This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. So post-ampulectomy, here you can see grasping the resected tissue with the snare that we just used for resection. This is then retrieved from the mouth and then sent to pathology for formal evaluation. We then turn our attention to the pancreatic duct. It's actually in this particular case wasn't that difficult post-resection to access the pancreatic duct. Ultimately we're able to get a guide wire out to the tail of the pancreas and subsequently place a pancreatic duct stent. In this case, I think this is an eight and a half French by 12 centimeter wedge stent. Choice of stent is really, I think, up to the endoscopist. I think the importance is to make sure that it's not a short stent with no internal flanges that's going to fall out rapidly. After addressing the pancreatic duct, bile duct is then cannulated and similarly a biliary stent is placed. In this case, a 10 French by five centimeter stent. After stent placement is then the time where you can go and resect any remaining tissue. I like to do it in this order because this way I know that both ductal orifices are protected. I can also work off them with a snare. In this case, this is a dedicated 10 millimeter cold snare to remove adjacent tissue to complete the procedure. This was the final look at the completion of our index procedure. All right. Thank you very much. We'll go on to our next case. Just one question for the panel then. How many stent the bile duct every time? No. I do. I don't because I do sphincterotomy. So I was also a bit curious about what's the reason behind to do it? Would that be the main reason to overcome a stricture or to put a stent in the bile duct? Yeah, for me to prevent stricture. But I think ampulectomy is such a procedure between just like six or seven panelists, everybody's doing it a little differently. And I think that just goes to say, you take all the techniques and you work to what works for you and the patient. Was that final pathology malignancy? I saw something pop up. Yeah. Final pathology was intramucosal cancer with TVA and high and low grade dysplasia. So I think that's also very important to note that sometimes just the biopsies alone are not going to be necessarily diagnostic what the final pathology is. And that's where also using MRI, MRCP, or EUS, you can also look for any invasive components or nodes that may tip you off that this is a potential malignancy as well. Okay. Last question. When are you bringing, what are you going to do for follow-up? The patient came back about two months later. Actually that patient got pancreatitis, which unfortunately a good portion of them do. But she came back at two months with no evidence of residual adenoma and planned for yearly surveillance. She also had additional downstream large adenomas, which we resected on subsequent procedures as well.

post-ampulectomy procedure

resected tissue

pancreatic duct stent

biliary stent

residual adenoma