Hi, everyone. We're just getting ready for our last session with cholangioscopy. So it's taking some time to set up the equipment. But while we're waiting, I wanted to just address some of the questions from our audience. One question was, is, do you ever use RFA for stent removal after tissue ingrowth? I think that's a really good question because we were talking about tissue ingrowth and obstruction in stents to have to deal with that, especially in malignancy patients. It's a good option. We know that there's some data for delirium malignancy, but I think probably the easier thing to do to deal with tissue ingrowth is to leave a fully covered stent. Uzma had talked about before that there's a little tip at the end that has to deal with tissue ingrowth, and that might be an area where you might want to consider RFA, but I would say that there's definitely more literature for malignancy. Another question from our audience is, what kind of stent do you use for EUS-guided hepaticogastrostomies, fully covered metal stents? I would say that, yes, covered metal stents is preferred just to mitigate the risk of biliary leakage, which can happen in anywhere from 5 to 20%. But obviously, then you have to deal with the migration issue. But in terms of trying to mitigate biliary leakage, I would say covered metal stents is the way to go. Last question is, do you have a slim duodenoscope? We don't at our institution, but the manufacturers do have the slim linear EUS scopes and also the slim duodenoscopes. They're 11.6 millimeter channel versus standard duodenoscopes that are over 13, and they have the same therapeutic working channel, which is great, 4.2. They're lighter, and if you can get your hands on it, I think that would be a great option. But currently at our institution, we don't have that. The disposable duodenoscopes are also slimmer in diameter, a little over 11 millimeters for the AMBU. I forgot about what it is for EXALT. We have our Boston scientific colleagues here who can also help us with that. But there are other disposable slim duodenoscopes if you choose to use that. We are back with our team. Thank you so much, Julie, for hanging in there. Yeah. Really appreciate it. I'm Linda Lee from the Brigham Medical Director of Endoscopy there, and I'm here with one of our phenomenal advanced endo-nurses, Tabby Grant. You heard her speaking earlier today, and we're going to be demonstrating, I think, two more things for you guys today. Stone extraction from the bile duct and then cholangioscopy with the spy scope. So first, we're going to talk about, I think, what normally people use the most, which is balloon extraction of stones from the bile duct. We're going to have Tabby kind of go over an example of a balloon and how she sets it up. So, Tabby, take it away. So we pull the balloon out of the package. It has two ports, one for injection of contrast, one to control the balloon. And then usually down here, there's a port, this happens to be an RX system, that you connect to flush the line. Every time you go down with a wire, you want to make sure that all your tubing is flushed prior to going in. I have put the wire down, and I'm going to hand off to her. And, you know, as you guys probably know, there's many different companies that makes these balloons, but it's a pretty simple concept. The balloon, you inflate the balloon upstream proximal to the stone, and then you pull it down. Now, you don't, if there's multiple stones in the bile duct, you don't want to pull all the stones out at once. You want to kind of go one by one as seen on fluoro. And then as far as the balloon, they come in different sizes. And again, this depends on what company's balloon you're using. Different ones, you know, go from eight and a half to 15. There's 15 to 20 balloons and kind of all kind of in between. So you just have to know what company's balloon you're working with. And know how big is your bile duct in your particular patient, and then just kind of gauge what size balloon you want to use based on that. There's also balloons, so most balloons, usually the injection port is upstream, so it injects proximal to the tip of the balloon, but there are some balloons that you can inject contrast both above and below the balloon, either at the same time or one or the other. So again, you just need to kind of know what company's balloon you have. Those and, you know, we don't have those balloons for the most part because they're more expensive. And so what I tend to like to do is I tend to inject contrast in the bile duct and then go above it, blow the balloon up, and then I, you know, drag the contrast down while my nurse is injecting above it as well. You know, when you're doing the injection. So we're just going to demonstrate. This is a model, obviously. And I have the wire with the balloon, we're going up. We don't have fluoro to demonstrate and I'm hoping that I'm above the stones now. So let's blow the balloon up. Awesome. And so, so in real life right you'd be looking at fluoro, knowing where your stone is, and then just going right above that stone inflating the balloon and then starting to drag it down while leaving. Can you show us the endo view. And so I'm starting to drag down. I might have bitten