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Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
PTC/PBD Indications & Contraindications | Biliary Intervention
PTC/PBD Indications & Contraindications | Biliary Intervention
Consider ERPC over PTC/PBD | Biliary Intervention
Consider ERPC over PTC/PBD | Biliary Intervention
Percutaneous Biliary Drainage  | Biliary Intervention
Percutaneous Biliary Drainage | Biliary Intervention
Left PTC/PBD | Biliary Intervention
Left PTC/PBD | Biliary Intervention
Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
Difficult Biliary Access | Biliary Intervention
Difficult Biliary Access | Biliary Intervention
Pre, Intra, and Post Operative | Biliary Intervention
Pre, Intra, and Post Operative | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
adventBARDcancerceliaccenterschaptercolorectalcookCordiscoveredcysticdataductextremelyfavorfavorablegoregrammalignantMeditechMemothermmetalmetastaticmultipleocclusiononcologyovergrowthpatientsperioperativeportalSmartStentstainsstentstentsstricturestumorunresectablewallstentZilver Stent
Benign Biliary Strictures | Biliary Intervention
Benign Biliary Strictures | Biliary Intervention
Stone Management | Biliary Intervention
Stone Management | Biliary Intervention
Biliary Stricture Case | Biliary Intervention
Biliary Stricture Case | Biliary Intervention
Biliary stricturechapterdefectsendoscopicfillingfluoroscopicimagesinterventionlaserscopestonestonesstricturetrans
Imaging Examples of Defects | Biliary Intervention
Imaging Examples of Defects | Biliary Intervention

good afternoon thank you so much for invitation to speak to you I have a privilege of working at Johns Hopkins and we have a fairly large practice we at the main hospital itself we have 11 rooms and during a day about two of them are have a biliary case actually going

on at the same time so it's actually a fairly large volume of our practice and so the gamut of bluie intervention goes from really simple stuff to really complex and it is something that our trainees specifically will come to

Hopkins for and many of times they will end up being the blurry and experts as soon as they arrive at a new practice so certainly it's something that we deal with every day I just wanted to give you a landscape overview and share some good

cases that we've done and hopefully you may something have some comments or learn something about the way we do it but I'm pretty sure throughout the country a lot of great Billu work has been done currently there's no question

though the Blooey access and access to the Blooey system has really been played out in most hospitals perth by GI and ir and obviously surgery but almost a lesser so today and the rat in at least four IR is the PTC PPD or transparent

Col angiogram but it's actually a recurring role and I actually speak and have a sort of special interest in transit paddock colonoscopy as well so we play scopes through the skin through the liver and do a lot of balloon

intervention I'll show you a few cases like that but in true these access points are germane to what specialty you come from and obviously endoscopic beeper oral and if you eye are usually usually through the skin and there's no

question GI now in some hospitals I'm sure you have advanced endoscopy that will go through the stomach straight into the leftover liver so there's no question of a blurry landscape is changing quickly but no question that

this is quite common but yet most patients and internal medicine specialties will be looking at blurry disease by access point through scopes through ercp so going back from the Duden up or directly through in there's

advantages disadvantages something it's fairly obvious to everybody that you know no question is selling it to a patient if it had both choices that ERCP through the mouth and nothing invasive nothing sticking out their body

is attractive yet the outcomes are very similar but nonetheless there's pros and cons and through the trance of had a crap or two percutaneous route you do definitely have tubes at least sticking out

initially and this is often solved by GI as the main differentiator at least a discomfort but yet we are able to address almost every problem at times and often where'd they pay a lot there's

no question why would we do it so the

the usually when there's enteric surgery frequently GI is unable to go once the bowel has been rehook tup through a either Worple procedure or bariatric surgeries where they essentially disconnect the direct communication with

