good morning everybody
so we're going to start the this morning
session with the case of a 70 year old
woman who was admitted in another in the
emergency department of another
institution about a month ago with
abdominal pain initial workup suggested
biliary acute pancreatitis and the CT
scan done at the ER confirmed the CBD
dilation in CBD stones the patient had a
rapid resolution of her symptoms and she
refused to stay in the hospital against
medical advice
nevertheless she accepted to come as an
outpatient with no symptoms at that time
her lab tests were normalized but an MRI
confirmed that there is a CBD stone and
a CBD dilation so the patient has
accepted to be admitted and she will
undergo ERCP with biliary sphincter ah
to me and the stone extraction and we
can join doctors ready Mustafa in the
procedure room hi good morning Maggie
good morning you know it's a pleasure to
be here in this workshop as usual
fantastically well organized workshop to
do the first case I have with me
supervising me Mustafa Ibrahim Mustafa
so I'm very confident that with him in
the background supervising I'll succeed
assisting me is Christian and Felicia
with the guide we're that experts the
guy dress and the most important of
course we have fear not a man helping us
with anesthesia because this is the most
important than you can say that this
patient is in prone position is also
intubated which is the usual practice
here so everything is under control and
safe and this is very important because
we have passed the null lymphocyte being
180 we scope inside when we approach the
papilla you see it's a very abnormal
area then a big fold which is
overlapping the papilla we've been
waiting for you fiddle around a little
and you can see the difficulty here the
papillary opening is not seen very
clearly the default coming here so what
we did was to use
shaped radio focus our turn more wire on
a I'm actually using a cotton it's like
you said - sprinter Tom from Wilson cook
which is the dome shape so it doesn't
enjoy the popular so much the guide wire
is deep inside now be able to pass it up
and you can see the fluoroscopy picture
can we see the fluoroscopy yes you can
see we are right up there the the
problem here was that you can see the
fold here you know which was actually
coming on to the fabula so there was a
little difficulty but once you push the
fold which was easy to go inside now we
are going to get some contrast and then
very important that I always inject
right from the top near the hilar region
because a small stone I don't want to
push it so if the fluoroscope can go
towards the towards up towards okay now
Christian I can inject some contrast so
small amount of contrast small amounts
we are looking at the intrahepatic ducts
which look very fairly ok you can see
the stone already there can you see the
stone it just behind the scope but I
pull it back a little and you can see
yeah you can see the stone nor can you
it can inject some contrast can inject
so what is very important is that I'm
trying to look at the lower end of the
viaduct at this stage to see whether the
stone is going to come out easily or
whether I'll require a mechanical
crusher
so now I pull the papal out actually so
you can see the papal are much better
and das perfectly and right from the
bottom I'm going to inject some kind of
inject now well we can get some contrast
leave the guide wire in place and get
contrast okay so now you can see the
lower end quite well and if the camera
can if the floor can come down down down
to the lower end it's good for us that
we see a nice lower than there and you
can see the stone right at the load and
here can inject getting it contra
so it's very important that the contrast
comes through who's going for you to
make a good picture of the stone the
picture you can take a picture there I'm
going to suck on this here and then and
you can see that in the upper part here
just behind the spoke when I push the
scope down when I push the spoke down
you can actually see the stone just
behind the spoke can you see it then in
fluoroscopy it's very nice stone the
sign of the store is approximately
nearly the size of the scope which is
about one point two millimeters so what
we decide now is to do a spin trata me
but it's very important that we have to
see whether we can do a full spin trata
me the papal air is out now
now it goes okay now it looks good in
the beginning of the before shows the
show it was it was noble villa
it is only very small Barbarella so once
you fiddle with it I mean I've seen
right naggy
succeeding with the nurse to push the
guide wire so now I'll ask now Christian
had to bend the spin to Tom a little and
very important this I'm going to put
only a part of the spin to Tom only
one-third of the sprinter Tom towards
the common bile duct and you can see if
you can see my hands my right hand is
away from the away from the knobs here
he's going to control the shaft
I'm turning my body to the right a
little so that I have good control of
the shaft and then I use an endo cut
mode which is a standard mode what they
use here you can see my control Here I
am using my shaft to pull the scope up
to control it I'm not doing much except
elevating the spindle Tom a little
controlling it yeah and then I get
closer to the papilla as I keep cutting
it and you can see again it's very
important to adjust your spindle formula
too much of it is not inside and making
small cuts here this patient is an
aspirin so I'm also watching carefully
whether I might at some stage have to
use some coagulation current and I can
cut across the fold here people
