Siddiqui. And this is... Hello, my name is Steve Regner. I'm a therapeutic endoscopy physician, I almost said nurse, at University of Chicago. And I'm one of the nurses at University of Chicago Medicine. So, you know, our goal with this virtual session is to go through the same hands-on stations that are being taught here in Downers Grove. And the first station that we were going to discuss is just biliary cannulation. But before you even get to cannulation and your scope down in front of the papilla, I think it's really important just to review a little bit in terms of the preparation that we do with our equipment, starting with the scope and then moving to what kind of sphincter tome or cannula that you're going to use to cannulate. And if you were listening in the lectures this morning, you'll see that everyone has a preference. And I'll talk to you a little bit about what we like to use in our unit, but we also have different companies and products here. And so the first, I'll just show you this ERCP scope. This is a Fuji duodenoscope. All duodenoscopes usually have a 4.2 millimeter accessory channel. And that's very important because you're going to be passing 10 French devices, whether it's stents, cholangioscopes, and you want to make sure that you have easy passage of your devices. Most scopes now for ERCP are going to have, if they're reusable, they're going to have some sort of disposable tip or what we call a novel duodenoscope design. And then there's obviously completely disposable scopes. We use Olympus in our unit, but Fuji and Pentax both have disposable tips. So if you can just show the tip of the scope here, it comes uncovered. And then Steve's going to demonstrate how you, most of them are all very similar, how we just kind of pop that cap on. So most of these caps are fairly simple to apply here. You want to make sure your elevator is out of the way and gently slide the cap over, making sure that it has a very snug fit over the tip of the scope. And sometimes with these disposable caps, they can get a little bit twisted during a case or when you're putting the scope down or pulling it out. So it's just important to make sure that it looks like it's properly fitted before you put the scope in. And then also when you pull out, make sure it's still there because there are reports where these caps can fall off. So then we'll move on from the scope to our equipment. Some people like to use just straight cannulas. And depending on their configuration, there are some that only let you, that are single channel and only let you do an injection or a wire. Everything I use typically has at least two channels so we can do a wire and injection both. I always cannulate with a sphincter tome. My go-to is a long wire system with a dash sphincter tome. And one of the advantages I like of this one is that it has this dome tip where it kind of tapers down at the end. And for me, I feel like it's really nice to kind of slide into the, engage, slide into the papilla and engage it so that you can get your wire. And then my go-to wire is an O2-5 Visiglide wire. Most wires are always going to have a hydrophilic tip. You want to make sure that everything has been flushed with water ahead of time. In the lectures, again, you were hearing that everything needs to be flushed and just soaking wet because once things get really dry inside these catheters, it's really hard to exchange and to move your wire and tomes in and out. But Steve, if you want to just demonstrate. Yeah, that's a big thing to harp on as well is the wires really don't like any other materials. Contrast especially also can make the wire and catheter feel very sticky and difficult to pass. So usually these products are now coming preloaded with a wire. The exception to that being obviously our comfortable setup. Our usual setup, the devices are coming separate. So we are prepping them separate. We did go through that beforehand. And so I just took some saline or water and flushed this hoop. There's usually an extra bit that comes at the back here that's like a rubber stopper to help you from splashing water all over yourself. But generously irrigating the whole hoop and the wire. And then as you are advancing the wire in, just make sure there is a little slide here on the dash tome that is able to tighten around the wire. You're going to want to make sure that is open before advancing the wire. Or loose. And then when he injects contrast, he's going to tighten it. And then also you want to know for your tomes or cannulas what their diameter wire is able to handle. So for this particular tome, it comes in different versions. Some are O2. We can put an O2-5 wire. This one can put an O3-5 wire in it. And all the sphincter tomes, they always have markings that kind of help guide you as to how deep you are into the bile duct and where you're going to have your cutting wire extending. And there's various lengths of cutting wires as well. And again, that's up to physician preference a lot. And then on your end, if you want to show how you can bow the cannula or the sphincter tome. Okay, so this golden control here is just the area that we would use to bow the catheter. And if you pay attention to both my hands and the tip of the catheter, as I squeeze, it slowly will bow. Typically at