off too much more than I can chew. Oh, there's the balloon. I don't know where the stones are honestly. Yep, we didn't see any balloons come out. I mean, stones. Yeah, so I don't know where the stones are. Where's your put them tabby, like way in the intrapartic bile duct. All right, so I'm going up. That's real life right because sometimes you might see it on your initial cholangiogram, but sometimes they might float up and bloom up again. It does happen in real life, just like you said, so we're going to try again. I've gone up, I think, pretty high and I'm trying to pull down with the balloon, which doesn't feel very tight here so I'm not sure we're getting any stones. No, I don't know where the stones went. Can we get more stones in there are maybe not so high up balloon down. I would say that sometimes if you've got a duct that's really full of stones. One good tip that Linda sort of mentioned is to just try to take them out one by one, starting from the bottom and working your way up top because you don't want to be dragging multiple stones down from the top down because then you'll cause a sort of a traffic jam situation. And you know when you're pulling the balloon down, you also want to be intermittently looking at the wire, so that hopefully you're not losing the wire as you're doing your balloon sweep which I mean does happen. So certainly not the end of the world but that's where you coordinate with your nurse or tech and do kind of occasional floral I don't like to just keep stepping on the floral pedal, we talked about radiation safety earlier this morning so I just kind of do little taps of it just to check and see where the wire might be. So let's blow the balloon up again and see if we can retrieve any stones here. I also like, there's a balloon on the market that has outer markings. So once you do your initial fluoroscopy to see where you are ideal for stone removal say, you know, above the above the stone whatever that marking is on your balloon. Yeah, so I'm sorry guys I don't know I seem to be completely unable to take the stones out and maybe I push them all the way up into the intrapartic ducts at this point, pulling down, but we get the picture. Yeah, exactly. So let's show you guys. So as I said, I think most of us and Julie do you usually use a balloon or basket for, I'm a balloon girl. Yeah, I like I've used obviously both, but I think it's actually just for me more work to try to get the stone into the basket. And that's a lot of work for me that I don't want to do. And so I'm just really facile with balloons and so I almost never have to use a basket. Yeah, no, I agree with you. I mean I almost exclusively use balloon and it's pretty rare when I use a basket. So there are different baskets available. Now the the con to a basket is that it tends to be more expensive than a balloon. So that's just another kind of real world financial reason why we don't tend to use baskets as much. But again, there's different types of baskets different shapes. There's wire guided non wire guided. Obviously I think wire guided, you know, tends to be easier to use, especially if you're having you know difficult time getting into the bile duct. So, Tabby, can you show us we're just going to show you the basket here. So if you can zoom in on that you can just see the basket. And then, And then as Julie said, you know, once you get this up into the bile duct. This is very different from balloon right because the goal of the basket is you're trying to get the stone into the basket here. And, you know, usually I have the assistant close a little bit but I don't have them closed down completely on it. And the other thing you always worry about with basket uses you never want to get it trapped inside the bile duct. And so, you know, there's certain techniques certainly equipment and techniques that you can use to do emergent lithotripsy where you cut off the end of the basket and whatnot but not all baskets are like that. So if you have any concern, because the stone is a little big or, you know, oddly shaped, then you just want to be mindful and be using a basket that can be converted to something and then also make sure that you have the emergency lithotripter around so that just in case you can get yourself out of a potentially sticky situation. So you can kind of see where the stone is. But, yeah, I tend not to use baskets, very much unless I'm doing mechanical lithotripsy. So, now, actually, since I couldn't get the stones out with the balloon I know I'm not going to get it out with the baskets I'm not going to torture you guys. We're trying to do that but what we're going to do next is we're going to show you the kaleidoscope. And here it is. And I think honestly the the hardest part of kaleidoscopy is setting it up. Alexis and Tabby are fantastic at doing this and I'll just say a brief word about kaleidoscopy. Now there's two companies in the US, where we can that make kaleidoscopes, of course, Boston Scientific with their SPI scope which is what we're going to demonstrate here, and then Microtech with their IMAX scope that just came out this year. So the differences is that the IMAX there's two different diameters of the IMAX so the SPI scope is 10 French, the IMAX has a similar