generally it's a myth that you can't cut
you can cut the fold safely is no
problem and then again I'm pulling
pushing my strokes go back so that I get
a good orientation
pushing my spin at home in and out to
get this good orientation and then I cut
the inner part of the Sprinter has to be
cut there is a little cut on the fold on
the top it doesn't matter
now I pull it back again a little I got
some more distance to cut because the
stone is fairly large so I want to cut
more the option when it is a very small
popular we thought whether we should use
balloon dilatation most of I agree I
don't think now it's necessary no it's
not really I'm just cutting very careful
and you can see that how I'm
manipulating my shaft here moving my
body to the right and left a little
and every time you should bring the
shrink comes out here so that it gets so
you can see the inner part very nicely
now I have a few millimeters most more
to cut I can do that there's no problem
so what I'm going to do is to now again
I just my shaft a little put my scope
back a little and then very important
that you get a good orientation you can
see that now so you know you can tell us
when to stop there is still some
infantry broom there but okay so we
follow you we cut the infundibulum
it's very important not to lose sight
all the time so you see what I'm doing
is I'm adjusting myself in such a way so
I don't lose sight of what is happening
there is actually like you know
suggested some more infundibulum and is
also small splinter area deep in the
bile duct which is better cut so that
the stone comes out more easily
[Music]
and now you can see that it seems to
very okay what's why I agree yes yeah
yes you know I think the most important
any of the common ballots yeah you know
now I think what's important is that
Christian is going to flex this winter
term completely can you flex it and I'm
going to remove it and see how easily is
going to come off see that it's coming
out very easily this means it's one
centimeter very easy and this means we
can remove the stone quite easily now
hopefully I'm doing a little radial cut
sometimes I like this on the other side
so that you even bigger stones can be
brought it okay now we are cut
completely I'm now going to remove
everything and we're going to use a
basket now you can use a basket or a
balloon in a stone like this which is
about one centimeter I prefer a basket
no can take out everything some people
tend to put the guide where you can do
that also put the guide wire in place
and pass the wire basket north of the
Loom yeah I think it because the stone
is just fitting the bilat wall you can't
remove it with a balloon also but the
basket you can catch the stone nicely
and I'll just I'm cutting the bill the
guide wire in place just as a guide so
that way I can pass my basket along this
this is not necessary with a big
splinter term like this but anyway it's
so it's okay so I'm not holding my guide
wire here with my hand on the left side
the trick here is to use an angled guide
where very important I think this is a
point that I like to emphasize here an
angle guide wire is very important when
you're calculating a papilla like this
which is very hidden we are going to use
the web basket from Wilson cook again we
are going to use it to into three
centimeter basket which should be
sufficient in this case not on the guide
we're just on the side on the side not
in a guide wire yeah no it's not a
basket basket basket the web bass listen
to me not to you so we were debating
yeah you can yeah some people would
advocate to do is fing drop less to
instead of a swing drop to me the stone
is not too big so what is your thought
on this that's a primary sprinter plasti
I would not do because of the chance of
pancreatitis in these cases and this has
been reported but if you the stone was
little larger
and the papilla was not so large has we
saw it finally I would have probably
done is winter ah to me of five
millimeter or eight millimeter followed
by a large balloon Sprinter plastic
which we do very commonly but we felt
that this fellow is big enough and
therefore we adapted we sort of took
this course but primary sprinter plastic
would be only indicated in certain
special circumstances where you have a
patient the coagulopathy cirrhotic liver
for example with smaller stones now when
I do a primary sprinter plasti one
important point is I always do long time
so that instead of one minute I do it
for five minutes now you can forget in
the fluoroscope picture laughs you can
see very clearly the basket going along
the side of the guide where here now you
getting the fluoroscopy I are getting it
there is I think the study of endoscopic
swinter ah to me with balloon dilatation
combined with villainous winter ah to me
and I think this is actually a
meta-analysis and
we also have an asia-pacific consensus
where this is commonly done and it's
advocated for stones more than one point
two centimeters can you know what I'm
going to do is I'm going to go just
above the stone here open the basket
open the basket and then you can see the
stone is going along with the basket so
I just no no no wait wait close the
basket no I don't want the stone when
you buzzer buzzes then again in the open
it's exactly the space but I want to go
this way boy
so that's a very important teaching
points always open the basket above
above can you open now Cristiano can you
open Christian is open the basket and
I'm going to come down here and then I'm
going to shake and at this point I'll
remove the guide we're okay I'm doing