the start, there is a little bit of tension that it will slowly begin to bow. So do give it a little bit of time because if you just mash down fully on this, as you notice, there is another gold stop. And I am not completely, right over here, I'm not completely bowed up. If I go completely bowed up, it can sometimes fold or kink the catheter. So just be cautious when you're initially bowing to go slowly and wait for the catheter to respond. There is some delay in feedback. And then especially if you're utilizing Boston scientific tomes, they have a slightly higher range of motion when it comes to the bowing motion. So very important to kind of just be cautious. And there's also some sphincter tomes that are able to rotate as well. There's one by ConMed that's newly out that can rotate fully. And depending on the papilla configuration, you may have to kind of cannulate the bile duct and then adjust your scope position and maybe angle the sphincter tome wire into an appropriate cutting angle between 11 and noon. Sometimes, or what I like to do is I tend to, once I get into the bile duct before I cut, I'll go into a long position and that usually always lines up pretty well. But then going back to the sphincter tome, Steve, what do you got connected here? So again, right now, this would normally be the contrast port here. Right now there's just water going to that. But that would normally be your contrast port. Again, once you're going to inject contrast, this twist here basically just tightens against the wire. That is where the wire inserts. Again, this cook product is a long wire only. But once it's time to inject, you'll want to tighten that around the wire and I can kind of demonstrate. So if you don't tighten it all the way, you get a nice little fountain that comes back at you. So it is very important to make sure that is fairly tight. In case you forget to tighten it, you will soon remember. One important note though is if you are going to move the cannula tome, once that is tightened, it will pull the wire with it. So it is also important once you are done injecting, you want to absolutely loosen that back up. Otherwise the wire will not be mobile inside the tome. So if you get your wire in a good position and then tighten this and forget to loosen it back up, you run the risk of removing your wire if you move the tome. And then the key to any good sphincterotomy is having a connection to your generator. And that always has to be connected. So every now and then we might forget it. And your patient or in this case our pig model has to be grounded. And in this particular case, we are connected to an Irby generator. I do not know if you can show the settings here. But this is the new VIO3 version. And most of us who use this generator, you are going to use again a blended current, usually an endocut setting. And then typically if you are going to use force coag or even soft coag, that is going to be once you are doing some sort of hemostasis like with a bicap probe. And then we will show you also a Boston Scientific tome which can go long or short wire just to have as a comparison so you can kind of see the difference in the tips. And also for those of you who go short wire, this tome has the ability to be strict or what we call when we pull the wire down to where the short exchange part happens. And this can come preloaded or without a wire. So as you will see on camera now, this is the portion that you would be able to strip down. If I turn this here, if you pull up, it will strip downwards through the catheter. And kind of important note intra-procedure, it has happened on occasion that during if you like to start as long and transition, if this begins to strip the wire down, it is very difficult to maintain in a long position. More often than not, we will suggest going just straight to short once you are in. So that is just an important note about the transition on this one. If you notice the wire is kind of starting to buckle out of the long position here, it is best to just move to a short technique. And then if you can just show the tip of the the tome again, just a little bit, we'll pull the wire back a little bit. You know if you just compare the tips of the tomes, it's up to physician preference, but if you compare them, the Cook one is a little bit more tapered and the Boston one has a little bit more of a kind of blunt end. Again, both great tomes though and can get your get you cannulated easily. This can also take an 035 up to an 035 wire, and if you want to demonstrate stripping. Yeah, so once you're down into the scope and you're past and the request is to strip, you would just basically pull up, hold, support the wire in the back so you don't have any tip motion, and strip wire down. Typically you will have a portion already down the scope, so you would just strip all the way down to the point where your cannula enters the accessory channel. And I think that the way you do it is great because sometimes if you don't kind of use a uniform passage of your thumb all the way down the tome, sometimes you skip areas and it may not come out of the catheter all the way, so you try to just make it one long movement. We're going to keep stripping. So if you start long, you can just pass the tome down, the wire will be controlled