I'm really thrilled and happy to introduce our first speaker, who is one of our phenomenal nurses from Brigham and Women's Hospital, Tabitha Grant. We call her Tabby. So grateful that she left her previous hospital to come join us. And again, she's one of our key go-to people for advanced endoscopy at the Brigham. And she'll be talking about ERCP room setup, preparation, and equipment. So Tabby, thank you. I'm very excited to be here. I love ERCP. And I love working in our advanced rooms. I know a lot of hospitals don't do quite what we do at the Brigham, but this is our general setup. I tried to cover general basics to start with. If you have any questions, feel free to interrupt me. I have no disclosures for this assignment. So things you'll need for basic setup, normal saline, 10 and 20 cc syringes, 4 by 4 gauze basins, contrast, pillows or a gel roll, head support, grounding pad, bite block, PPE, and lead. So this is our back table setup, where we put all our supplies. As you can see, we use the normal saline, the basin with the gauze in it, contrast. We have the two different size syringes. We have two camps on the syringe size. A lot of our girls use 10 cc syringes. A lot of our guys use the 20s. When you're using a tome or a cannula, pushing contrast through those can be tough. The smaller syringe is easier. On the hand, it pushes easier, especially through the tomes. 20 cc syringes, I have tried. I will go in and cover a room for one of the guys. I can't do it. I have to change syringes. And then some saline syringes to flush all your wires and cannulas. This is our room setup for our fluoro table. So we prone all our patients for ERCP. We have a head pillow, a pillow, and a gel pad to support the front of the chest, a grounding pad, and the small pink donut we use to cover ports and defibrillators, things that are implanted in the chest, to help support those so that we're not crushing them against the table. This is my lovely friend, Jen, showing our lead aprons and our PPE. All of us wear shoe covers. As much as you try to stay nice and clean and dry in ERCP, it doesn't always happen. Keeping your wires very wet with the gauze, you want to make sure that they are wet when you hand them to the doctor. It helps when you're passing to keep those wires wet so as you pass through and into the bile duct that they move smoothly so that you don't lose the wire during exchange. We cover our feet with our shoe covers, a gown, mask. Everybody was in masks until recently. Some people have started to repel a little bit now that they're not as often. Lead apron and lead goggles. Let's talk about scopes. Side viewing scopes, as you see on the left, with an elevator. Most scopes now have an end that comes off. You want to make sure that's on and tight before you pass the scope down through. The scope on the right is a disposable scope. We do occasionally use disposable scopes. Some for really easy cases. Some for cases with patients who have infections that you don't want the chance to pass on. They're difficult to clean. I know some facilities are using disposable scopes only because they don't do enough cases. It's not worth trying to process an ERCP scope. Other scopes to consider, depending on the anatomy. If you're doing an altered anatomy, you may need a longer scope. We do use a thin adult colonoscope for patients who have had whipples because you're going down further. So you have to think about what scope you want when you're processing and coming up with your plan with the doctor. Equipment. So we have cutting wires, cannulas, and then you have to talk to your doctor. Do they use long wire, short wire, the RX system, tomes, and cannulas. Tomes are the cutting wire. They help direct the direction of the wire. They also help with cutting and opening the ampula. The cannulas are just straight. If you have a stricture, often the cannula is easier to get through. And wires. Wires come in multiple different styles. This is a basic dream wire that I have up there. The end is hydrophilic. The rest of the wire is pretty stiff. Some wires become completely hydrophilic. And on those wires, they're extremely important that you keep them wet. Other common equipment. Sweeping balloons. On the bottom left, pass the wire up into the duct. Get above the stone once you've cut. Pull up the balloon and pull down. It will clear out the duct, allowing you to remove the stone or help pull down a stent. Things that will help clear out the duct. Dilation balloon is on the right. Sometimes you end up with a spot that is strictured that you cannot pass more than the wire passed or you can't get the balloon to come down through. And you can dilate the duct a little bit. Other equipment. Stents. Plastic. They come center bend, one end bend, double pigtail. They come multiple different sizes, lengths, depending on what you need. Metal stents come fully covered, uncovered, and partially covered. And it will depend where you're at in the duct to what styles metal stent you want to put in place. Alright, my pop pops.

ERCP procedures

equipment

supplies

back table setup

scopes