French and the smaller French diameter scope as well. SPI scope obviously has accessories that can you can use like SPI bite, SPI basket. And you can use all those through the IMAX scope as well. So I'm going to have Tabby kind of go through how to set this up. First, all right, we pull it out of the box. You take the processor over on the tower, and you plug into the tower. As this connection. And it locks in place, and it does that gives it its light source, so that you can have light. If you're doing SPI glass or IMAX you want to make sure you have a long wire 450 or longer. Because the length of the SPI glass, plus the length of the scope and the wire into the patient. You need the extra length in order to keep control of the wire as it comes up through here. You want to flush all the ports and accesses before you go down. You want to also flush on the end of this. There is a connection for irrigation through the phalangioscope and suction and you want to test and run all of those before it goes into the patient as well. So you would have the wire down through the scope into the patient, you would have that length out, you're going to back load the wire through the end of the SPI bite and come down until you get close to the doctor. So this is the SPI glass and the IMAX, as you know, you can see there's, there's two dials here with locks on them to move it in both directions up and down and side to side. So we're advancing, pretending like we have a wire and advancing the SPI scope down the channel here and then if you can show us the SPI, the phalangioscope image now. And this I'm at the elevator now. And then let's go back to Tabby here for a second I know I'm having you switch around oh actually they can see Tabby I think right. Yeah, so she's just gonna attach the SPI scope to the duodenoscope. So, the SPI scope, you said on the front, you pull the rubber around and it hooks into these brackets here. On the IMAX, you slide it up and the lock goes over the top of the biopsy chamber. And it can be a little difficult sometimes. Yeah. So when I'm setting up, I try to pull that rubber before I start to put it on the scope, give it a little less tension, when it's time to actually hook it on. And so now you can see we're at the elevator here, coming out, and you see the SPI scope. Actually, do you guys see the endo view. Yeah, we do. Okay, okay, great. And then I'm going to see if I can try the freehand. Get into the bile duct here with the SPI scope. And maybe we'll see the stones that I couldn't. I was just gonna say, this is real life. You're not sure if you have duct clearance, maybe your fluoroscopy image is not great. You don't have the best fluoro equipment. And you're really not sure you can just throw up the cholangioscope to really just ensure duct clearance. So I'm not quite sure what that white thing is I'm coming to book. Oh, look at that. So now we see some stones up there. That's cool. And then I don't know if we're at the cystic duct takeoff or if that's the bifurcation. But, you know, nowadays, the image quality is so wonderful. With the updated SPI scope and the IMAX did not used to be that way. You probably remember this Julie as well in the older days where it was not great to see. So cholangioscopy, I think we talked about this before. It's important to give periprocedural antibiotics because there is a higher risk of cholangitis. And that's mainly because in real life, what we will be doing is we'd be pumping water in to get visualization. But obviously, if you pump too much water in, you know, that's going to lead to pushing bacteria within the bile duct out into the portal venous system. And so you have to be very mindful of that and always thinking about suctioning at the same time as well. So I think Tabby, you know, showed you the various ports for hooking up the water pump as well as the suction. But that's something you should always be mindful of because it's easy to kind of forget when you're in the thick of things and just keep your foot on the water pedal constantly. And then just totally forget, you know, to suction intermittently. You can also lock. I don't know if you can zoom in on the spy scope here. And Tabby can show you if. Yeah, let's put this through for a sec. So this is a spy basket. Yeah. And then if we pretend that this is a wire, you can actually lock the wire by turning this, right? Yeah. So you just turn that clear plastic thing and it will lock the wire in place. Although you still have to be kind of mindful and look at the wire because in my experience, even if it's so-called locked, you know, when you're doing things, it can still move. And so this is the one port that you use for everything. So, you know, once you've gotten up there using wire guidance, you take the wire out. And then if you need to do spy bite because you're trying to, you know, diagnose an indeterminate biliary stricture, the spy bite goes down here. And then Tabby, you were showing us what this is. This is also a basket, much like the previous basket, just smaller. Oh, can you zoom in again on the... Yeah. So can you guys see? Yeah, it's a small, tiny basket. Can you show us the measurements of the basket, actually, the spyglass basket? Let me see the product. Yeah. It