till you're in, and then you're going to strip it down, and then you only have wire just in the very tip here, and then you're going to lock it. But say if it was already short and you're passing it down, you need to pass both the tone and the wire, or say if it's a balloon, you need to pass both of them down together to make sure that they're both going to get to the end of the scope. And when you're pulling your wire, if you're controlling the wire now at the accessory channel area, you got to make sure you don't pull it too far back because then it's going to come out the side hole where you have your short exchange happening. But the advantage with short exchange or a short wire system, A, the physician can control the wire throughout the case. Sometimes that's helpful if you don't have as experienced nurses as I'm lucky enough to work with, so you can control that. But, and also it's just quicker, right, when you're trying to exchange out a long wire system, you do want to coordinate with your assistant and make sure you're in sync so you don't lose access. But with the short wire, once your wire is locked, you can pretty much bring it very quickly up to the accessory channel, and then you just have to exchange over a couple inches versus the entire length of the tome. So, but both are excellent. And similarly to the other one, you're going to have an area where you can put your contrast and where you can connect your tome. But I don't know, Julie, if you can hear us and if there's any questions from the audience. Hi, guys. Can you hear me now? Oh, yes. Thank you for going over the equipment for cannulas, sphincter tomes, various wires, short and long. We don't have any questions from the audience right now, but I encourage our virtual audience to please chime in with any questions that you have. The beauty of a small group such as this is that we really can get intimate with our questions and really get individual attentions to really anything that you'd like us to cover. There's going to be a lot of devices today, so we can definitely do that, both on the physician side and on the staff side. And it would also be helpful if the virtual audience can also type in in either the chat or the QA where you are and what experience you have with the ERCP. If there's any burning questions you'd like for us to cover, that would be appreciated. And Julie, I think it's interesting, you know, as we learned this morning, everybody has their preferences on equipment and devices. So I do a long wire. I use a dash sphincter tome and an O2-5 angled VisiGlide, which actually we hadn't touched on before, but your options are a straight or an angled tip. And I think this is an example of an angled tip if we can show that, but what's your preference for your ERCP? Yeah, so, you know, it's all very endoscopy preference. I trained with both short and long, but I have to say that because of efficiency and also for control, I do like the short wire system. So I use the RX. Most of the time I start with an O3-5 wire straight. It could be any kind of O3-5 wire. I've switched also to O2-5s. I do like the VisiGlide O2-5. I think that's a really great wire and it really can get you into some situations where you might not otherwise. And also it's not too difficult to use like the O1-8s, but I only use angles if I have to get into a certain area like higher work or if I want to get into the cystic duct that I can't with my straight wire. I think, you know, people might ask why don't you just use the smallest one? Isn't it easier to maneuver? But, you know, as you know, when you use those O1-8, O2-1, they're so small. Sometimes it's hard to visualize on fluoroscopy and also they're not stiff enough really to deploy a lot of your stents over. So you probably use them to gain access, but then you, as soon as you do that, you're going to switch out for an O2-5 or an O3-5 wire. I like angled because I feel like sometimes it will knuckle if it's a little tight space or an angulation in a Sharpay kind of papilla and that'll get me up. So it's just, that's just been my preference. But again, there's no objective data that says one is better than the other. But now any other equipment you think? We covered wires, tomes, cannulas. We do have a question from the audience and we'll probably want to go into the VisiGlide wire a little bit more and the angled VisiGlide and if you can rotate it, please. Oh yes, actually Steve was just showing you. I'll hold this. Thank you. This is a great example of when it's nice to have an assistant who's really good at manipulating the wire, but I don't know if you can zoom in on the wire tip. He was kind of showing how easy it is to rotate this wire. And one thing I will note as well is occasionally if we already know it's a previously difficult case or we need to get into specific locations, I'll actually change out my gloves to a smaller size, which can be uncomfortable, or if you actually have access to sterile gloves, sometimes they're a little bit more substantial and give you a better feel on the wire. But that's dedication to the cause, so a little discomfort, but then you're doing it so you feel the wire better. I know some people even sometimes kind of tear their gloves a little to actually feel it on their finger, but I do