the guide well normally you close the
basket or you know I was always I always
open the basket keep it open
and what I'm doing at the mid part of
the CBD is to shake it well it's very
important so that when you do this
shaking movement what happens is the
wires go around the stone otherwise the
wires we're not going on the stone so
I'm doing a lot of this shaking movement
and I also can inject some contrast to
the basket at this stage to see where
exactly the stone is whether it's right
whether it's totally in the basket it
seems to be partly yeah now stop now now
you can see you can inject some Catalans
sometimes also some contrast little
contrast just to show you yeah little
contrast to show okay yeah that's okay
now you can see it very nicely you can
see the stone so you can see the stone
is caught in the basket don't cross the
basket yes I'm going to come out with
the basket now when I come up to the
popula I have this technique where you
then no no don't don't close it I think
Christian is really active so what I'm
going to do is look at my hands this is
very important
I'm not going to pull the stone out I'm
going to hold the basket please get this
close to the cross the papilla and then
I'm going to hold the basket with my
left hand okay and then I'm going to
turn this big knob down down and turn my
scope to the right so with this movement
I get the stone out now so you can see
this little resistance but hopefully it
should be down low okay screen fluoro so
when you do this movement you actually
don't see the stone coming out but you
can see that on the endoscope it has
come out now can you see the stone now
yes yeah so this movement is very
important don't try to look at the
endoscopy view of seeing the stone
coming out it looks nice but basically
you want to get the stone out in the
contour of this bile duct and this is a
way so put your stone very close to the
papilla and then make the big knob down
and then turn your body to the right and
push the scope down when you do this
movement the stone comes out very nicely
like this so this is a big stone that we
see it's about 1.2 centimeters
now what is very important I'm going to
do is an occlusion : Joe Graham so for
that we use the we use the balloon with
the guide where now you may ask me why
take another laxity because of the
workshop we're using otherwise we can
probably use the same the same basket
but the balloon occlusion is better so
what I'm going to do these balloons are
little stiff so you can see I'm going to
reshape the balloon I put it with my two
fingers and do this so the balloon is
shaped towards the bile duct with a
guide wire inside I go deep inside and
this will just take another two seconds
for us to finish just because we want to
be sure that there are no smaller stones
that were missed in the earlier
or pictures because sometimes even : do
Gramps can miss small stones and this
has been repeatedly demonstrated now
I'll ask I'll go cross the papilla you
can see that these balloons can be stiff
so I'll go close and also asked
Cristiano to pass the wire inside fluoro
Toro no so we see the obvious Moria more
up pops
can you flow now input the good wire
inside wire inside why any resistance
flora up yeah so so this can sometimes
be a little tricky because you're
dissecting the planes there so put your
basket very gentle and then we are now
why and say now I'm going to inside okay
so I go deep inside and you can see that
my my balloon is right on the top I'll
get the flora on the top there yeah and
then I'll inflate you put some contrast
in first put the corner can you get the
center so that I can see this more
center difficult no yeah yeah can you
inflate the balloon little inflated yeah
so we are right at the hilum now can you
keep injecting as I pull the balloon
trawl the balloon down you're injecting
now to see a nice picture that we are
going to get there nothing there nothing
there
Yussef I agree it looks clear you guys
keep injecting keep injecting keep
injecting keep injecting and it will
assume with you yeah the same way same
way down can you go down down so I want
you to see this movement again what
you're going to do you see when you show
us the collegia gram yeah yeah can you
see the collegia gram now you're not
seeing it no okay yes just once again
yeah that's better yeah no I'll just go
down can you go down to the end here
yeah India you can see the balloon there
but can you get it Center balloon in the
center yeah okay
bengi show us again the manoeuvre to
extract yeah so what I'm doing is see
I'm going get the balloon down at the
Papillon here okay and then my right
knob is turned to the NA right my
fingers are holding the holding the
balloon here and then I put the big
knocked down and turned my body to the
right and push the scope down and you
can watch this fluoroscopy the
fluoroscope image is big it's better
fluoroscopy down down down you can make
it down there as it's coming up you see
this I'm just moving to the right and
pushing it down and the balloon comes
out so you're pulling in in the same
axis of the common bile duct I know the
bell you avoiding to create an angle
exactly so I think this movement is very
important not to look at the ampulla
when you're doing this but to look at
the fluoroscopy see that now it's okay
so it's clear now there are no more
stones we are very sure that is
absolutely clear so the procedure is
then over there's a nice stone there
which was positive one yeah
okay Guiteau wrap is so enough yes okay
doctor already we congratulate you for
this wonderful demonstration I think we
are ready to go back to my inner