is 15 millimeter wide. Great. Yeah. That's kind of big. All right. So we're going to go down. Oops, sorry. Can you unlock that for me? Cool. So now we're going to go down with the spy basket. And now it can be challenging to get spy bite or spy basket. It's a different story. But spy bite, like if we're trying to get a spy bite down here and you're having a hard time, we do what we call walking the dog. Can you show us a cholangioscopic image now? So walking the dog is when the assistant is just opening and closing their hands. Because sometimes with these kind of very thin, skinny devices, and I'm actually having that problem right now, it can be hard for them to come out over the elevator. So I'm just changing my position. So as you can see, I've kind of fallen back with the spy scope. And then trying to see if I can get the spy basket to come out, which doesn't want to come out. So this is, again, oh, there it is. You guys see that? Yes. Yeah, yeah. Cool. All right. So this is, again, real life where things aren't working. So what I did here was I pulled the spy scope back and then started pushing the basket out again. And then that allowed me to overcome probably the elevator. That's usually where things get stuck. So now, oops, I don't want to push it up even higher. So now what I can do is I'm going to use my knobs a little. And then let's see if we can open up the basket. All right. So the basket's open. Oh, dear. Now I have a million stones. Uh-oh. So I don't think this is necessarily what I want to do, but we got some stones here. Let's close a little. Wow. Okay. And then I'm probably just going to come out with everything now. Everything meaning the spy scope. I'm just going to try to pull the spy scope out, although I think I might have bitten up. There we go. There we go. It's just as satisfying virtually on a model as it is in a person. Oh, my gosh. You're so funny. Oh, there they are. Oh, yeah. So let's see if I can show you where the stones are. I think we dumped them down. Yeah. So this scope is kind of stiff, so I'm having a hard time showing you guys. But as you can see, the spy thingy came out. So let me try to go back in, and I can show you that the stones are hopefully gone. All right. So I'm just going to try to get back into the bile duct. and then let's see oh we still have some stones here okay so let's go again okay here we go let's open up the basket cool and then let's see mm-hmm all righty try closing a little see if we capture the stone at all oh I think we got it now so y'all can see that and then I'm just gonna come out with the spy scope and then there's a stone right there very nice can you yeah yeah cool you can open up the basket and then we'll just kind of dump it in the duodenum what is the suction like in the IMAX kaleidoscope versus the spy um it's like what is it like it's very similar honestly I'll have to say you know from having used the IMAX several times it feels very similar the image quality is wonderful and I think the the main difference is that they do have a thinner scope than the 10 French and so for example we were able to use it in this person had an incredibly long cystic duct stump that was almost like a curlicue with a stone unfortunately at the end of it so yeah so so we were able to actually get the IMAX like all the way around but use the thinner IMAX to do that so I think that's that's very nice so yeah but the suction and the water pump you know it feels very similar to the spy scope so anything else you'd like us to demonstrate with the spy or any other questions from the audience can you talk a little bit more about the cholangioscopy accessories so you demonstrated the basket can you talk to us about when you would maybe use a snare snare so I and I'd love to hear you know your take on this too I'm not sure we have the snare to show you guys we can show you well let's show the spy bite just to show you how tiny it is and then we'll talk about the snare I'll see if we can locate a snare spy snare mom while we do that they're going to go back to the balloon can you talk to us about when you would want to inject above and when you would like to inject below oh got it so for me personally you know when I'm so if we're doing a stone case then usually I'd like to do an occlusion cholangiogram at the end unless they have cholangitis if they have cholangitis I don't do that but if they don't have cholangitis and I will do an occlusion cholangiogram and so that in that case you know it's always injecting above why would I inject below that would be if perhaps there's like a lot of stone burden in that person and I'm and the duct is really big and I'm just not sure if I did get all the stones out honestly another time I do it is if there's any concern for like retroperitoneal perforation you heard about perforations earlier then I like to drag the contrast down below the balloon so that I can see and make sure that the contrast is not extravasating out so those are the main times when I think about you know either injecting below or having contrast below me as I sweep down with the inflated balloon yeah I agree I think I mostly use injection above and even if I want to look at a perforation down low I'll just actually have the balloon