not recommend that. I think you definitely need gloves. But even if this was a straight one, I think it's very nice for rotating, which is again why I kind of, I like this wire. The feel, especially with the 025, it feels similar to an 035 in terms of being able to deploy all your stents over it, but has the additional flexibility of a little bit smaller wire. But it's kind of pricey. Can we zoom in on your hand, Steve, while you're rotating it from the handle perspective so the audience can see how you rotate the wire? Yeah, absolutely. So there are devices, torque devices. Generally we avoid torque devices just because with the amount of distance we are going to be using in the case, they're a little bit inconvenient and time consuming. So that was one of the big reasons I just switched. And then it's just a pill rolling motion in order to twist. And sometimes it takes a little bit of extra grip, but very easy. Now you may get into situations intra-procedure where you feel like it is difficult to rotate and you should definitely either focus on adjusting tip. Sometimes you can be against tissue and make it very difficult to rotate. So this is very much a feel kind of technique. There is a lot of tactile feel involved with once you get into like specific direction of wires, especially when you're trying to either pass stones or get past strictures. There's a lot of feel involved with the movement. And oftentimes we'll even use our fluoroscopy. You'll almost see the wire bounce off, say a left-sided duct and you're trying to get in there and it keeps going in the right. So it can help you kind of focus in on that. But even when you're cannulating, you may just need to move it a little bit. But I would say for cannulation, probably we're not doing as much rotating. It's usually higher in the duct. But again, it's nice with that angled tip because it can knuckle and get you up there. So yes. I think it's also good that we showed that because you may not stock those rotatable shrinker tomes. You might have just regular tomes and you really want that rotatability. You don't have to all out purchase it. You can rotate this wire, which is a lot more user-friendly. So it's a nice option. And also those, I mean, sometimes with those rotatable tomes, they say they rotate, but once you're down in front of the papilla, I would say the rotation is not always optimal. And sometimes then it kind of deforms the tome a little bit. So, because you can try to rotate all of them a little bit, but, and then also one thing we didn't bring up just in terms of having a wire lock on your scope. I think that's obviously really helpful in terms of also just kind of giving you the ability to lock your wire and you can, there's all different brands out there, but usually you can lock at least two wires and then that way, you know, you have a little bit of security, especially, you know, if you have a tough case that was hard to get into. And this one actually has a seal on their cap as well to prevent bio from kind of leaking out. All right, but then we're just going to pass it down. We're using chicken hearts, which do remarkably look like a papilla and, you know, before you cannulate again, all of us faculty, despite our differences, some things are going to be uniform for everyone. You want to try to get in really good position and look at the papilla for a second. You know, is it one of those really tiny ones where, you know, it's going to be a nightmare? Is there a lot of redundant tissue on the intra duodenal segment? Is there a tumor there? Because all of these are going to help you go through your algorithm of how you're going to, you're going to cannulate. But it all starts by getting in front of it. And ideally you want this on FOSS position, because then it helps you stay close to the papilla, visualize it fully, and then you can try to kind of get under it and then cannulate. You almost want your tome to make like a little U shape and then go up towards the 11, 12 o'clock position. And also depending on what the papilla looks like, you know, if it's a very tiny, tiny papilla, I don't have a lot of room to needle knife. And depending on the indication, I may go to an EUS rendezvous as my next maneuver. If there's a lot of tumor covering up the papilla, trying to needle knife into that can be a little bit dangerous and be not that easy. You're going to make a lot of false tracks. So you may again, switch out to some other technique. All right, so we're just passing it down now. And then so our elevator was closed. Now we're going to open it a little, and then we're going to try to position. I try to kind of stay a little bit close and I almost use the bend in the scope actually to help me stabilize because my goal is always to have the left hand be able to, my thumb especially to move the elevator and my big knob. If I move the big knob towards me, it's going to move the papilla towards me and away. And then I'll use probably the scope shaft a little bit more for my left, left, right. And then you want to kind of line up and then always kind of be going upwards a little bit. So once having, I do the touch technique, so I won't keep the wire outside the tip unless it's really small, then I might do the wire. But usually I'll engage the papilla first and then