Hi everyone, we're back. I just wanted to start off with a couple of questions from the prior session for you guys. One of the questions was, is there a particular wire type that you use if you're going to do double wire technique? No, I mean, I still use that 025 angled Vizzy for both. Usually if I get into the PD, I'll just leave the wire. Again, people differ on what they prefer, but I don't like to put the PD scent until the end of the case. But then I'll go with the same wire in my tome to get into the biodepth. Okay, great. I do the same as well. I'll start with my go-to wire and then leave that there and then do the biliary cannulation with the same go-to wire. But there's no preferences to 018, 025 or 035 if you're going to do a double wire technique. The next question from the last session is that, do you have a reliable method to measure the size of your sphincterotomy? Yes, again, so say if this was a real papilla, normally you're always going to see your terminal fold and you never want to cut past that. But if there's not a clear-cut landmark, we'll just put the tome in, bow all the way and then come out. So if I know this wire is 25 millimeters in general, once it's bowed, I don't really ever measure the sphincterotomy in terms of an actual number, but I gauge it by how big is the duct, how big is the papilla, how big are the stones that I need to get out. If I'm going to do dilation-assisted sphincterotomy, I purposely do not cut all the way to the edge of my papilla because I want to leave a little bit of tissue so that when I dilate, it's going to be very pliable and allow those larger stones to come out. And again, a lot of it's going to be based on how big the stone is. Great, thank you. You do anything specific? No, I don't. I think the most important thing is just measuring with what is appropriate to the duct size. I do know, I'm sure that question is from when you're clicking on your, for instance, if you use probation software, it always says what your sphincterotomy size is. But I actually don't think that it really is clinically significant other than the fact that obviously you want to just make sure you're cutting to the duct size. And then just important things that you might want to remind yourself is that some of the equipment do have those markings on the outside of your catheter. They're usually five centimeters. So sometimes if you do need to measure for whatever reason you want to know, you can sometimes use that because that is readily, you're using it and it's readily, those markers are there. But not all manufacturers have that. True. All right. So we were going to try to show stents in this next kind of session. But first Steve wanted to kind of, to show us a little bit how he may knuckle the wire. So sometimes when you're going in, as you're passing the wire, pardon, this may be a little difficult to show at this angle. And also because I'm doing this blindly. But occasionally you will get a knuckle, if you can see on that. Right at the top here. Right there. Yeah. So you'll have that bend in it. And that's for us, usually, yeah, that's a great thing at the start. We lost it there, but as you're going up into these intrahepatics, having that knuckle for us is kind of more or less, let's see if I can get another one into this channel. It can be a safety net that you're not going to, I guess, perforate some of these deep intrahepatics. It's just a little bit of a safer way to advance. I guess you could have also seen the advantage there of the angled wire that if, say we want to switch over then to the right side, and we have this on fluoroscopy, I can kind of take the wire and spin it. And maybe on fluoro, we can see that we are at hilum. And then as we advance wire, we can kind of redirect it easily just by giving tiny little spins on that wire and around the areas that we are passing to target anywhere that we want to go. And now we're kind of zooming in. So you can see that's the hydrophilic part of the wire. So it doesn't have those stripes on it. And on fluoroscopy, you can see it's a little bit darker. And that becomes important when you're trying to place a stent, because it's very hard to get your stent across that floppy part of the wire. So you always want the hydrophilic tip a little bit higher up than where you want the end of your stent to kind of end up. But so now we're going to exchange out on the tome. So usually we'd be doing fluoroscopy, but here we're kind of looking at it. So Steve and I are kind of working at the same pace in terms of me pulling my catheter out and he's pushing in. So I don't know if you can see our hands. So my elevator is open right now. And then also if you just show the end of you really quickly, you see your marks on your wire pretty much staying the same. You don't want them to move around a lot. And then now once the tome's in, I'm locked. So now my elevator is closed and we're locked and now you can kind of go back to our hands. But the key is to communicate. Some people like to say exchanging, exchanging, but he and I can both kind of feel how much he's pushing in versus how much I'm pulling out. And so we can kind of do it a little bit more quickly and then also endoscopically without using fluoro. So again, you're using less radiation. Those markings are not moving. So we know we're good. Oh, this wire is getting sticky a little bit. I would say probably the most challenging aspect of teaching non ERCP staff is the long wire exchange. And I think it just takes a lot of communication, but it is a lot of tactile feel and practice. So anytime that you are done with the case and you've got the wire and the tome that's already open, I would encourage people to just go back there. And if there's people that need more hands-on training to just practice, even that long wire exchange with each other, just to get more hands-on experience with it. I think that's probably one of the biggest hurdles in ERCP, exchanging wires. Agree. I think that's why so many people like to do short wire because it just takes that extra time and effort out of it. All right. So then now we're going to go with a stent. So let's say you want to put in a 10 French stent. So your options usually are 10 or 7 French, and then you're going to need something to push that