inflated but out of the papilla actually just really wedged up in there and then inject above from there and I could see and assess in that way as well so but yeah it's hard to sometimes stock both above and below balloons and like I said might not be a cost-effective or efficient way but sort of thinking outside the box with the balloons that you have yep exactly so this is spy bite if you can zoom in on the tiny spy bite here which can you open that yeah do you guys see that yeah we do and we see how tiny it is so you know you think oh my gosh you know this is gonna resolve all our issues with indeterminability of strictures and unfortunately not because it's such a minuscule bite of tissue and and you'll be you know yeah you heard about this earlier today from dr. Widmer's talk but yeah it's tiny bite of tissue you can only do one at a time which is kind of a pain because if you're having a hard time getting it down you know an out of your spy scope you know then you're like walking the dog multiple times so it can certainly be kind of a pain to do but a great accessory I don't have the spy snare to show you but basically it's just a tiny snare and I think that I have not used it much at all but you can use it for example if there's a migrate a stent that's migrated inside you can kind of you know try to go up there with the spy snare through the spy scope visualize the end of the stent and then try to capture it you know with the end of the snare so I think that's kind of a a nice indication for the spy snare have you used it much at all Julie no I would agree with you Linda that there's I haven't really had much need for it or I haven't found where I would really use it but definitely when you're in a jam with trying to grasp things snare the snare is a is a useful option I would also advise people for spy bites that you should write actually in your pathology notation that these are micro bites because sometimes your pathologist you know they're going to be expecting you know regular gastrointestinal biopsies and when they don't see actual pieces of tissue floating in the formalin jar they might just throw it and say no there's no specimen here that you really worked hard to get so you really want to just write on there for your pathologist like micro bites please be aware so that that might help and then once your institution's used to it then they sort of have a protocol there agree what do we write on there all ours but we put an orange sticker that says minute yes everything the path slip itself the jar the jar lid yeah so that they're well aware that there is something in the jar right right to avoid exactly what you just said Julie because that's heartbreaking yeah no it's heartbreaking when they throw it out and it's like oh my gosh you know it wasn't just a simple forcep through an EGD scope this was like a lot of work to get it yeah yeah any other questions or things you want us to show you guys no questions really from the audience about cholangioscopy I think that it's really nice that we have another option on the market for a disposable cholangioscope and it's nice that you know if you can get your hands on it to find the subtle differences but I agree with you the slimmer one particularly if you're doing work deep in the deep in the bile duct and maneuvering through cystic ducts it's definitely stiff it's definitely heavy and so that that option is very nice for us yeah and it might be I have not used the IMAX and the pancreatic duct but you know that might be another nice area you know with the thinner scope as well yeah yeah definitely it'd be very interesting the more experience that we collect with that yeah no I agree and then you know I'm sure Boston Scientific would prefer if it was still just a monopoly on their part but I personally think it's always nice to have more than one option not just from a financial point of view but also I think you know competition makes people better you know as long as it's not malignant competition you know but I think to a certain degree it kind of makes people think a little harder and kind of try to improve their technology so yeah yep I'd also just mention that I actually use short wire with my spy spyglass and you can do that only because I am such a short wire system person that I don't like to use a long wire but if you really wet your equipment and you flush it you can what you know float it like you do with like a glide wire same idea but you can use a short wire and not have to open it up if you happen to just be a short wire person so just FYI for those of you guys out there who are in the same position as I am yep yeah agreed so any last thoughts or summations about cholangioscopy stone removal I think one of the audience members brought up an interesting technique actually that I use all the time which is this torque maneuver with when you're pulling the balloon out particularly if you've got a really big stone and just not a simple easy pull through that's a good point that the audience member brought up because your scope maneuverability is much stronger than you tugging on a balloon and so that torque rotation at the very end of the duct to pull out sort of a large stubborn stone is a very valuable technique I