So not all ERCPs are created equal, and most people learn very, very quickly that the distal common bile duct is a very, very friendly part of town. The proximal common bile duct is like a bad neighborhood where you got to really, really pay attention, have your radar on, look over your shoulder, totally different. Proximal biliary interventions take a lot more time and skill. You've got to be much better with catheters and wires and steering and selective access. In the distal common bile ducts ricture, if that wire's anywhere in the bile duct, you're just fine. In proximal rictures, you're going to be manipulating the wire or wires and getting into multiple ducts simultaneously. You've got to be good at steering catheters and wires and getting stuff exactly where you want it. There's also more risk in these cases, mostly for cholangitis. So for higher cases, you want to delineate the biliary anatomy, get tissue to rule in or rule out malignancy, which is much tougher. If I stick a 22 needle in a pancreatic mass, I know that greater than 95% of the time I'm going to get a diagnosis, whereas these proximal cases, you're going to get a diagnosis maybe half the time. And you may find yourself coming back again or two more times, getting tissue, trying to sort of get the patient across the line to an actual diagnosis. You're going to have to selectively access and drain the ducts in question, leave jaundice and try your hardest not to cause cholangitis, which you may, in fact, go ahead and do. But you've got to kind of use everything, use your ERCP, cholangioscopy. We'll talk about different tissue modalities, EUS, maybe an intraductal ultrasound. These are patients that probably, unlike the distal common bile duct stricture, these patients probably really do benefit for an MRI because you'll be able to see in three dimensions the ductal anatomy much, much more clearly. The best disease for thinking about cholangiocarcinoma, proximal disease, hylar strictures, proximal strictures is PSC, because these two diseases are very, very intimately linked. PSC is a chronic inflammatory fibrodestructive disease of the biliary tree, strongly associated with colitis and inflammatory bowel disease, and it's the most common cause of indeterminate biliary strictures. Again, distal stricture is easy. Proximal strictures, especially in PSC, often very difficult to decide. Is that benign or is that malignant? And just like all other liver diseases, PSC can progress to all the complications of cirrhosis, especially cholangiocarcinoma. It's also strongly associated with gallbladder cancer and HCC. A lot of people don't think about hepatocellular cancer in the context of PSC, but it causes cirrhosis, and everybody with cirrhosis is at high risk of HCC, and I used to forget that. Then I had two patients with PSC that got hepatocellular cancer while they were under my care, and they both died of it, so that was a real kind of eye-opener for me. So when we talk about this stuff, we talk about the dominant stricture, right? You'll hear this term floated all over the place, like, oh, that patient has a dominant stricture, right? So people have struggled to really define this term dominant stricture in the context of primary sclerosing cholangitis, and if you look in the journals, there's a lot of different technical definitions where people have tried to pin down, like, lengths of strictures, widths of strictures, location of stricture, and none of them have really ever caught on, right? And everybody kind of is using their own definition of a dominant stricture. So in that view, or with that in mind, I just went ahead and made up my own definition of a dominant stricture, right? So my definition of a dominant stricture is the cholangiographic finding of a stricture that stands out amongst all others in a person with PSC, right? It's as intuitive, easily applicable. I will be the first to admit it is a bit subjective, right? And Jessica heard me say this yesterday, because I think you're hearing this lecture for the second time now, right? I call this, like, the janitor diagnosis, like, the janitor walking past the ERCP room with a bucket and a mop, who knows nothing about ERCP. You could point to the cholangiogram and say to that janitor, where is the duct block? And they would go, right there, right? You don't have to know anything about this disease and say, like, oh, that's the dominant place. That's where the pipe is clogged. And janitors are really good with this clogged pipe thing, so it actually makes sense, right? So, Uzma, where's the dominant stricture? I don't see the distal duct well, maybe... Well, assume for the purposes of this question, it's not the distal duct. Okay, maybe subtle towards the hilum, mild stricturing there. Okay. See, there's intrapadic dilation. Because you have bilateral dilation. And pruning on the right, and dilation. Yeah, these ducts look terrible. You see that there? Yeah. You see that growing there? That's really subtle, though. That's a cholangiogram. Yeah. Right? So that's the dominant stricture, right? But again, your eye kind of goes to it, right? Here's another one. Anybody else want to play? Who wants to guess? You want to guess. You seem like a bright and energetic young man. Where is the dominant stricture? This is a pretty easy one. Do you