It's my honor to introduce Dr. Martin Freedman, who needs no introduction. Can I call you godfather of ERCP? I was going to say grandfather, but I don't want to. I'm the son of godfather of Jack Benes and Steve Zoller. All right, we could say that. He's at the University of Minnesota, and he'll be talking about endoscopic management of chronic pancreatitis. Thank you. Thanks so much, Usman and Linda, for inviting me and all of us. Really fun course. This is about the most fun you can have at a course, and I really enjoyed being here. So a disclosure. Not only do I not have COI, but I specifically don't have COI with the Freeman stents, which are made by Hobbs. I kind of wish I did, because I found out that they've sold about 100,000 of them over the years. So if I had a couple of bucks per stent, it would actually have been real money. But too late. So I guess for that, I'll take the ethical path. But if it was a little more money, I might have traded that in. Anyway, chronic pancreatitis represents a spectrum. Pancreatic duct obstruction is just part of the problem. Older trials. Oh, cool. It's a digital pointer. Older trials suggest, quote, surgery is superior to ERCP. But endoscopic management's evolved like IT has evolved in AI. There are many types of surgery. Endoscopic therapy's advanced. Pancreatic stone cleared. I'm going to show you this. You can clear all pancreatic stones. Outcomes are the same as conventional drainage surgery. And so how do you do that? Main thing is integrated care is essential. And chronic pancreatitis, it is so not a single disease. It's a huge variety of etiologies, everything from two-year-old to 102-year-olds. Different etiologies, morphologies, symptoms. So it's a syndrome rather than a disease. We know well now that actually more than half of patients with recurrent acute progress to chronic, depending on how you define it. The other thing is, if you look at all chronic panc, only some of them are symptomatic. We have a lot of elderly patients in Minnesota who have severe calcific disease as 70, 80-year-olds that have no symptoms and no alcohol history. So it's the minority of patients in the minority, duct strictures, head body stones. So if you're focusing on main pancreatic stones and strictures, it's actually the minority. And pain can come from many sources. You can have pancreatic duct obstruction, which we're a little over-focused on, I think, and all these other sources. And not to forget, neural inflammation and central sensitization, though in my opinion, that is used as an excuse not to do interventions in patients with chronic panc in some situations. And I'll get into that with total pancreatectomy aisled out of transplant, which I'll get into in a minute. The other thing is that pain in chronic pancreatitis is actually no significant statistical correlation between imaging and pain. So this is a patient with a monster pancreatic stone who had absolutely no pain. This is somebody with a relatively normal-looking, minimal change chronic panc who was tortured with pain and had a total pancreatectomy aisled out of transplant. So it doesn't mean that if you have obstruction and pain that it isn't the obstruction causing it. It's just that it means you cannot look at a CAT scan or an MRI or an EOS and tell somebody they do or don't have pain. What do you do for chronic panc? And I'm not going to go through all these, but you need good primary care and in advanced cases, pain management. If you're going to stick stents in these people, you really need to address all these other issues, including enzyme replacement, nutritional support. And then the things we do, we're going to concentrate on this. One of the innovations we have started is outpatient IV fluid therapy. And we have a paper we submitted to DDW. These patients with recurrent pain or pancreatitis, set them up to get up to three times a week a liter or two of LR and Zofran at an infusion center instead of going to the ER, and it dramatically cuts hospitalizations. If you try to do this by yourself as an endoscopist, like this guy, as long as you're on the straight and narrow, you're fine. If a cat runs out into the street and you have to make a sudden turn, it probably won't turn out so well. We're a little over-focused on this. In Minnesota, we have... This is an older iteration of our group, but it's just as big. It's for chronic panc working group, and it's focused on total pancreatectomy, islet-out of transplant. But we vet all of our borderline, could go endoscopic or surgical or whatever, patients through that. And we meet every week for an hour. And Melina Bellin is our fearless leader who has five NIH grants for chronic pancreatitis and as a pediatric endocrinologist, so a unique person. You can do ERSP, SVAL, and EUS. I like to brag about my colleague, Sean Mallory, actually invented the EUS rendezvous in 1999 and published the world's first series in 2004, just before Michelle Kahala. We still work together. Very important aspect as well. And I'll show you some cases. So what do you do? Endoscopic therapy is a huge number of things beyond stents, which I think are overemphasized. And you can just read them here. I want to get to the case. What I really want to do is show you cases and ask you what you would do. And I think they'll bring out points. But this just lists all the things we do. You need a