totally agree that's an excellent point and I also use my body quite a bit where I kind of move and rotate my body as I'm holding you know on to the scope or the balloon and and the other comment I'll make about kind of large or difficult stones is I love balloon sphincteroplasty I think that is such a fantastic easy technique in the U.S. you want to make sure and do it after a small sphincterotomy because the randomized trial there was I think at least one person who died of pancreatitis when that wasn't done so which is not the case in the far east the literature is kind of weird because in the far east they seem to do fine even with just balloon sphincteroplasty without sphincterotomy but here in the U.S. you must either do one or they must have had one done and then you do your balloon sphincteroplasty and then you know you make sure just blow it up to the diameter of the distal duct because obviously you don't want to over inflate and use like a 20 millimeter balloon if the distal duct is only 12 millimeters or something but I love that technique and it's just beautiful to see that huge orifice and then the stones just kind of come tumbling out. Yeah I think that's a great technique and I just employ the audience to give some guidelines for these maneuvers and dealing with second line advanced procedures for choledoacolothiasis and then just some final thoughts about training because I know that's sort of been a big topic. Linda we were talking about you know what can you do or what advice you have and Tabby you can sort of chime in on this because you guys are very experienced up there of training your staff to do ERCPs. Do you have any special tips for turning a general GI staff to do more therapeutic procedures like ERCP? Yeah so I mean Tabby can speak to this you know more than I can I think but I agree that that's not easy and I think we still struggle with you know what's the best way to do this and in a large part we've struggled a lot because we've been so understaffed for a long time so it's just been very challenging because honestly I think what you need is time and consistency in that room. It doesn't work for a new person to be in that room like one day and then two or three weeks later they're in there for another day and then a month later they're in there again you know that that's never gonna work so you really in my opinion I think you need someone really in there every single day for at least a week ideally if not longer than that and then once they've done that though again you don't want them to not be in that room for another three months you know you want to kind of be on top of their rotation and making sure they're kind of regularly rotating back in so that they're building their skills and not constantly going back to ground zero and kind of relearning everything but I think you know they I don't think they should immediately start on the wires I mean I think they need to start by you know helping set up the table you know figure out where the equipment is what all the different pieces of equipment are and maybe do hands-on with the different reps you know for whatever companies that you use to have them show them you know how a tome works how a balloon works etc etc and kind of start with that kind of training before they actually then move on to manipulating wires etc etc but tabby I would love to hear you know your thoughts as well I 100% agree we start our new nurses in that room and they work with the tech or with the nurse as the tech and we go through table setup and room setup where the supplies are being able to pull the supplies from the cabinet in the dark before they move to going on to the wire and then when they go on to the wire we try to keep them on the wire for days at a time so that they get that tactile feel that you gain with experience and then over time it comes along we it's not always easy because like Linda said we have been short we are starting back into that process now we have a bunch of new people that have been going through and three weeks really is kind of a baseline three to four weeks of just doing ercp and advanced cases is kind of where you need to be before they're ready to run with it with an advanced tech or somebody that knows as their second person yeah and I think the other thing I'll say is that um you know I don't think every single nurse or tech uh is cut out to be an advanced endo nurse or tech just like every single gastroenterologist is not cut out to be an advanced endoscopist so you know I don't so I think it has to be a marriage between their interests because if they have no interest in it then it's kind of you know really bad forcing them to do something uh but they should be interested and they should also have some kind of aptitude because it does take you know clinical skill to be able to do uh I mean obviously we're talking about ercp but advanced endoscopy is so much more beyond that so it does take a lot of technical ability on the nurse and tech part as well yeah I agree with you I think uh you know emphasis definitely on collaborating with your industry partners um you know the reps are there they're eager and it's their job to come into your unit and supplement the education um on their devices