want to come up and use the clicker and show? Okay, near the surgical clips. That's a good thought. I would agree. Like, right near those surgical clips. That is also a bile duct cancer. Why are your scopes always flipped? It's so funny. Your scopes are flipped. Yeah, I know. This patient, it was interesting because when we did this case, this patient did not have an arrow pointing to something. So I actually added that arrow later. Patients don't come like that. This was a 17-year-old boy. And this was his initial presentation of PSC. And he had a left hepatic duct stricture. And that was a malignancy. And he had lung metastases. So his initial presentation of his PSC was a terminal diagnosis of cholangiocarcinoma. What about this one? This is a little, here's an interesting one. So extreme pruning. There's almost no interhepatics left. They're all obliterated. What do you think of that, Graham? Anybody? Is there a dominant stricture in that picture? There is, I promise. Oh, her distal is not normal. Her duct's dilated. The other one, the distal is normal. So this one. See that blunt, just sharp cut off. And that's benign. To show you how tricky PSC is. And I followed this lady for years before she died of something else. And she never, ever, ever had a positive brushing or biopsy. So we can do brushings. And I'll talk about different kinds of brushings. We can do biopsies or FNA or FNB. So you can do regular brushing, which I still do in all these patients. And you get three possible results. Positive for malignancy, negative for malignancy, or the ever unpopular atypical cells. Which is like literally the pathologist sitting on the fence. And it's super duper unhelpful. I had a tweet earlier this week about how unhelpful it was when the pathologist says the brushings are atypical. The good thing about brushings is if it's positive, it's really positive. It's cancer. But the bad thing about brushings, if it's negative, it might very well be cancer. And that's a hard thing for patients to absorb. And like for example, we have Epic at our institution. And they can look up their path. And then they'll see like, oh, my brushing is negative, yay. And then I'll be like, oh, you still have cancer. And they're like, what? And I'm like, well, we have to go back and re-brush. But I think you have cancer. Like that's a very, very hard thing for them to absorb when they see in Epic that their brushing is negative. But brushings persist because they're cheap. They're really, really cheap. I think we pay about $80 for a brush catheter, like very little. A couple years ago, Ben Witt and I, Ben's a cytopathologist, we made the ABS score, the atypical biliary brushing score. And it was a way to take people who had an atypical result on a biliary brushing and mathematically see if they had cancer. So we made this scoring system as a result of a fairly complicated analysis. And basically, if you had four points or more, the odds were very, very high. Like I think it was greater than 90% that you had cancer, right? So older age, if the endoscopist thought the stricture was malignant, not if the pathologist thought the cells looked suspicious for malignancy. It actually turned out not to be relevant, right? If there was a mass, common hepatic duct stricture, PSC or C99 greater than 300. So you could see how, for example, in atypical cells and presence of PSC, you already get two points. You're already halfway there mathematically to a high likelihood of malignancy. I'm a big fan of FISH. FISH stands for fluorescent in situ hybridization, which is another additional test that can be done on a biliary brushing. If you want to do a FISH, you have to do two brushings. You can't split the sample. You'll generally end up with two non-diagnostic samples if you split it. So if you're going to do FISH, do a regular brushing for regular cytology and then a second brushing for FISH. And what they do is they will stain the tissue with these biomarkers that have colored fluorescent chemicals on them. And they will look for annuloploidy, an unequal number of chromosomes. In all of your cells, you should have two copies of each chromosome, no more, no less. But they can look for things like trisomy or annuloploidy. And they can identify these abnormalities literally on the cellular level. And it's debatable and different centers agree or disagree on whether or not you can call malignancy just on the presence of a positive FISH, like in the setting of a negative brushing. But I can tell you that I've sent people to surgery and liver transplant for positive FISHs who were found to have malignancy on the X plant. So this is a negative FISH study. And you can see here they've used three markers, two reds, two greens, two blues. This is a normal cell. There's no annuloploidy. And this is a positive FISH study. And if you count these up, these are individual cells. And if you count this up, the numbers don't match. Well, I was going to say, I don't know. Our liver people on one positive FISH have not been acting right away. I forget which guidelines that they're citing where it says repeat and do it again. And that's what we often hear. But sometimes when we just couldn't get it, we've sent them to the OR. It's an adjunctive test. There was one question from the audience, though. If you have an indeterminate