lot of fancy equipment if you're going to do ERCP for chronic panc, not O35 wires and standard stuff. You need every kind of wire, balloon dilator. We use angioplasty balloons quite regularly for high-grade strictures or obstructing stones. They go over. It's four French peripheral angioplasty balloon that's just long enough. It has to go over an 018 wire, but it's kind of magic to get through tight spaces and all this other stuff. Let's focus on pancreatic stones. Basically, ERCP, SWAL, surgery, and don't forget medical management, including PERT therapy. OK. Cases. And these are all patients I've seen recently in clinic. I have a firm principle in presentations. I never bend facts or do composite cases. So I try to be faithful to the absolute detail of this patient, because patients, there's an ultimate reality that we cannot fabricate or synthesize, even with AI. So 43-year-old male, CKD stage 5, on dialysis awaiting renal transplant, the CT scan shows this monster stone sent to us for, what do we do about this prior to a renal transplant? So my question to you is, and you can see here, MRCP. Notice you don't see the stone well on MRCP CT. You need CT.MR for calcific disease, but not a mildly dilated upstream duct. What's the choice of therapy? ERCP, SWAL, surgery, or medical? Anybody want to venture a guess? You didn't tell me if this patient's having symptoms. There we go. No. Well, he has somewhat loose stools. We get this referral all the time. Right. They get scanned. They see a big stone. Right. Well, that's spot on, you know, but I presented this at DDW, and you always get a few people who say, well, you know, do this, that. So he has, actually, steatorrhea. We did a fecal acidase, put him on enzymes, but he has no pain. So leave it alone, OK? All right. Now, this is my favorite case. If we only get through these two cases, I'll consider it a success. And these are, I call it tale of two twins. So this is eight years ago. We had a referral from Mayo Rochester, actually a pediatric GI at Mayo Rochester, for consideration of total pancreatectomy. I'll have a transplant because we're the center where that was invented and pioneered, biggest center, et cetera. She's 17-year-old, entering 12th grade. She's a high school athlete. She's had recurrent acute pancreatitis since she was six. She has episodes where she gets admitted about every four months, but then she feels fine. And the disconnect between morphology and symptoms. No interval pain. She has the most typical pathogenic mutation of the PRSS1, hereditary pancreatitis gene. And she has an identical twin who had a pusto, I think, in Memphis or somewhere at age six. And here's her CT. She's got a monster stone in the head, the neck, and another one in the tail with a big duct. What's the best therapy for her? And referred by Mayo, by PSGI, to consider TPIT. It's the way we roll. We meet every week. Shanna Cutler is our brilliant pediatric TPIT, and it does all adult and pediatric livers, but all the pediatric TPIT. So instead of, you know, so presented this group, what are you going to tell this 17-year-old adolescent girl who is on a, I don't know what she was like, on a dance team or something, and gets knocked out every few months with pancreatitis and gets right back up? Yeah, so... Given her young age... Right. Yeah. So it's a very good consideration. But there's a problem here. She's an adolescent woman. That's a tough time to go through. You know, you've missed six months of your life to get that. Also, she feels great in between attacks. So, you know, and we're big on... Everybody gets genetic testing with us. We have a full-time pancreas geneticist in our program. Any other ideas? What about a pusto? Okay. Well, let me show you why not a drainage operation. Anyway, so I don't want to belabor this, but she's perfect for endoscopic therapy. And I have a very large group of hereditary pancreatitis patients, and I'll show you. If they do really well with endoscopic therapy, they don't need a total pancreatitis. Hereditary... Well, yes. But they're, you know, they're at higher risk of cancer, but only about 7%, not 47%. What about... And we never do TPIT just to prevent cancer. And what about your thoughts, because sometimes in our group, because we do TPIT also, about burning the pancreas out by repeated episodes of... I think we have other ways of doing it. Okay. So we... This was eight years ago, and I'm not sure I get the video to play here, because I don't have a mouse here. Can we click on the... Click on the... Just click on it, unless this will do it. Let's see if this does it. Yeah. If you just click anywhere, I think it'll work. No? Well... Oh, I thought they'd check this, and it would play. Yeah. So escape... If you can hit... Is somebody back there on a... Are you on the computer? Yeah, great. If you hit escape, it'll play. And then... Yeah, down there. Just hit that. That's fine. It's playing. So just leave it like that. I only have one other video. Anyway, I want to take you through this, because this was eight years ago. Yeah, it's like I said, if I run short of time, I've got some very... We've got extra time now. Yeah. So this is our CT. Back eight years ago, we started with S-Wall of that big stone, and then we did ERCP, and you can see that the big stone was barely fragmented. So when you're going to remove these, you need a big