stent up with. Again, we tend to use the cook stents, but Boston Sci also has some good stents as well that I think we have available here. With the 10 French stents, it's often helpful because they're a little bit bigger to have an introducer catheter through them to give you a little bit more stiffness and like a railroad to pass the stent up over. But that involves a little bit more kind of training, I think. There are some systems, as you mentioned, that are all one piece. We have one too, the Boston Advantix. We can show you that too. Yep. Also, because we can't find the other one. Oh, we have it, but is the stent there too? I have the stent. Okay. All right. But this one comes everything in one piece. So again, I think just knowing what you have in your unit and how comfortable you are with the different pieces of equipment. This one with the Oasis that goes through, the stent is loaded onto it. You just have to remember you're going to, at some point, once you're in a good position, you're going to have to pull back the catheter. So with the Oasis, you're just pulling back on it, kind of straightforward, and here, you pull it back from here, and you have a locking device when you're in position. But same principle, you got your stent that's loaded onto your introductory catheter. And again, you want your catheter to be higher than where your stent is going to end up, and then your assistant is giving you kind of tension by retracting this inner catheter while you're pushing the stent up on the papillary side. Is this for you? Oh, we don't have any. If you want to drop a little bit on the gauze, please. Key thing, again, everything should be wet. Sometimes, if it's a really tight stricture or you're passing two stents up, we might put a little PAM or mineral oil to make it a little bit less sticky. The other thing, I'm going to take that off, though. No, you don't want that. Yeah. So a lot of these systems, they come with these flap protectors to make sure that your stent goes in straight and the flaps are flat. I don't particularly like them, so I usually take them off. I don't use them either. Yeah. I think they're more cumbersome. I agree. And sometimes, one time I pushed it all the way through the scope because I wasn't, I was just kind of putting the stent in, so I don't usually use them. I just try to make sure everything's kind of straight when I pass it in. One thing we should also note is this is technically a shorter wire than we would typically use on a long system. This is only 270. These also come short wire as well. We, at our facility, use longer wires. I believe it's 350CM wires that we primarily use. So when you're passing down, just make sure your flap kind of goes in straight into your cap. Sometimes it can get bent, and that can make it a little bit harder to pass. And so it is, actually, this is a little bit, this is short, so we got the wire here. We're going to lock it. So for the staff members out there that are assisting during these, if you do have a longer wire that you would use, if you're using the OASIS system, you will need a full-length wire because it is long wire only. With this Boston system, you can use the short wire. But I'm re-hooping the wire just for our own organization. I think this is a valuable tool for anybody that needs the extra hand keeping your wire set in the hoop that allows you to free up your other hands to assist. Let me see. I'm trying to, we're in a Trendelenburg position here, which is not ideal. So now you see the stent coming out. But again, my hydrophilic tip of the wire is a little bit higher up. So I'm still going to put my introducer catheter and my stent over the non-hydrophilic part. So that introducer is plenty high. What length stent is this? I don't remember. Let's look at that. For the most part, you know, not to make generalizations, but usually, you know, 10-5 is really short. You might use that in a bioleak situation. 10-9 is probably going to get you close to the hilum. And then you start talking about 12-15 centimeters when you're trying to stent into the left or right system. So this is probably plenty high for the introducer. I know, what, how long is this? Nine? Okay. And this is actually a seven, this is a seven French stent actually. So with this short wire system, it has an introducer catheter, which is nice. The cook stents, you just have a regular pusher that just goes straight up. But so now I'll say disengage. And so he's going to unlock, and then he's going to slowly pull back on this wire, I guess. Another comment on that stent is that the introducer catheter can be varied in its length before you actually place it in there. So if you know that you just need it up to the bifurcation, for instance, or the common hepatic duct, you might not need all of that introducer that comes set in the package. So you can always shorten it to whatever length is your liking. And you can always adjust if you need more. So it's very nice in that way that you can adjust live. So these stents, they do have flanges that help prevent them from hopefully migrating. And so you see my flange or my flap here. And I like to know that, okay, the stent is completely out of the scope, because sometimes you may run into trouble where you try to pull the wire catheter too early, and your stent can get stuck in the scope. But I know on this view, okay, my flap is out, my introducer catheter is out, and I see the end of the stent. So now in order to fully deploy it, we're going to pull this wire, and then you're also going to pull my regular wire. So now we're out. You got to pull this all the way out. Now we got the wire out. There we go. All right, sorry. And now our stent is there. But yeah, so it just depends on the preference. Which one do you use, Julie? I use this one because it's all packaged together, so I think it's the easiest to use. Yeah, we tend to use the crook, but I do like the fact that even this 7 French has an introductory catheter, because sometimes you need that a little bit extra stiffness just to get up through a tight stricture. Let's see. Okay, we're going to take a break for one second so we can take this stent out, and then we'll show a metal stent. Great, thank you.

ERCP procedures

wire types

sphincterotomies

knuckling technique

stents