Our first lecture this morning is from Dr. Doug Adler. You met him yesterday. He's professor of medicine at the Advanced Therapeutic Endoscopy Center in Denver, Colorado. And he'll be talking, actually he's going to give two lectures in a row on how to manage a malignant distal biliary stricture, and then followed by the role of ERCP. So, we'll start off with distal strictures, then we'll move into proximal strictures. Distal is pretty easy stuff, pretty straightforward stuff. Hylar becomes a different ball game, right? So this is a really, really typical story, right? We get this call, and I'm sure Uzma and everybody else gets this call 10 times a week, right? Octogenarian, weight loss, sometimes abdominal pain, sometimes not, and jaundice, right? They'll say like, oh, my urine's a funny color, my poops are gray, right? And you can kind of like basically make the diagnosis here, right, in an octogenarian. Like, could she have a stone? Yes. Does she have a stone? Probably not, right? This is sort of a malignant type story, right? She's got a cholestatic lab pattern, and her CA99 is elevated. But remember that CA99 can be elevated in all sorts of settings, and it doesn't really mean a ton. At the University of Utah, sorry, at, yes, at the University of Utah, where I used to be, and at my current place, Porter Adventist Hospital, if you go to the emergency room with a hangnail on your left pinky, you will get a chest, abdomen, and pelvis CT in the emergency room. And then the radiologist will recommend an MRI on top of it. So she gets a CT scan, and she's found, surprise, surprise, a three centimeter mass in the head of the pancreas with dilated CBD and a PD, and as is often the case with pancreatic head lesions, some portal vein and some superior mesenteric vein involvement. So what do we do next, right? So we have her CT, right? Would anybody get an MRI? Anybody? No, neither would I, right? So her next steps are what? What do you think? What's our next step? U.S. and? She's jaundiced, right? So she needs a tissue diagnosis, and she needs to have her tumor interrogated, and she needs a stent. I don't know, we drain everyone. We drain 100% of these people. It's very tough to tell an 80-year-old yellow lady that you're not gonna drain. We're not gonna drain her. But we said she has portal vein and superior mesenteric vein involvement. Yeah, plus it's fun. So lots and lots and lots of guidelines on this. So we were having a debate yesterday Uzma, where is the distal duct begin? No, but I mean higher up, like what's the top of the distal duct? Like where does it be? When does mid-common duct end and distal common duct begin? I just call proximal duct right before the cystic tape. Okay, interesting. Put it in the third. Okay. It's a judgment call on that, and I understand you. So this is probably the most, by the way, can you guys hear that rain? This is the most important slide in the deck, right? Like when you see somebody come in in this setting, 85% of biliary strictures are malignant, full stop, right? And this patient's in her 80s, right? So her odds of having malignancy just at the very outset are super, super high. So again, 85% of biliary strictures are malignant. The lucky person has chronic pancreatitis or an inflammatory stricture, maybe a little less lucky, has a surgical injury, but most people with biliary strictures have cancer. And this kind of is what we think about when we see patients with biliary strictures, right? Pancreatic cancer is the big one, right? Probably the number one cause of malignant biliary strictures. Cholangiocarcinoma we'll talk more about in the next talk, the often discussed but rarely seen ampullary cancer, gallbladder cancer. And if you're at a decent cancer center, you'll see a lot of METs. So I've kind of practiced in large cancer centers my whole career. So we see a lot of METs to the liver that can cause biliary obstruction. On the benign side, we kind of went through this, right? Chronic pancreatitis, inflammatory strictures from stones, surgical injuries, autoimmune cholangiopathy, PSC. Depending on where you practice, you might see a lot of PSC or a little PSC. When I was in Utah, I never ever had a day without a PSC ERCP. In Colorado, much less so. For reasons unclear, it's geographically concentrated in some places, right? And then a few other super rare things. So just recognize that pancreatic cancer has been and will always be probably the number one cause of distant malignant biliary obstruction. Tumors in the body and tail usually don't cause jaundice unless it's from metastases and hepatic decompensation. Head lesions obstruct the bile duct. Genulesions sometimes can. If they're rightward enough, a genulesion can kind of reach over and get the duct, right? I think we have an example of that in this talk. Remember, we're talking about distal stricture in this lecture, right? So cholangiocarcinoma, once in a while, you will see a distal cholangiocarcinoma, but that's really, really rare. What are you doing, Uzma? She's been working on my computer. Oh, this one's