pancreatic sphincterotomy, not a little one, and then I think it's very important to do balloon dilation, so that you don't have a high-pressure situation. And mechanical... We actually reported the first ever mechanical lithotripsy for PD stones, like, umpteen years ago. It doesn't work very well. So here's Spyglass. This is the first digital Spyglass EHL we'd done, I think, and I call it turning snowballs into snowflakes. And, you know, it took about an hour, but we actually got all the way to the tail. So we drilled through the first one, the second, and all the way to the tail, and got total fragmentation, but it, you know, and had already failed S-Wall of just the headstone. And then you have to get the stones out. We normally use baskets, not balloons, because balloons typically push the fragments into side branches. But we had gotten most of it out with basket, and then this is cleanup. There's a bit of a snowball along with the snowflakes. But we got what we thought was total duct clearance in one session. This is the only time I use stiff stents in pancreases, pretty much, is for either strictures or, you know, to help break up stones. These are five French Zimmons. And so if you're going to do pancreatoscopy with EHL, and we've done 52 patients now with sometimes multiple sessions each, but a pancreatic digital spy with EHL or laser. And so, you know, we've learned a lot about do's and don'ts. But ample pancreatic sphincterotomy, and we usually do balloon dilation too, and the reason for that is not just getting the scope in, but it's when you're doing all that infusion to get the fluid to reflux out without acinarizing the pancreas. Sometimes, I'll show you a case where we put a three French stent, single pigtail to the tail, acts as a rail and as a guide, and then also efflux of fluid. And then, you know, I usually start with 10 pulses and go to 100 watts right away, maximum. Well now, the new auto lift just has high power, high power. And then, we only have a few cases a year that we can't break up with EHL, which is very safe, easy to use, great for bile duct stones, you know, it's just marvelous, and we have to go to laser. Laser scares me a bit just because it keeps on burning. In one case where we think the guru is doing it, we think the laser beam went all the way through the patient and burned a hole in her gown. Some miracle and she didn't get sick, but EHL is very forgiving. So here's just one paper that was just published last year from Dutch Group Prospective Study. They did that surprisingly modest total stone clearance of 71 percent in 34 patients. We've done 52 and we have about 95 percent clearance. But we don't go after stones if they, you know, we are very quick to triage patients to fry procedure if they're not TPIT candidates. So anyway, what about ESWAL versus single SWAL? This industry standard in Europe, we've done it for 25 years. The problem with ESWAL is you can really only target one stone, separate anesthesia, and it doesn't clear the stone, it just breaks them up. And so we've gone totally to first-line pancreatoscopy if, you know, occasionally stones will come out with sphincterotomy, large balloon dilation, and baskets. Let's say, you know, maybe 20, 30 percent. You don't need advanced techniques. But we do it, like this case, index ERCP. You can treat multiple stones. You can clear all of the stones, but you really, this is not a, this is not something I think you want to get into in a community setting, and I don't think it's something to do unless you're in a center for chronic pancreatitis. I'm not saying you have to be in a TPIT center, but you want to be in a center where you have wizard pancreatic surgeons, and what we do up front is, you'll see in a later case. So what happened to this girl? You think she ended up with a TPIT? No, she's doing fabulously. She's doing so well, eight years later, that I had to track her down to come in for follow-up. However, her identical twin, who had the pusto, presented earlier this year acutely ill because they left a stone at the head. She blew out a pseudocyst. We had to put in NJ tube bleeding for two weeks, and then spyglass, EHL, that. Then she did well and had a minor re-collapse. Here they are. This is with their permission, the, I call them the terrible twins. Which one do you think had the pusto, and which one, which one is the patient who had the pusto and two ERCPs, and which one had the, the case video I showed you? She's a personal trainer, and she had, she's doing fabulously. I made her get a repeat CT, which I don't usually do, because she has progressive disease. She had one residual side branch stone in the head, no other stones. Duct has gone back to close to normal, and she has A1C. We also have to check A1Cs. You need to be a complete doctor. A1C of 5.5. Another twin, now is doing well, but, and also A1C, but had, you know, didn't do so great. Okay, so why not drainage surgery in this case? I was going to say, do you think that there was an issue with doing the pusto too early in the one twin? Well, apparently, for some reason, that twin got sick when the other one made it through. Yeah. Not sure why. But they have, they're identical genetically. That's what I was going to say. They look identical. And I'm not sure, you know, it just shows the, whatever, vicissitudes of environment versus heredity. But why not, why