and soon you'll be rewarded. That was the one that had failed that I got his stone out. And that's all I have. Me and my AV issues.

cannulation

sphincterotomy

ERCP procedures

wire-guided cannulation

double wire technique

pre-cut sphincterotomy

duodenal diverticula