I'll say, Steve, try the wire. And also, you know, we're looking at our angle under fluoroscopy. And one little note for the staff as well that are supporting the operator, as you're coming out of the scope, just verify that your wire is right at the tip. It's very helpful to know that way you're not going very far with these, the cannula we're using, it's obviously easy to see the wire come to the tip. The faucet has a blue tip that you cannot see a lot of times that the wire is exactly at the tip. And then as the cannula in this case goes into the papilla, we like to use like a knocking technique, we call it, where I'm just basically gently tapping the wire forward. And again, this goes back to the tactile feel that we can feel once we've engaged into either the bile duct or pancreatic duct. Oh, it looks like we're in. I don't know if you can show the model, but it's harder to feel on this one though. Yes, there is no feel here. But I can tell. And again, a lot of times we'll feel it or I'll feel the wire give a little and the key is don't just watch, watch your assistant or if you're controlling the wire, once you that wire is going in, then you want to follow it up with the tome. And then I'm going to inject to confirm I'm in the bile duct. So you see these markings here, they're basically, I think every five centimeters. So it just kind of gives you a guide as to where you want to cut for this particular tome. I like the gold is kind of what your goal is on just having a little bit of tip of the tome and cutting wire in the orifice because you don't want to cause a lot of charring. The key is you want to just, when you do your sphincterotomy kind of splay the mucosa open and less charring, less heat effect at the papilla because you don't want to cause pancreatitis either. And if you see the end of you, I kind of have that U shape now that I was talking about where it kind of makes a U and then the top part kind of, it goes into the papilla. And then once we're ready, I'll say, okay, let's get hot. And then you will put the wire this. And again, we got a grounding pad on. And this looks pretty good. And then bow a little bit. You want to make sure you're also outside of the scope completely and that you're not charring inside the scope. Sometimes with these chicken hearts, we might have to use a little bit higher current. So there are different cutting wire lengths. They come in twenties, thirties. Is there a cutting length that you prefer? I think we use, I think it's 20, is it 25? It's around. It's the shorter one. What do you use? I use a shorter one as well. I was wondering if there was be any time there'd be advantageous to use a longer. To me, I don't think so, but you know, I guess some people, depending on how they cannulate and how close they are, they might like to have that. And then some have kind of a protection so you don't cut the fold on top of the papilla if there's some overhanging mucosa. So there's different variations on it, but usually we have a smaller cutting wire. And this one actually, we can show you on the package. Let me see that package. I believe this one is a 25, which is what we use. I don't know if you can still, cause these always tell you kind of the dome diameter, the length of the cutting wire and the length of the entire catheter. You also see that you need at least a 2.8 millimeter channel, which we have. So for some reason I am not cutting though. Let's see. We might try. Sometimes these chicken hearts are a little bit harder to cut. Yeah, it might not have good contact on it because of where the pad's at. We're not getting an error message though, but we may have to pretend a little bit. There it goes. Got a little bit. It's not really doing it though. We're having a little trouble here. Well, let's pretend then. There might not be good conduction between the chicken heart and the stomach. I'll have you hold this for one second and then I'll just show kind of where we want to cut. So ideally if we're engaged, it's going to be kind of between 11 and noon there. So I think some of the good time to talk about some techniques to really get yourself in an ideal position for cutting. So definitely want to make sure that you really splay that tissue. Some things that I like to do is I like to actually insufflate air at the time of the synchrotomy. So I really know that the duodenal wall is really opened up. And then just making sure that the cutting wire is really taut against the duodenal tissue. And then again, we talked about this morning the importance of cutting to where you need to. So that usually means duck size and or to the duodenal limit. Correct. And I like to go long most of the time. This tome, a lot of people sometimes say it does veer a little bit right. So you do have to angle sometimes a little bit left. But if I go, if I go long, which I can't really do in this model, my alternative is just I'll just angle a little bit left. This is not an example of splaying the tissue. But again, it's just a little bit different model. But ideally, just that very tip. I would also say for troubleshooting, when you see that you've done really everything you can, you think you have good apposition to the tissue, but you're really just seeing sort of just a charring effect. That's a good time