not yours. Oh, I thought that one was mine. No wonder, I was like, why do you care? For the virtual audience, they can submit questions to the Q&A. Got it, got it. I thought you were working on my computer. I was like, I've got a document open, you're free to edit it. So yes, distal cholangiocarcinomas can exist, but they rarely, rarely do. Almost all cholangiocarcinomas are proximal, and I think in the last 10 years, I've seen two or three distal cholangios. That's it. It's really, really, really rare, but it can happen. I posted this picture on Twitter just last week when I was making these slides. Follow me on Twitter. And this is, ampullary cancer can clinically mimic pancreatic adenocarcinoma very, very closely in terms of symptoms, weight loss, pain, but the big difference is it's curable, right? And for reasons unclear, ampullary cancer rarely metastasizes before it's discovered, probably because it makes the patient jaundiced and alerts the patient to its presence. The nice thing is most of these people can be cured by surgery, either a transduodenal sphincteroplasty or a Whipple, and you can get rid of ampullary cancer. And every once in a while, we'll run into somebody who will say, oh, I had a Whipple 20 years ago for pancreatic cancer, and we're like, no, you didn't. And they're like, yeah, I had pancreatic cancer, and we're like, no, you didn't, not if it was 20 years ago. And then if you look in the records, it was ampullary cancer, which makes a lot of sense. Gallbladder cancer is something we don't think a lot about, right? If you guys are doing ERCPs and you see those anomalous pancreatic obiliary junctions, just recognize that that's a risk factor for gallbladder cancer, which is a lot of people don't know that. And if you look, you may find a lot more anomalous pancreatic obiliary junctions than you think. Doesn't mean the patient has to have a cholecystectomy. It means that maybe just say to the patient in recovery, like, hey, you have this thing, your risk is a little higher. Would you like me to refer you to a surgeon? And actually, very often the patients say no, but at least you can say that you discussed it with them. And then, like I said earlier, meds. I've kind of flipped my thinking on this topic. And it used to be that if the patient had a lot of meds and they were jaundiced and the oncologist would say like, hey, do you want to do an ERCP? The billy's too high for me to give chemo. I was kind of like, nah, I don't think so. And then a couple of times I was wrong and either somebody else did the ERCP or I got kind of pressured into it and I did it. And lo and behold, there was a dominant stricture, right? A significant stricture from one particular med that was pushing on the ducts and I was able to normalize that patient's billy. So now I've kind of gone from being a no to a yes. And if people call me in this situation, if I think it's reasonable, I will go ahead and take them to ERCP and look because I've been fooled enough times by MRIs and CTs that didn't really show the obstruction, but ERCP did that I will now take these people to ERCP. I think we kind of covered labs a little bit. Just recognize that CA-99 is only positive in about 70% of patients with pancreatic cancer or malignancy. Also recognize that people with cholangitis, chronic pancreatitis, a surgical stricture, all of these things can raise your CA-99. What does the CA stand for, Linda? What does the CA stand for in CA-99? Everybody gets this wrong. Everybody thinks it's cancer antigen. It's not. It's carbohydrate antigen. So again, I personally like getting CTs more than MRIs and distal strictures. I kind of feel like it's quicker, faster, easier. The patient doesn't have to wait the way they have to wait for an MRI. And I can read it. Like I can read, I feel like I can read a CT as well as a radiologist. Not an MRI, but I can read a CT as well as a radiologist. So my threshold to get a CT in these people, if they haven't gotten it already, is very low. The CT will almost always in the report say, recommend MRI for correlation. And we don't usually get that. The other problem too is it can be hard to get an MRI fast, even in a big hospital. Many years ago, I needed an MRI for my heart. Many years ago, I needed an MRI, this is a true story. I needed an MRI and I was a physician at this hospital. And they were like, well, we can get you in in like four days and I was like, four days? I was like, I need an MRI today. And they were like, four days. And I called the head of MRI and I was like, what can we do? And they said, if you can come in at three in the morning, we'll do it at three in the morning. And I came in at 3 a.m. and got my MRI because it's just hard to get an MRI because has anybody in the room had a CT? You're in that scanner for like 60 seconds. MRI, you're in that scanner for 45, 90 minutes. So they just can't, they don't have the throughput. So I rarely, for distal biliary obstructions, I rarely, rarely get an MRI. But even with the MRI, it's so much more subjective because of the movement too. I