RO mouth so once summons has the surgery there's no question almost IR is always consulted and frequently the only way and and we certainly deal with many ways of the dressing biliary disease not just therapeutic but also diagnostic and

staging and so like I said reduce a lot of scopes now there's sort of no reason you could never do a Balu intervention and it sort of said that ascites and frequently should be a relative contraindication we don't really find

that certainly you can embolize your way out of access into the brewery systems i think this is a relative and every now and then when you have vast numbers of cysts in the liver and polycystic liver disease can't be a barrier to performing

it and we made sometimes then refer those so there's no question sometimes you may want to think about Jia should taking over if they underlaid it but frequently in fact at most of our believe cases are transferred in as

complex and transfers into our hospital are ones with underlay the bill Redux mainly misadventure after lap laparoscopic cholecystectomy or just overall a really complex balloon save case there's frequently transactions or

massive leaks so underlaid is really something we deal with on a daily basis when should you not do it it's very rare

that you cannot correct care gulapa thee or something a bleeding disorder so frequently in how we do this in our

trainees do it and I'm sure you've seen your physicians and do many of these but in truth those anatomical considerations are important to start at the right line the mid-axillary line and pointing your needle towards an tears of a sternum so

it's superior cephalad anterior direction mainly because the ducts are most concentrated near the hilum of the liver your chances of finding a bluish duct is the maximal at that point and it's

actually not clearly understood by many even ir trainees that there is a path of high success and that's really from the mid-axillary line in the sub course sub-region going again towards the surface sternum and in the lateral

position sometimes it's often very difficult sometimes when using over intersecting below attacks but everything and here to the hilum is left ducks everything post here to the hilum are

right ducks in those in Anna and p├║blico considerations are critical and frequently why people have problems understanding bluie disease or addressing complex beauty problems is because they don't know the

anatomy and the one that catches surgeons are specific laparoscopic surgeons is that 6% low right anterior posterior insertion where there miss identify a posterior right segment draining and it looks like a cystic duct

and they clip it in next minute they have massive leakage that they can't cannot control intraoperatively or they just see a whoosh of Louie that's mainly because they have cut the wrong duct and removed the gall bladder the leaky is

not going to come stop so obviously when

we do drain the Louie systems we actually do this extremely successfully as interventional radiologists and it's a very high technical success like I said in this sort of supine position

from the mid-axillary line and these things are and you've seen a lot of these how these done really you need to pacify the system you get trans you most post people go trends in to cost Albany because the liver sometimes can be

tucked up way above and we usually want to make sure that the lung and the costophrenic angle doesn't come down low in nothing I take a deep inspiration first to make sure that you're not dealing with and then we now map your

track than you find some people do this with ultrasound guidance frequently with and dilated structures and most of the time it's actually much probably routine to actually do blind passes in the like I said the path of high success and to

pull back when you a passive our blue system is the only structure that doesn't wash away generally portal vein hepatic vein hepatic artery all of those structures are cylindrical

tubule alike are not are going to wash away move away and quite quickly and you can see this PDC and show in fact a left insertion of a right into your ductal system and frequently this will be something that we would have to make

people watch out like I said identification of choosing the right duct thereafter after you've identified you've performed a color angiogram is to identify how you're going to drain this and the most important thing to identify

is a peripheral duct doesn't matter which one there are ones with higher success but then within the lateral position find one market on the table then with a second axis as a to stick axis and I'm sure this is very germane

and common you've seen get into the peripheral duct and the AP fluoroscopy get a wide down you get a tube down and then eventually go it with a coaxial system getting a skinny wire converted to a larger wire and then following that

with a below a tube and your goal is to really get axis that goes transpannic through a perfect century through obstruction or no obstruction if it's just untie elated and through into the small bowel and lock a some type of

locking system it's interesting the size that you choose does make it different so if you go larger than the 12 french-trained initially the risk of bleeding actually goes above 10% for initial axis so the best is to probably

start with a 8 and 10 and that's what we typically do this is what we connect what it ends up looking like left a

biliary axis and certainly and in some people hands they think this is very difficult one of the most important