to just step back and reorient yourself to see if you can get into a better position and really splay out that ampoula a little bit more so that you have more cutting one to one and less charring. Correct. You can also try to adjust your settings a little bit on the generator for this purpose. Can you bow? Bowing up. But for the most part, I don't adjust them too much. So we kind of put where we started it. Let's see. It's starting to a little bit. So I shorten the cutting duration, sorry, lengthen the cutting duration and shorten the cutting interval to try to get through this chicken heart. But usually there is something either with your grounding pad not making good contact with the skin, or like you said, you're not making good contact with the tissue and then you're getting kind of either no effect or a charring effect. So and then again, as you're doing it, you want to make sure you stay in the plane. Obviously, if you go too far to the left or right and you see a perforation, your goal is get in the duct and then put a fully covered metal stent and leave that in for, I would say probably around six to eight weeks and then come back. The patient should totally do fine. And otherwise, if you do a normal sphincterotomy, when you inject contrast for your cholangiogram, you just want to make sure there's no extravasation. If you notice there's bleeding during your sphincterotomy, I would finish the sphincterotomy and then usually my algorithm is I'll try balloon tamponade where you blow up the balloon just at the ampulla and kind of press it up against the papilla for maybe a minute, see if that stops. Then I might do some bicap at the apex of the cut. Then I might try some epinephrine injected again towards the apex of the cut. And then I'll go to a fully covered metal stent. I do tend to put a plastic pigtail stent through the metal because if you have a lot of clots or even if you had a lot of stones, sometimes they can just clog up the metal stent. So you want to make sure you maintain patency. All right. This cutting may not work. So any questions from the audience at this point? I think we're good. There is a general question that we can probably talk towards the end about a situation probably that we're all dealing with staffing, but how do you train a general staff person to start doing ERCPs and other advanced procedures? Are there any guidelines or recommendations from the ASG or other resources that they can look for? I don't think there's anything official. I will say, you know, Steve joined our unit, how long has it been now, two years? And we have a very rigorous onboarding for our nurses. Sometimes I think it's even more than for the physicians where it's about, is it a six month period? It's time. A large portion of it is time and getting used to the different techniques. Just because typically, at least in nursing, I can't speak for on the tech side of things, but on the nursing side of things, it's getting used to a completely separate set of products. And then you have to have the desire to be involved in these cases. Without that desire, it's kind of difficult to, you know, train that into somebody. So you really have to want to be involved in these cases. Yeah. You're not a passive observer. But for our nurses, you know, they're assigned, you know, their trainer, and then they shadow them in cases initially just observing, then they'll, you know, start doing one task at a time, whether it's just setting up the equipment before we pass it down or manipulating the wire or, you know, passing us other pieces of equipment, and then you're solo. But for us, it's six months, but that's just something that's been created at our institution. But I don't think there are any national guidelines. Julia, your place, what do you guys do? We do the same. I think the most important thing is desire to want to do these higher level cases. And then we do the buddy system, as you say, with shadowing, lots of hands-on piggybacking for a duration of time. And then again, flying solo when we feel like that they're ready, starting with, it's sort of scheduled where you start with some cases that are more basic, and then move on to more that are heavily tech and resource involved. One thing, when I was talking about going into long position, where you kind of push in the scope, rotate clockwise, I don't think I can do it here, but you want to make sure your wire is up far enough so that you won't fall out when you go long. And then one other tip, sometimes you can't 100% tell where your terminal kind of horizontal fold is at the edge of the papilla. So what you want to do, you're thinking, oh, did I cut enough? You know, I'll cut, and then I'll have my assistant bow all the way. And then I'll see, okay, can I pull the tome out easily without any resistance? So here there's a little resistance, so I would probably cut a little bit, well, not too much. I might cut a little more, but it's coming out. Unbow? Unbow. I might have rotated our chicken heart, but yes. All right, I think maybe we'll just stop here for a second. We're going to switch models and then go to the next station. Okay. Thanks guys. All right.

biliary cannulation

endoscopic retrograde cholangiopancreatography

endoscopes

cannulas

sphincter tomes

wires

scope preparation