not do drainage surgery in these patients? And if I read, you know, I know there are guidelines saying drainage surgery is better than endoscopy. I'll show you my interpretation of that. It's, again, you don't want a one-size-fits-all. Why not drainage surgery? Any ideas? But what, you know, Uzma alluded to it, in typical PRSS1 childhood onset, this is unusually endoscopically treatable disease. And I have about 10 PRSS1s I've treated over the years who've done great with endoscopic therapy. About 100, because we have a huge referral center for this, that don't do well with endoscopic therapy. They end up with CPIAT. So now the problem with the guidelines is they're based on older, very older, 20-year out-of-date studies that show that PUSTO is better than endoscopic therapy. That's okay that Doug's leading. He was co-author of one of those guidelines, which I deeply disagree with, okay? It was ACG guidelines. They showed better results with surgery, but it was mostly middle-aged smoker-drinkers in Europe, okay? That's a different disease, and they only include patients with really large ducts and dominant stone stretchers. All they did for endoscopic therapy was one study used S-WAL, one didn't even use S-WAL, and none of them had pancreatoscopy. And they didn't target total stone clearance with endoscopy. So guess what? And they didn't include marginal surgery candidates, and they didn't consider hereditary pancreatitis in TPIAT. So to me, those trials are like doing a randomized trial of horses versus Model Ts on hill climbs and all-around performance. Which one do you think would win? And then publishing a guideline that says, you know what? Horses are better than cars. But, you know, it's 2023, almost 2024. Drainage surgery hasn't changed much, but endoscopic therapy has. And then just to prove that point, the Dutch who do fabulous follow-up, they do fabulous. The Dutch Pancreatitis Study Group is the world's model for prospective randomized trials of pancreas, pancreatitis, and intervention. They randomized patients to immediate surgery versus step-up approach-rated endoscopic therapy, and then if they failed, they went to just drainage surgery. And they're all large duct disease. And they did show overall better outcomes with early surgery versus step-up endoscopic therapy. I'm sorry. This is step-up therapy, is Mickey Payne's score, wasn't as good as if they went to immediate surgery. On the other hand, if they got complete duct clearance, they had almost identical results to early surgery. How did, how often did they get complete duct clearance? Only 62 percent of the time. We were up to about 90, 95 percent. Granted, I'll show you patients we go direct to surgery and we're not dogmatic. But the other thing is the future of hereditary and early-onset progressive pancreatitis and small duct chronic pancreatitis is total pancreatectomy, islet-out-of-transplant. It was invented at the University of Minnesota. Oops. Sorry. Can you go back there? I hit the wrong, I must have hit the wrong button. It was invented in 1977, we've done over 800 cases, published over 100 articles. Melina Bellin has five principal, she's PI of five NIH grants on this now. Yeah, if you can just find that slide, it was, go a little higher, keep going, sorry about that. Keep going. I've got a lot of slides, if I don't get through them, cut me off. There we go. Impact of drainage surgery and then if you can go to presenter mode, that's great. So the problem is drainage surgery kills your islets. You can't do it, you have very poor islet yields after drainage surgery. So we typically avoid that in hereditary progressive disease. That being said, you know, if you do that, you don't want to do this same approach to all patients. We have done drainage in middle-aged patients with stable PRSS1 who are symptomatic, who are either diabetic or will never ever want to have a TPIAT, which is, and this is just data, I won't take you through it, but robust data showing that prior drainage surgery kills ability to harvest islet cells, and I won't go into why, but what doesn't kill the ability at all is preoperative ERCP, and this is Guru and Joel Munzer, this is the multi-center post-study that Molina's PI has included all the major centers doing TPIAT. Just to show you a paper we published like 12 years ago in CGH, kids do fantastically with TPIAT, this is terrible, this is physical and mental component score of the SF36, and this means their life is miserable, this means their life is normal, and they go from miserable to normal in two years, and that's kids mostly with hereditary disease, they do better than adults. This is Molina and, you know, stunning, five NIH grants, phenomenal clinician, crossover from endocrine to pancreatology, and this is the post-study, we're going to, there will be a presentation at EDW and we're shooting, you know, she and Guru are doing the primary data analysis, but they look really good and hopefully it will be a game changer. To me, it is to chronic pain as liver transplant is to liver disease, a very small percentage of liver patients get liver transplant, sometimes it turns out horribly, I know we're a huge liver transplant center, but it's the thing to do when, you know, just because some patients turn out bad doesn't mean it's a bad operation. The difference is, it's, I think it's actually easier to decide when