stricture, is PET CT ever helpful? It's not really. It's tricky because if you put a stent in there, it may light up around the duct just from the stent. So maybe, maybe. I don't think these tumors light up that well, though, in general on PETs because we don't get them. A lot of them are like desmoplastic and hypostatic. The other problem, too, is, and I see this a lot in my current hospital, is I cannot get a PET CT done without a diagnosis of malignancy. Insurance will not pay. And a PET CT is buku bucks. So, again, FISH is a really, really good test. The big problem with it, and anybody can do this. You guys can all do this. You don't need to be anywhere special to do this. It's a send out. It usually has to go to ARUP or LabCorp or one of those. But the big problem is it can take a couple weeks to come back. So, like, if I do a brush cytology on Monday, I have that result Tuesday afternoon. If I do a FISH on Monday, I have that result three or weeks later. And that's a big, big problem because sometimes the patient is coming back for the next procedure and you haven't gotten the results of the prior procedure back. So, again, I'm going to try to make this really practical, right, as we think about getting into HILAR cases. Dr. Freeman's not here, but Marty's written a lot on this topic and he's very, very kind of cut and dry about it. But in real life, it's hard to be kind of cut and dry about a lot of these cases because they defy a lot of rules. So, again, you want to review the pre-procedure imaging before doing a HILAR ERCP if you can, right? And, for example, Dr. Freeman has written a lot of papers and they're true. I can't argue with a word of them saying, like, you must have an MRCP, look at the MRCP and plan your ERCP step-by-step-by-step before you get in there. But I don't always have that imaging. And if Grandma Jehoshaphat drives six hours to see me from Kansas and she's booked into the 4 o'clock slot on Friday and she brings her MRCP report, that's maybe all I have, right? I don't have those images to look at to plan, right? Or if Grandpa Jehoshaphat brings the MRI on disk, it never works. It never opens, right? And I don't have time to run to radiology and see if they can, you know, decompile the images and make it work in our packs. Like, it would be great if we could do that. The systems don't talk. And it's interesting, in Denver, Denver is, like, the king of the systems don't talk. Like, I literally can't talk to the hospital down the street from me. Our computers will not talk to any other computers outside the system. Not the university, not the VA, not Kaiser, not HCA. Like, nothing. Like, there's, like, firewalls around everything. You want to try to access ductal segments with wires before injecting so that you don't accidentally inject a system that maybe you can't drain. Bless you. But sometimes that is just not possible, right? Because dye is molecular, and dye is going to find its way all over, and sometimes you will find that you're injecting stuff that all of a sudden you're like, oh, I don't know if I can get a wire in there, right? And if a segment has slow or poor drainage due to stricturing, you want to drain it, which may not always be possible. The angles may be unnavigable, right? The strictures may be too tight. Sometimes you just find yourself in a difficult situation. Recognize that you may have to do more than one ERCP to get good drainage. I talked yesterday about how I have a guy who I just discharged last week who has cholangiocarcinoma and a common hepatic duct stricture, and I put one uncovered metal stent in there, and it looked great. Like, it just looked fantastic, and we were like, everything drained, good job, and his belly didn't change. Like, it went from, like, 13.6 to 13.4 to 14.1 to 13.6, and we were like, huh, it didn't work. And then we had to bring him back and place multiple plastic stents through that metal stent into multiple ducts above. And then his belly drained. But we were like, that shouldn't have happened. But it did, and we had to take him back. You may not be able to provide complete drainage no matter what you do. Some of these people may get a PTC. And these people definitely, definitely, I know that there are a lot of feelings about antibiotics and a lot of strong feelings about antibiotics. These people need antibiotics, intra-procedure and post-procedure. I'm very partial to Levaquin, but you can use whatever you like. Doug, one question from the audience about fish again. Is it only positive in cholangiocarcinomas or other cancers? I mean, fish has been validated in bladder and urethral cancer. Fish for biliary cancer is largely considered experimental but almost all of the research on fish in biliary disease is for cholangiocarcinoma. So that's kind of about the most that you can say. So first case. Uzma, what do you think of this gram? Jessica, I asked her yesterday, so I can't ask her again. Let's see. See, by the way, just for the ERCP course, there's a wire in the PD. I did a two-wire cannulation. It throws me off how yours is flipped from mine, so I have to think about it for a second. So you're up on the left side. Your balloon's on the left side. There's my balloon right there. I guess I'd call that in the common hepatic. What do you think of that? a lot of dilation on the