feel like you have to lie still for that long. Right, that's a good point. So again, we wanna do an ERCP and we wanna do an EUS in this person, right? We know there's a mass, we wanna get tissue, right? And we wanna closer look at that mass for staging and we wanna stent them. Because as Uzma said, the odds that this person gets neoadjuvant are exceptionally high and the odds that this person gets surgery are actually pretty low, right? In their 80s with vascular involvement, right? I mean, I know what the guidelines say, but the reality is most of these people don't go to the OR. I'm gonna skip that slide. Well, this person, this person got an MRI. And again, this is just such a classic image, right? So here's a sort of massively dilated extra hepatic biliary tree with intrahepatic duct dilation. Sometimes these people on an emergency room point of care ultrasound get told they have cholecystitis. They don't, right? They just have a big dilated gallbladder because that's obstructed too. And you can see the CBD pinches down to like a little bird's beak, almost looks like an esophagus and achalasia. And at the exact same level, the pancreatic duct is cut off. And then you see upstream this big dilated, tortuous pancreatic duct, right? With visible side branches. And you can almost guarantee, even though this is a T2 weighted MRCP MIP image, the maximum intensity projection, you can almost guarantee that that pancreas around that duct is gonna be all atrophic, right? It's just been chronically obstructed. The parenchyma is no longer functional. And this is exactly what you can expect to see, right? On the EUS. You almost know what this is gonna look like, excuse me, before you even put the scope down, right? You're gonna have a large mass in the head of the pancreas, a large solid hypoechoic mass. There is the bird's beak of that CBD, right? Just terminating at that mass. And right there is that PD obstructing, right? And you don't really, in this particular view, you don't get a great sense of the vasculature, right? But you got two thirds of a stack sign there. But there's correlation between the MRI and the EUS. And I always say to the fellow, like the CT, the MRI, and the EUS must agree. Like if they don't agree, more likely than not, we've made an error. The CT, the MRI, and the EUS, with rare exceptions, kind of have to agree. And this is what we do, right? And if this was an older image, I would say that that's a picture of FNA. In the modern era, we would say that that's a picture of FNB because we've pretty much all gone to core biopsies. Do people still have pathology come to their procedures? Who's math? A few. I used to. And I wrote a lot about ROSE, Rapid On-Site Evaluation, where the pathologist would come and make a smash prep and look at some slides right there. Now we do MOSE. Have you guys heard of MOSE, right? Macroscopic On-Site Evaluation. If the tech looks in the jar and says there is a core, we're done. That's the end of the procedure. And this is exactly what you typically see on ERCP, this long segment structure. This correlates very, very well to that MRI. Here, what's interesting in this image, this must be a different patient because you don't see that gallbladder, but you typically will fill the gallbladder because there shouldn't be a reason in this particular patient for that gallbladder to be obstructed unless the tumor involves a cystic duct orifice, which it can. And here's a stent that's gone, and we'll talk more about stents later in the talk. Again, this is a different one, right? So this is a person who has a previously placed metal stent, right, and you can see they've probably developed recurrent jaundice because when a balloon is put underneath and injected, you see a stricture inside the stent. So it's hard to call that a common bile duct stricture per se. I would call that tumor ingrowth, right, into the stent itself because they have a previously diagnosed stricture, a stent was placed, and you can almost guarantee that that is an uncovered stent because you wouldn't see that pattern in a covered stent. So that's tumor ingrowth through an uncovered stent. What would you guys do for that? Like if you saw this in your room, what treatment would you give? Patients, yellow. Ruzma? Well, actually, our co-faculty, Jason Rogar, when he was at my fellow at Yale, he published a study that said the most cost-effective and efficient treatment was to put a metal stent. Yeah, and I think that's what most people, you could put a plastic in, it's not a violation of the standard of care at all to put a plastic in, but if the patient has known malignancy and they've had significant tumor ingrowth, right, and that's exactly what happened here. And you could argue to put a partially covered or a fully covered or an uncovered in there, you could do all sorts of different things there, but I think the answer is, in general, you want to put another metal stent in this patient to try to give them the longest amount of time without a stent in place to keep their jaundice at bay. So this is a