somebody needs a liver transplant if I can venture a guess. Case three, I just want to show you some of the fancy stuff. I see Chris Thompson is still here and will relate to this. You can do pancreatoscopy EHL via any route, and this is a patient who was a retired psychiatrist who played multiple sports, non-diabetic, and had a whipple for a pancreatic neuroendocrine tumor 15 years earlier, but developed relapsing acute pancreatitis without chronic pain and absolutely did not want a completion pancreatectomy, islet auto transplant. We did a U.S. rendezvous on her, but it was brutally difficult. She had a very long afferent limb, and it helped her. She went pancreatic for three years, but came back with a pancreatic stone you see here. Here's her remnant pancreas. Here's the stone. Here's her gland. We did, I think, you know, we've done about 20 of these now where we go transgastric, not just for a rendezvous, but actually through and through pancreatic gastrostomy. We do it a little different with angioplasty. Yeah. Okay. Sorry. I rarely get accused of not being loud enough, but I will do that. We did a through and through pancreatic gastrostomy with angioplasty balloon. We used 22-gauge needle, O-8 wire, and angioplasty balloon, and then three French stents because it's no cautery. Did you leave the stent in long-term? Oh, yeah. Yeah. Then this pancreatic gastrostomy, we do pigtail with a straight end way down there, and then we put a pigtail through the anastomosis into the jejunum post-whipple. I will say that post-whipple is where we've had most of our complications with this because often the pancreas is not adhesed. If you do it post-necrotizing pancreatitis, it's all stuck, and we've had two cases post-whipple where it went flawlessly, but the pancreas fell away from the stomach. Anyway, this worked well, and then we published this technique. It's a variant on things other people have done, but the idea of it is to create an atraumatic pathway and curl the pigtail. You have to use Boston Scientific 3-French because it has a tighter pigtail than the Cook 3-French, and it's a little less cracky material, and then we go back, add a second stent, and it's basically a wick, like a seton, and creates a fistula. Once that's matured, can you play the video here? You'd have to escape and hit play, I guess, unless I can make it work. Yeah. Great. Thanks. What we're doing here, as you can see, we're passing the Spyscope through the stomach, through the pancreatic gastrostomy, into the pancreatic duct. This is where, because I didn't want to pull out all the stents, I'm not that confident in our security of our pancreatic gastrostomy, which is that I leave the 3-French stent in and use it as a guide. Also what it does is it allows drainage. If you look at that series from the Netherlands, they had 26% pancreatitis. We've had about 2% pancreatitis doing SPY, EHL, laser, and I think because of balloon dilation and in tricky cases, leave a 3-French stent as a rail and an exit path because you're infusing saline the whole time, sometimes liters of it, and you don't want to pressurize the pancreas. Anyway, she did fabulously. We replaced the stents, but the stones are all gone. That was about three years ago, and she's now in her late 70s still playing golf and racquetball and stuff. I guess if you just click here, it'll play. For that case, though, you had a 10-French opening for your- Yeah, we did. I still- That's a little big. The problem with the big stents in pancreatic, I'd be curious if anybody here, and I'm sure not the attendees, but faculty done, I know Chris has done them, you've done pancreatic. I saw a case you showed where you did it. Well, because you always worry, again, like you said, you can get separation and leak, so you don't want to dilate up too big, at least when you're placing the stent initially. We had two three-French stents in for about six weeks, and then just like a peg, we assumed it was adhesed. So yes, we balloon dilated it to ... Took out one of the stents, left one in, balloon dilated it to, I think, six millimeters. Did the spy, and then I just replaced a bunch of ... Sometimes what I've done with these is put five French double pigs or seven French double pig tail from the stomach through the anastomosis into the jejunum of the double pig, and then a bunch of other stents. The three-French is mostly to establish the same, the track. The problem with big stents in these is they work great until they block. I'm going to show that. And then how did you get the stone? You just flushed out the stone? Basketed out and pushed it through. I pushed it through. They were so fragmented, I was able to ... And I balloon dilated the panc-J and the gastro, pancreatic gastrostomy, and basically pushed flush, pulled all the stones out. Now what if I just show we're not dogmatic here? And a one-size-fits-all doesn't work. 55-year-old male, intractably painful, already a diabetic. And we get patients all the time with diabetes, can't you do a TPIAT? Well, not really. It's like somebody with no hands, will I be able to play the piano after surgery? Well, not if you couldn't before. You can't transplant back. And it's really a re-implantation. If they're already diabetic, especially on insulin, there's no way. So not a candidate for that. Look at the CT here. Huge burden of stones all throughout the gland. And