other side though on the right yeah see that's true the right side of the screen is the right side of the patient on the right that's why you do that interesting there is a reason why he does that oh I don't know that whole area strictured so yeah what do you see up here there's our left and I'm a little dark yeah a little bit of dye doesn't look like a ton of ducts it look I mean it I don't know if that's a PSE on that side it's hard to say now I'm injecting a little more look at that right light up a lot of a lot of liver on that right to drain was this I mean is this an atrophied or tumor filled side that's a really good question is the left atrophied right and and the left side often atrophies more than the right and I'll tell you that for these examples I'm going to show between now and the end they all are non-surgical candidates with established diagnoses we'll just put it that way for to simplify the discussion we need to see the pre-procedure imaging sir yeah they drove from I mean some things on that left side for whatever reason it's not filling and then well look what happens next all right oh there's more there on the right look a whole other segment there on the right yeah that appears with some additional right this is what I mean like these are much more challenging cases all of a sudden you're dealing with a lot more than you think you are yeah now you have a lot of contrast in there too a lot of contrast in there and then it gets even worse there's more on the left than you thought with even more injection right look at that gallbladder I was begging for mercy I was throwing me off at the beginning because I saw that but right but now look there is some duct on the left now it's probably not perfect but yeah is duct on the left but I I don't know I mean at this point what the clinic I mean what benefit you're gonna get from injecting more on that left side because at this point I probably would have just come back and said let's stent the right and look at that angle look at this angle is almost a full 90 degrees I don't know if you'll make that but the one I don't know if I'm gonna make yeah the other one I would stent okay that's exactly what we did so we put a this is a laser cut non for shortening stent in the right and we put this thing in the left here too even though there wasn't much duct there this duct was coming off there and if you look that duct is now draining okay because originally I was thinking what would be the benefit of even hitting that left side but I see your point you're trying to trying to get that one right so there we were able to drain that whole thing with two metal stents but you know this was not a five minute ERCP I would I would have just done the one probably really and you wouldn't have been I don't think you would have been wrong part of the part of the point of this talk is to show you that like this stuff isn't so cut and dry and that's the hard part too because you know you're trying to guess where am I gonna just get maximal drainage from the liver still got my wire in the PB stent it maybe so again two metal stents and I'd like to say that the patient did well I would say that the bilirubin fell that's always I feel like you're like in the morning waiting okay hope that bilirubin is down a lot and you really don't always know and the other thing for the those stents they're metal that he put up in the liver but those were uncovered yeah yeah that we usually agree on just because a those are the ones that are smaller caliber but be in theory you don't want to block off one side of the liver I do too actually just because these patients live much longer and so after about a year when they keep coming back with occlusions half the time you end up putting plastic in them again but now you're limited in where you can move and especially with adjunctive therapies like ablation maybe you're gonna see some improvement so no regular plastic say regular yeah when you agree yep because if you use pancreatic sense you may have limited sizes or yeah depending on what your lab stock I'm not a big believer in adding extra side holes I don't know some people I know like to do that the hard part for me is always just getting the length right on my guesses with the plastic because those are gonna be a lot longer you guys seen the cook side hole maker no and I'm not kidding you guys think I'm making this up it's in the cook catalog I've used a cook makes a little device where you can like drill side holes and a biliary stent if you want that's just for decoration no I was just gonna say exactly what he was my said that that's why my practice is kind of changed because of the need to go back and do revisions and you have limited access to other segments you see progression of disease and you may may not be able to access certain radicals that need drainage they get obstructed they get stone disease so it's kind of a nightmare to go back in with these uncovered metal stents and try to get adequate drainage but that kind of led to our discussion of you know geographically the practice is much different because his patients are traveling they may never come back in mine are really you know quite easy for them to follow up it's tedious to bring them back every few months for for stent revisions but personally I'd rather kind