different patient. And you can see, though, it looks almost exactly the same. And again, these EUS findings are highly conserved. And what I mean by that is that the patients look the same. These people have never met each other, but they tell the same story, and their ultrasounds look the same. So you know that you're going to put the EUS scope down into the duodenal bulb, wedge it, and you're going to see this exact finding. And here you can see, again, that bird's beak image of the CBD up high. You don't really get it. In this particular view, you don't get a great view of the pancreatic duct. But I imagine if you just rotated a little tiny bit, you would see a large, dilated pancreatic duct, because you know it's going to be obstructed. And again, here we are doing FNB. Here's another one from a different patient. And you can, again, start to get a sense of how similar these all are. Distal stricture, big dilated system above. Interesting where that wire is. Not 100% clear where that wire is. That might be in the cystic, or maybe somewhere funky. But that's a little bit of an odd wire position there. But nonetheless, they're in there somewhere. Here's another metal stent. That's a redo. Again, another example. Looks just the same. And you'll get really, really good at doing these EUSs. It's kind of like when you're just starting out. These are great cases, because you get an ERCP, but it's typically with a native papilla. And you get an EUS that gives you some intervention to do in the form of a biopsy. So I remember starting out loving these cases so much, because you kind of got to do everything you're trained to do in one procedure. There's the FNB. So would you call this mid or distal? What do you think, Linda? Mid? I was going to say more proximal bile duct, because it's right near cystic takeoff where the clips are, assuming. And what do you people think? Proximal, mid, distal? Top half. Top half. That could be a genuine tumor. That could be a pancreatic genuine tumor that's a little higher up, just reaching over. I would call that mid to distal. Is that fair? Is that a cop out on my part? Maybe. Another metal stent. Another EUS example. This person already has a plastic stent in their bile duct. And if you look in that mass, you can see that there's a plastic stent in there. In this particular image, they've caught the portal vein. And it's a little unclear. Maybe right there is a little portal vein involvement, or that could be artifact. We'd have to rotate a little bit to know for sure. So Doug, just going back to that image there for a second, there is a online question that's asking if you do ERCP before EUS, and there's a metal stent in there, does this cause subsequent EUS imaging to be difficult? That's a good question. It's been looked at in a couple of studies. And the answer is, if there is a stent, plastic or metal, it does not affect the accuracy of EUS staging. Here's a question for the group. If you're doing a double, not an EGD colon, an ERCP EUS, what do you do first, the ERCP or the EUS? EUS. Anybody do ERCP first? I do. I always do the ERCP first. Well, for me, if I have on-site cytology to confirm cancer, then it affects what stent I'm going to put in. Right. Anybody do ERCP first, besides me? Why do I do that? I do that because I got burned a couple of times. I got burned because the patient got unstable, and I had to stop, whereas I feel like I can very, very quickly get a stent in and take a brushing. And then the EUS, I can do sort of more at my leisure. So I always do the ERCP first so I can just get that stent in, get a brushing, and then do the EUS afterwards. But I did have a couple of cases where the anesthesiologist was like, they're hypotensive. We got to stop. So I used to do the EUS first. Now I do the ERCP first. So there's another question about doing EUS before ERCP from online. They're saying, does doing EUS before cause bleeding in the tumor from biopsy and further stenosis slash difficult deep cannulation? You may cause bleeding. I mean, everybody knows sometimes you get a little bit of blood when you do the sticky, sticky. But I don't think it should change staging at all. More of the same, right? Tumor, ducts, more of the same. Here's some spyglass pictures. I almost never use cholangioscopy for distal strictures. It's usually not helpful. Usually the EUS is going to answer pretty much all of your questions. If it is the rare distal cholangiocarcinoma, you could do a distal spyglass. But all choledicoscopes don't work so great in the distal duct because things are collapsing as the duct inserts into the ampulla and the duodenum. But it's not wrong to do. But I just typically don't do it. So here's the question that everybody really wants to know. What stent to use? And if we had another five or seven hours, we could fully answer this question. So Uzma actually said, I spoke to Uzma before, and she said it was OK. So we're going to do a separate five-hour section starting right now just on which stent. That should carry us right to about. I don't think that's long