the guy's still smoking a bit, but not drinking. So what would you do here? I'm just going to save you the torture. We presented this ... We do this about 10 cases a year, because we see a huge volume of chronic pain, do you? We have maybe 10 cases a year where we just talk to the patient, look at their anatomy, especially diabetics, middle-aged, like the people in those randomized trials, not the rest that they generalize the guidelines to, but those that we'll say, especially if they live 500 miles away, just do a FRI procedure. And this is Greg Bielman, who's our surgical wizard director, who's done the most TPIATs in the world now by a long shot, but he also is brilliant at FRIs, Whipples, everything else. And this is that patient. You can see he's filleted open, the pancreas here, all the stones out. But the FRI versus a pusto is coring out the head. And we always do FRIs, not pustos, with very few exceptions, depending on the anatomy. Because if you leave the head alone like that six-year-old, then stones in there, they come back to bark later. And what they do with FRI is a pusto, but they go down into the head. Should have turned that off, sorry about that. Go into the head and core that out. Plus there's pain relief from coring out the head, and it's actually better than Whipple in randomized trials for chronic pancreatitis. So we, PD stones, must tailor to symptoms, morphology, comorbidity, individualize what's best for that patient, but include the trajectory of the disease. So we try to avoid, as I said, drainage operations in progressive young-onset hereditary disease, even if it's large duct calcific, because there's a reasonable chance, even if you clear the duct, they will progress and relapse. And if you've done drainage, you have nowhere else to go with them. And then they have a very long life to suffer. What about pancreatic strictures? So here's a rare, super-dominant stricture with duct dilation. And this was proven. You always worry about cancer, but this is proven to be benign. Now, the standard approach has been one big stent, but we've really moved to multiple small stents. And I'll show you why. This is actually from Raj Atam, who's brilliant, who is our fellow faculty and is at Kaiser Southern California now. He's the guy for all of Kaiser Southern California. Triple 5 or 7 French stents. The only problem with 7s is they're very stiff, and they tend to poke at the patient and can even injure the duct. But you can do single large stent, multiple side-by-side stents, fully covered metal stent. And surgical Frye, that's a talk about Frye versus Pustoe. And then Whipple, very, very seldom for chronic pain. There's a few. They have triple obstruction at the head, the bile duct, and the duodenum, which you do see in benign disease. Sometimes we'll do Whipples. But the way Greg does them is also fillets open the tail so you don't get that syndrome of post-Whipple obstructive pancreatitis, which I think we probably treated 30, 40 patients for that over my career. It's just brutal. And Marty also, well, you're going to talk about it probably. But when you're stenting these, it's not like one simple stent procedure. Oh, no. It's a lifetime. So you have to also counsel the patient. I mean, we had somebody sent by a former fellow of ours who had been out for a long time who tried a rendezvous on an obstructed patient, failed. Some complications sent them to us for endoscopic versus surgical therapy. And I talked to the lady in clinic. And I said, did they explain to you that if they got through with a rendezvous and stented you, you'd be coming back for the rest of your life for stent changes? She was, as one of our nurses said, lightly educated woman, but very responsible. I said, heck no. I said, if we could do a one-shot surgery, and it might not be great. She was a middle-aged diabetic smoker, drinker kind of thing. But no, ex-drinker. But the point is, you need to lay the pathway out and help decide. So Costamagna pioneered biliary stricture. He's a surgeon from Italy, brilliant endoscopist. He's basically an endoscopist. I'm sure you guys all know Guido there. Brilliant. I actually did live cases with him once in Brazil. Brilliant guy who's basically an endoscopist. And he's pioneered aggressive stricture therapy of the bile duct and now the pancreas with multiple plastic stents. And very good results, but these are very unique patients to have one dominant head stricture. It's very unusual, especially alcohol disease. It's usually multiple strictures. And hereditary disease, the same thing. We used to use Jolin stents, which are fenestrated, soft stents. The problem with those, they work great until they plug up, and then they plug the whole duct. And that's the problem with any one big stent in the pancreas. Because the pancreas is not, as it turns out, a duct. It's a gland, unlike the bile duct, which is a duct going to a gland. But the pancreas is not just a tube. And the advantage of the multiple stents, I typically do five French stents. And again, this isn't data driven, but just experience driven. Multiple five French stents, even three, four, five, because it leaves side branches open to drainage. So typically, this is a guy who lives in central Michigan who has two CFTR mutations, who's been doing this for 15 years and refuses DPIT. But we can go six, eight months between stent