of start fresh then to have to try to go through the metal stents but it's it's a difference in what we're seeing in our practices yeah that's a big deal from the virtual audience if you're putting up two metal stents how do you how do you do that simultaneous one after the other well that's another trans capillary yeah I have multiple wires up first so I try to get all my wires up first two or three wires and then just sequentially stent I try I don't typically do like one branching through the other I'll do to anybody where it's like side-by-side same sometimes I try to get fancy and do both simultaneously but you need an extra assistant and yeah and those stents don't aren't reconstrainable so you got to really be on top of the timing so it's easier I think put both wires and one after the other who in the audience would like to interpret this oh man there's more images to come they want to see those before they make conclusion but I'm showing it as we took the images this is as we learned but this is again where pre procedure imaging comes into play just because you you have an idea of where you are what that segment of liver looks like okay there's a little more info the plot thickens that looks bad and look that wasn't there before that also looks kind of crappy and there's a decent amount of duct up there would you guys do heavy lies the crown do you think man over there in the blue shirt next what do you think you know you got a shrug we got a shrug from the audience right so again you see we were able to kind of get two wires in right so we're there we just have a wire on that left side and then we got a second wire up that right side this is kind of I was talking about you want to get your wires up first right this is one of the most important things I'm going to say in the whole course in case you guys haven't figured this out yet the most important thing in the RCP is not the sphincter at home or the catheter or the balloon or the stent or the stone it's the wire whole case is the wire like all you're really doing in the RCP is guidewire management you have your wire where you want it you have total control if you don't have your wire where you want it you have nothing so like really learning to ERCP is really like a year-long soliloquy and exegesis on guidewires so here we've gotten two wires up one up that right side that really tight stricture and one on the left right now that's a really really good picture and you see like look I got my catheter up that right side through that stricture and look at how much liver is up there right there's a lot of liver up there to drain and then sort of similar to the last one we got a longer laser-cut uncovered stent on the right and I did go for that duct on the left too and you can see like stuff is draining you can see a difference in these pictures and again I'll just sit there for a few minutes at the end of the case talk about the latest Netflix show Kim Kardashian whatever while we wait for those ducts to drain right and if it looks like the duct doesn't drain then I can't quit I've got to keep working to make sure that everything is okay I noticed on your other case also you don't cross your stents over sometimes I do okay sometimes I do but usually I end up doing that if I'm trying to go trans-papillary I mean yeah I leave them up high I don't go trans-papillary usually I leave these all in turn but you don't have them come together through the island sometimes okay in Japan they do a lot of fully internal plastic stents we don't do that in this country in this country if we use plastic sense they're almost always trans-papillary hanging down in Japan they're getting away from that and they're using short plastic stents up high and they're leaving them so they have a string on them that hangs down to the duodenum and they can grab the string if they want to pull it out at a later date so don't be surprised if in the next few years we have that in the United States right so here's how this person looked at the end case three is ridiculous but I'm just gonna show it because whatevs this is somebody who had a common hepatic duct stricture this person was 100 years old she had a common hepatic duct stricture in the setting of cholangiocarcinoma and then there was some distal extension over a few months we placed a second stent distally so this is how she came back to us with recurrent jaundice about two years later right so when we got in there right we saw that this was the mother of one of our oncologists believe it or not you can see there's a left hepatic duct stricture and a right hepatic duct stricture so the tumor which really started in the common hepatic had worked its way up and was now causing bilateral obstruction and this was a lady who was I mean remarkably well preserved for at this point a hundred and two years old so that's that's actually a better picture now you can see we're working inside the two previously placed metal stents and I got a wire up on the left there's so much dilation of the wire was able to coil on that left side and we got a separate wire up the right and again like now like we were saying I have total control like I have wires where I want them I can do anything quick question from the audience to do you use stiff wires or anything in particular for your wires I use two