enough. We still wouldn't. That should carry us to about one o'clock. We still wouldn't have the answer after that time. But a lot of times I'll be in a case, I've had this experience many times, where I'll say to the, we'll be doing a double, and I'll say to the circulating nurse, get a 10-6 viable with side holds. And then while the nurse is doing that, the fellow will say to me, well, how'd you pick that? And I'll be like, well, that's a good question. Because a lot goes into that decision. So a lot of it has to do with operator preference. Like, you're the attending. By law, you are what is referred to as the guarantor of the procedure. So you can pick whatever you want. So people tend to use the same stents over and over and over that they like and they feel comfortable with. But some of this depends on what your hospital stocks and what relationships with vendors you have. When I left the University of Utah and I went to Advent Health, they had different vendors. And some of the stuff I had used for many years wasn't on the shelf, and I had to sort of get used to some of the stuff that they had. What stents do I have experience with? What am I comfortable with? What delivery systems do I understand intuitively? What's worked for me in the past? What hasn't worked? What clogged? What migrated? Did it migrate up? Did it migrate down? Did the stent fall apart when I tried to take it out? All of these things are sort of spinning away in your head. Other things to consider. Does the patient have a firm diagnosis? And when I say a firm diagnosis, I mean a path report signed by a board-certified pathologist. I personally, and I imagine there's some difference of opinion on this, I don't generally put metals in without a diagnosis of cancer in the setting of a mass or something like that. Because I want to be able to pull it out and maybe resample if I have to. If the patient is very, very far away, maybe I'll put in a fully covered metal. But I usually put in a plastic on the first case in these patients and bring them back pretty quickly once we have a diagnosis of malignancy to put a metal in. I've seen people get in trouble, and I've been expert witness in a couple of cases where people have put in an uncovered or a partially covered metal without a malignant diagnosis. And when that thing turns out to be chronic pancreatitis or focal autoimmune pancreatitis, and that stent can't come out, and that person starts to develop secondary sclerosing cholangitis, recurrent biliary sepsis, needs to have a surgery to get that stent out, it's very, very difficult for the doctor to defend that. Does the patient live far from my hospital? And Jessica, we were talking about this yesterday. Jessica lives in one of the most densely populated metropolitan areas on the planet. She lives on Long Island. It's like 10 million people. So far on Long Island is like eight exits on the Long Island Expressway. But my patients in Denver come from Albuquerque, Durango's 10 hours away by car, Kansas, Eastern Utah. These are long drives. So I have to think about, well, if it's really hard for the patient to come back, maybe I should think about putting in something that's going to last a lot longer. Can the patient reasonably tolerate a follow-up ERCP? This lady is 82. There's all different kinds of 82-year-olds. Some 82-year-olds are pushing a wheelbarrow around doing gardening every day. Other 82-year-olds need help eating. And someone has to spoon feed them and cut their food for them. There's all different kinds of 82-year-olds. Can this person tolerate a follow-up ERCP? Or am I looking at one and done for this person? So again, I'm not saying I never place a medicine. But with rare exception, I mostly put a plastic in on the first one. Does the patient have a gallbladder? Do I have to worry about causing cholecystitis? Am I going to obstruct that gallbladder? Where is the cystic duct? Is it open? Is the tumor near the cystic duct? Is the tumor likely to overgrow the cystic duct in the coming days, weeks, or months? Does the tumor invade the common duct? Or does it just extrinsically compress the common bile duct? If the tumor invades the common duct, I'm much more likely to use something covered, because you're going to have a lot more tumor ingrowth through an uncovered stent interstices. Bless you. Whereas if the tumor is just extrinsically compressing the bile duct, like a foot stepping on a garden hose, then an uncovered stent is probably going to last a lot longer. Should I use a plastic stent? Seven French, really easy to put in. Clogs real fast. Eight and a half, I don't have to cut. Almost the exact same patency as a 10 French stent. I don't have to do a sphincterotomy. 