changes. We did straight stents. They plug up. They do great until they plug up. And do you like to vary the lengths on the end? Yes, feather them. Yeah, exactly. So we do, because you don't want all the stents exactly right. Thanks for bringing that up. You don't want them all to end at the same place. So we always do, start with the longest and do the next. I was going to say, I never called it feathering, but I like that. Yeah. Yeah, John Cunningham coined that term. He's another brilliant endoscopist. I think he's retired now, but brilliant work with Peter Kott in a long time. Not that well-known, but very inventive. So I want to show you the kind of whatnot. I mean, I have plenty. I could fill a day with cases I've done that have gone wrong. But this is somebody else's. And this highlights a lot of things. I don't think itinerant private practice is a good environment to treat chronic pancreatitis. But this is an alcoholic. And again, these are bona fide detailed correct cases. Small duct disease with dominant head structure had had multiple stents at an outside practice. But he got somewhat better, but he got jabbing pains. Guess what? These are, I don't know if you can see this, but these are seven French straight, not pigtail, straight stents that are ending right at the genu. And yeah, I see Uzma shaking her head. All of us have a lot of experience. And you're at a world-class benign pancreas center, too. So you also have this with TPIAT. So you kind of get the big perspective on what can go wrong. So what he did, it's fairly small duct disease, but he did get some relief with this diffuse head streak. So he put in a viable stent, 6 centimeter viable up to the genu, and said return in six months. Didn't make it six months. Made it about two months. Came in, thought he had an incarcerated hernias. His surgeon in the community did a laparoscopy and found what he really had was an inguinal abscess going to his scrotum. And here's the CT. So here's the viable. And why is this not a good idea? I'm really worried about covered stents in the pancreas. Pancreas is not a duct. It's a gland. Has a lot of tributaries, right? The side branches have to drain. So what he had is no necrosis of the gland, but he has massive extensive extra pancreatic infected necrosis that's tracking down into the spermatic cord and the scrotum. And here's what he had to have done. It's just this year. Scrotal abscess, debridement, scrotal debridement, and right orchiopexy, right perc drain, and ERCP. And so I went in. Guess why this happened? Because the stent was totally plugged. That's been my experience with viable. It's great for sphincterotomy perforations. Thanks, Chris, for alluding to that paper that we published. They're great for sphincterotomy bleeding. They're short-term OK for malignant obstruction, but not great for long-term patency. And this thing was totally occluded with sludge. And it's going to block all the side branches. And by the way, the fluid in his infected necrosis was very lipase-rich. So it was a duck blowout, basically, because he had no necrosis of the pancreas itself, just extra pancreas. OK, last case. Oh, sorry. Can you go backwards on this? No. How do you go backwards on this? On with the autopilot. Oh, OK, great. This is a 43. I just saw this guy last week in clinic. 43-year-old male. He was diagnosed with CF, two pathogenic CFTR mutations, about 10 years earlier when he and his wife couldn't conceive. And they found that he had, I think, a vas deferens problem. And they did a genetic workup. And he had CF. But like a lot of these patients, we see that no pulmonary dysfunction, no symptoms other than recurrent acute pancreatitis. He's doing fine. But every three months, six months, he'd have acute panic. And he had a heartburn-like discomfort between episodes. Very stoic guy. No medicines, nothing. So CT and MR didn't show too much. But EUS by Sean Mallory showed reverse devisum with a small stone in the dorsal duct. Now, reverse devisum is, I've treated three patients like this now endoscopically. This is the only one where it seemed to really help. But they have a normal ventral duct. But the dorsal duct is small and isolated and separate, unlike standard devisum where the dorsal duct drains through the minor. Here, only the small dorsal duct drains through the minor. But it had a stone in it. And this guy, there's no way he's going to have a whipple or a total pancreatectomy. But he's having issues. And this is where I preach tiny wires. Here is a very tiny minor papilla. Had to use secretin methylene blue to find it. I actually use a scope holder called a scope dock to stay absolutely stationary. It's one of the most microscopic procedures you do, at least in ERCP. I don't know about other advanced procedures. But tickle a little 018 wire in and knuckle it up in the end of that gland, which is all of about 2 centimeters long. I mean, you can't do that with a slippery tip wire. You just can't. It won't stay there. And then we put a 4 French, one of the stents I designed, that is 4 French, has a big inner flange that's soft. So it won't fall out. And this is it. That's 4 French. It's one flange, two flanges. Did a needle knife over it. We also cut the, because he may be passing junk out the major. This is the stent that I like to use for prophylaxis. I get asked a lot. It's a 4 French, 11 