five wires for almost every so do I ERCP I think I think that there's a myth of stiffness I think you actually have much more freedom and delicacy and subtlety with a softer wire like we use the two five jag we use the busy wires like angled or straight mostly straight I use angled oh two five so you don't agree and then what do you like two five three five angled straight I like you know two five and and in a hyler stricture I use both I probably start with the straight and then when I want to try to get into it a different sometimes also depends the end that what the angle is you're seeing so I might switch up and then they asked about dilation before you stent in the hylum I don't I usually do I do I like I like rotating the tome around and blowing the tome right to sort of like work my way into different places all these are also you know just sort of changing your scope position changing your tome all these things are kind of how you get it across the structure I think if you dilate it well I think if you're gonna do I feel like I won't get the stent catheter through without dilating other than that I don't die well I think that may be a benefit when you're doing metal those catheters are a little bit more low-profile easier to pass versus plastic stents so I think when I especially with plastic we do yeah and here finally I'll do metal she's 102 I don't want to see her back so we put another metal this is now her third metal stent up on the left number four is coming and there's number four it gets even dumber whoa cuz she comes back in a year he comes back later I'll show oh my gosh one two three four that's a little better view like the bionic biliary tree but she's a mother of oncologist and then she did great she did great and then she came back later that's how she that's how she looked at the end so that kind of lets you see it better because we're I think there are scopes out so there you can really kind of see how ridiculous we got in this case and then she came back down the road with gastric outlet obstructions we put a duodenal stent in her so five stents in this lady so what's that on the bottom left what is that object what generator like her power pack yeah so no it's not a colostomy what is that it's not a CD player yeah no it's about that big what is that it's a pain pump yeah that's her PCA okay and then just last thing too if we haven't muddied the waters enough we're gonna muddy them just a little further for you guys and I've just shown you a bunch of bilateral stent cases but do you really need to do that right is unilateral drainage enough and and this is a source of significant friction in the literature and if you look in in PubMed there's papers that say wildly different things regarding whether unilateral or bilateral drainage is better I think in general if if you have an opportunity to do bilateral drainage you should do it but if you can't it may very well be plenty and if you can drain maybe 60% of the liver the patient's jaundice should theoretically fully resolve again patients kind of like bilateral drainage and docs like it it makes you feel like you accomplish something when you take that picture showing the bilateral stents may help you more than it helps the patient but this was a paper that we published a couple years ago with the other sneaky I don't think you're on this one who's my and this was a multi-center international study of unilateral versus bilateral stents for hyaluronic laryngeal carcinoma and we were very very surprised that long story short unilateral looked as good if not better than bilateral drainage and I will tell you we struggled to get this paper published because a lot of the reviewers couldn't really argue with the paper but they just said like I don't like this paper you know like here's your data okay but this goes against what I think so we kind of struggled to get this paper published and it took a couple journals before we could get it accepted but it was interesting that the bilateral stent group in most ways did worse they died sooner they had shorter time to re-obstruction maybe that's just because they had more advanced disease right but again if you think one stent will do the job it's okay to try that and I mentioned earlier that I had that patient that I put just one stent in who I thought was gonna be enough and in the end it for him it wasn't so we're pretty much on schedule so high ERCP technically challenging diagnostically challenging don't start if you can't finish and this is something that like maybe if you're a modest volume ERCP provider send to Jennifer or send to Uzma like maybe maybe this is one for you guys because again if you find that you inject a bunch of systems and you can't drain them right that patient has a very very high likelihood of getting biliary sepsis and you may find that you can't treat it recognize you may have to more than one ERCP both for diagnosis or to achieve adequate biliary drainage recognize that these are higher risk cases and plan as much as you can but be aware that there's a pretty decent chance you're gonna have to think on your feet during these cases thanks guys

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proximal bile duct stricture

cholangitis

PSC

cholangiocarcinoma

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