10, you have to cut them. 11 and a half, a lot of people don't even know that there are 11 and a half French plastic stents on the market. Definitely have to cut. So in general, like this type of person, I would never do a sphincterotomy in. There's no benefit to doing a sphincterotomy in this setting. And we've published a couple of papers on this. A sphincterotomy only exposes the patient to more risk, risk of pancreatitis and risk of bleeding. If you want to put a plastic in, use an eight and a half. You don't have to cut them. If you want to put a metal in, you do not have to cut them to put a metal in. So some people believe that you have to do a sphincterotomy in the setting of a metal stent. That's totally not true, especially in the setting of a pancreatic cancer. So personally, I never cut these people. My partner likes to cut these people. I don't. Would you guys cut in this setting? No, I almost never do. See? There you go. The course directors don't agree. But why do you cut? I usually do a sphincterotomy just in case I fall out and I want to make sure I can definitely get back in. Sometimes with these really tight strictures, maybe it was tough to get in. And then again, going back to personal experience, had a couple of pancreatitis cases when I didn't cut. So I think, all right, let me take pressure off the PD orifice. Right. Move the stent a little bit over. Yep. If you're going to use a metal stent, uncovered, partially covered, fully covered, fenestrated, braided, woven, laser cut, all these things are on the market. And it's actually really important that when you're in your training, you get as much experience with different devices as possible. So when I was a fellow, I used to cheat all the time. Because I knew, like, well, Dr. Gestaut's going to use X, Y, and Z. And Dr. Levy is going to use ABC. And Brett Peterson's going to use 1, 2, 3. And I just, I was like, I'm not getting enough diversity of equipment under my belt. So I used to cheat. And I would open stuff. And then, you know, like, Brett Peterson would be like, hey, that's not my tome. And I'd be like, oh, but it's open. And then, like, that was how I used to, like, get stuff in my hands all the time. I would kill you if you were my fellow. I know. They wanted to kill me, too. But they're not dumb people. They eventually figured out what I was doing. But I got a lot of stuff under my belt. Because I would run to the cabinet and grab stuff during cases. Do you want a foreshortening stent? Do you want a non-foreshortening stent? All these things kind of come into play, right? So there's a online, sorry. There's an online question saying, do you place fully-covered metal stent in distal biliary stricture if the gallbladder is in? Yes, period. I think that 2015, I was a lot more worried about causing cholecystitis. And now I'm not. Because we know that it's much more rare than I think we thought. We have so much more experience with fully-covered stents. And now we live in the era where I could put an Axios in that gallbladder, right? In five minutes. So I don't personally worry too much about that. Now, maybe they end up at a hospital where somebody can't do that. And they get a Percoli, which we don't like. But yeah, I have to tell you, I think that a lot of this concern about fully-covered stents causing cholecystitis is overblown. And remember, you can cause cholecystitis with a partially-covered stent, an uncovered stent, or a plastic stent. With plastic. Yeah, I think I've had it happen more with plastic stents than anything else. I think it's more a matter of the tumor and the location of the stricture where it invades than your stent choice. I think if you have a little tumor that's cystic duct orifice, a lot of them will get cholecystitis no matter what you put in. So again, this is the available plastic stents on the US market. A lot, right? Uncovered metal stents, partially-covered metal stents, fully-covered metal stents. Some of these are not available in the US. But again, you can see how very, very quickly this spins up to a complex decision that involves you, your preferences, the patient's anatomy, your hospital's contracts, your hospital system's contracts, right? Now, you may or may not be in a system where you have some say, right? We talked about this a little bit yesterday. In my system, I have a lot of say. And I can go to our nurse manager and say, I want X. And then X appears on the shelf. But like, for example, if you work, for example, at the VA or you work at Kaiser, and you say, well, we have A, I want B, they may just laugh at you. Like, OK, you want B, but you have A. And that's it. And that's what we've agreed on. And that's the decision. And you have no say. So just recognize, depending on the institution you're at, you may or may not have any say. So again, distal malignant biliary obstruction remains super common. Critical to keep in mind, the top three causes of distal malignant biliary obstruction are cancer, cancer, and wait, let me think, cancer, right? Because that's what we see every single day, right? Get tissue, right? Lots and lots of stent options for a belly. If you're using the same stent every single time, that's probably not the best approach. And again, lots of factors to take into consideration when using a stent.

malignant biliary strictures

pancreatic cancer

cholangiocarcinoma

stent options

ERCP

imaging modalities

careful staging