and just basic skills on exchanging and all the things that we sort of talked about today so I would definitely employ everyone to reach out and become very friendly with your industry partners because uh you know it's a team approach and they want your unit to be as successful as you want it to be um so reach out to them and use them as a resource and they're happy to do that they're yeah they are yeah because it's more a busy for you is busy for them that's right um and then we sort of touched about it this morning but I guess at your institution you guys don't have a hard fast rule as to the ratio of ercp staff um versus to how many you know ercp procedural lists or procedures that you do um can you guys talk about that yeah I mean I'd love to have tabby chime in on this as well but no we don't have a hard and fast rule um you know part of it you know in honesty I alluded to some staffing issues um so we lost a lot of uh experienced nurses and whatnot who were very good at your cp and um and it's it's taken us time to start to kind of rebuild some of that we're still in the building process um but you know I again I'd love to hear tabby sauce because part of the problem and this was alluded to earlier today is taking call you know because if you only have two advanced endo nurses who can do ercp you know it's kind of tough to make them be on call like every other weekend or every week um so so that's part of our challenge is that because the nurses rotate through weekend call you know there needs to be a certain number of nurses who are able to do this so that it's not just like four nurses who are constantly on call I agree with that we have about 12 so we run about every 12th weekend of call currently um we try to have two to four advanced endoscopy nurses on during the day but we run multiple advanced rooms not just ercp and most of us that do ercp also do other advanced procedures so we have enough that we can run two to four advanced nurses every day so it's based on your we need that only because we do that much volume if you had just one advanced room you need at least one advanced nurse and an advanced tech or a second nurse per room that you want to run every day and if they work 12 hour shifts then you're going to need several in order to cover paid vacations and days off and those things so without knowing a unit I mean if you're running I would say two per day per room that is advanced would be a safe number to have on your staff yeah it's it's a real life issue that you know I've really exacerbated after the pandemic and it's it's it's valuable for the endoscopy unit to have trained and dedicated people in the long haul obviously and sort of the final follow-up for a question from our audience was does the asge e provide nursing certification for advanced endoscopy and the answer is no we don't have that currently but the asg is keen and understands how important that issue is so stay tuned yeah and it's actually interesting that you raised that issue of certification because raju from md anderson he has started this whole program focus on techs down there at md anderson where he's partnered with a community college down there and there's I forget how long it is if it's a year-long program or six months or something but this is designed for techs now not nurses but goes through that whole program and they do get some kind of you know certification at the end of that um so I think you know hopefully that kind of thing will expand um you know for techs and I agree you know as far as nurses go but I don't know about sgna does offer some quite a bit of education around ercp they also partner with the abcgn to do nursing certification for gi nurses so there are options out there for nursing staff through the sgna and the abcgn to get those certifications and those hours and they do offer some hands-on courses I would have to look on the website to see when they are throughout the country so there are options out there for nursing to get more education but a lot of your learning is going to come on your unit great thank you so much for that and all those additional resources um so we're just wrapping up do you guys have any final words um go for it tabby I hope you find this interesting we need more nurses to come into gi yeah no I mean I think you know for those of us who do it um and I know you share this opinion julie it's a ton of fun um I love ercp it's still so gratifying you know when all the pus comes out and we pull all these stones out everybody's oohing and I you know even though right yeah totally just like you were saying hey it's cool even though this is like spy scope you know you're seeing the stone come out right it's like the same thing so so it really is a lot of fun but you're helping your patients immediately right get better so so I think it's such a huge privilege that we're able to do that uh for our patients so um yeah so definitely we need more nurses and techs who would love to to do this and join us and team up uh with us on doing all this stuff great thank you so much guys um so this is the conclusion of our virtual uh hands-on training thank you so much for your attention and we'll see you tomorrow

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