centimeter, unflanged, very flexible, soft stent that drains really well. And the advantage of this is it will stay in for the whole of the procedure, even if you're doing a long case like Dr. Lee, Jeff Lee, was talking about. I do it at the beginning of the case. And then if it comes out partway, you can just push it back in. It's very soft. But they're always gone in four weeks, unless the patient has strictures. And then we did a biliary sphincterotomy. I did the same thing for small duct biliary sphincterotomies to put in a fallout pancreatic stent to avoid that edema. And then they pass them. And then this is the 4 French stent. And amazingly, and I mean, we're going to show you the good cases, because for every one of these, you flail and fail at making the patient better. But he came back, and everything felt better. He's not had an attack of pancreatitis since. He's had a little bit of flare where we gave him outpatient IV fluids. But he's gone for over a year now with no symptoms. All that heartburn went away. So there is a role for sphincterotomy only. I'm going to end with a plea for the SHARP study for Davison. But this guy wouldn't qualify. Reverse Davison with calcifications out. But I want to show you the last case, which I kind of already, it's a different one. And this also saw this guy last week, 43-year-old with recurrent acute pancreatitis. He is a, has anybody seen the latest Fargo? My wife's best friend is in, one of her best friends is the lead in it with Jon Hamm and stuff. But it's about a North, Jon Hamm plays a mean ass North Dakota rancher, ranch owner, who's a sheriff or whatever. This guy is a very nice, thoughtful North Dakota ranch owner, has two sphinc1 mutations, had five hospitalizations for acute pancreatitis in a year and chronic pain. But it was on narcotics when he came. MR was normal. And I offer these people very educated, informed consent. This is unproven benefit, high risk, but we've kind of learned to navigate that with, obviously, I'm biased towards my stents. But what we did is double sphincterotomy. This is one of those four French stents. Cut the pancreatic sphincter, the bile duct sphincter, and all these stents fall out. So when he goes 500 miles back home, he doesn't have to come back to have a stent removal or go to Fargo, which is about four hours from where he lives. So he actually did much better. But guess what? We didn't cure him. He's better, but not good. And he's only 43. So he's going to get a total pancreatectomy, all that transplant. He's got to sell half his ranch and plan for it. Is that what you do with this guy? Because it turns out, he's not on narcotics. He got off narcotics. And they do, our post-study is going to show that patients who don't go in on daily narcotics do much better with TPIT, as you might think. That's a similar practice of ours. Yeah. Right. They do better. It may just mean less central sensitization. Who knows what it means, but it's observation. But he's going to get a TPIT. So I'm just going to end with a plea here. Sphincterotomies for idiopathic pancreatitis, which again, there's a lot of overlap. Acute, recurrent, chronic, it's all a continuum. It all depends how you define chronic pancreatitis, morphologically or clinically. And are you using secretin MRCP, EUS, MRCT, what? But if you're doing it for idiopathic pancreatitis with relatively normal anatomy, it's extremely risky and very uncertain benefit. So I would suggest not doing that unless you're at a tertiary center that's a pancreatitis center and you've given informed consent. We did the part of the response study, but I still offer it. Anyway, if the patient has devicem and recurrent acute pancreatitis, please consider referring them to your nearest SHARP center. And if you Google SHARP trial, Grécoté du Rocher Yada for the PIs, it's NIH-funded, double-blind, sham-controlled, randomized trial of minor papulotomy or sham for devicem. They already closed it, though. Nope. I thought it was done, and they already submitted the paper. Nope. No, it's still enrolling. It is? OK. I'm actually the third biggest enroller in the whole study. I'll tell you exactly what's going on with it. We randomized 130 patients. We put 13 in, which is third most randomized. I've had about 10 patients that I have two now who won't do the study or do anything that would be perfect candidates. But 13 randomized. They've randomized 130, so he's going to be extended. So we're still actively recruiting. And the NIH, I understand, is, and I have no idea. I think Linda's on the DSMB, but I can't ask her. But top secret. But it's going to be extended, and we're actively recruiting. And I've given my heart and soul to the study because I have a clinic full of patients with devicem where endoscopic therapy failed and or caused chronic pancreatitis. I just had one in clinic, and I said, let's wait. The study results are coming out. Well, it's going to be a year. But now it's delayed. OK. So I don't know. Is there a SHARP center in Chicago? I think Northwestern, maybe. But I don't feel they've randomized anybody. So if you go on your, just Google SHARP study, if you're willing, and it's worth traveling. That's it. I'm going to end here. I'm way over.

endoscopic management

chronic pancreatitis

spectrum of diseases

integrated care

tailoring treatment

endoscopic therapy

surgery

medical management

SHARP study