things is actually recognized that blurry data system frequently will have the dorsal duct and then the Android ox or the main products in fact the ones that I stick youth so it stumpy short duct that's because you're looking them

head-on and if you look at it a cat scan you can see that left dr. systems adjacent to the left portal vein the stumpy short ones on the fact the ones looking straight up at you and those are the ones that you want to stake you

don't want to go in to post your dorsal that because then you have to go to right angle turns and frequently the reason why people struggle with left billary axis so it's what you're trying to achieve and

what you were hoping to do you can see the left ventral duct is always the ones actually most medial to the hilum if you access that wire will fly right down down into your CBD into your small power and you can follow it up sometimes you

can even use a foggy cap if you want to just do lift access in a pacifier the right it allows you to do bilateral blue access particularly sometimes surgeons like to have access ready bilateral access prior to surgery before they feel

the way up the end and so they can operate and resect kalanchoe carcinomas that are very very close to the hilum so it is sort of one trick of getting a bilateral a pacification of the brewery system is actually using occlusion

balloon a pacifier certainly if you can do this this things can go wrong and the acute issues are not that common even though they minor bluey sepsis probably the most difficult ones they actually blue sepsis can be extremely Lethal and

more arm since pate that patients who they ask you frequently and certainly that's probably the most problem I want he Mobley of bleeding can be an issue up to five percent depending on the size of your initial access that's actually

probably the most important denominator and the rest of them are relatively low probably the ones that will call physicians or your staff in the middle of the night on the weekends or the delayed ones because tubes leak they get

pull back accidentally and they we just really haven't got a great way of dealing what with long term drainage because it's external tube and obviously internal stains have addressed that and I'll go through that a little bit so

like I said it's actually very unusual

to have severe humor billion almost all all those that need your attention is about aghori portal veins though can be tremendously so the differentiation between hepatic artery and portal vein

bleeding is the big differentiator that will require you to do something about it most of the times if you injure the portal vein or hepatic vein these usually heal by themselves and it's counterintuitive the management of this

is actually to upsize your tube and they make sure the side holes are not adjacent to the bleeding vein it's crossing so it's counterintuitive that you upsize - for bleeding injure the vein more but

eventually those veins will thromboses off for that little branch the difficult situations of sahiba heavy hit an artery and here's one way we did a gram you can see the pacification the reason why you want to go into the peripheral duct I'll

show you always near the hilum is actually also very big blood are the blood vessels and the reason why we go peripheral the number of large vessels are much greater diminished so you always want in this patient was

transferred for an outside Hospital my PTC was performed by someone who obviously doesn't do a lot of these and access directly into the coma bar duct you can see all these filling defects all these filling defects in the combat

like those or clots and filled with someone who's actually had life-threatening significant he Mobilia and required what we did was they were just pacify the system get another peripheral access

right biliary system and embolize the track coming out and thereby removing the original axis that was placed by the outside hospital interventionists obviously the ones that aureus the most of the narco that will kill people is

the ones that hit our ease and pseudoaneurysm formation or tara Venus fistulas and I can be problematic in my only real ways their dresses trans cap the treatments a patient would have an angio we'd have to get into the pedagogy

find the feeding or it almost always though and we can predict way that bleeding artery is it's where your Y is crossing the architecture of the artery tree frequently you will not see it until you remove the tube so almost

always you would have to prep the right flank prep the groin to an angiogram with the tube in because you don't really want to be rushing at the beginning of your procedure you frequently do the angiogram not see

bleeding and then a second operator needs the described brake scrub get non sterile axes remove the blue tube repeat the angiogram and almost certainly then you'll see it but again it's very

predictable where it is but every now and then you get caught out and the bleeding side can be remote from where your actual Y or actual access transgressor you you do need to have a careful eye looking for that and so you

know when we looked at out and we do large numbers of blurry drainage the best predictor or and like I said Arturo Kimber Billy is actually related to your first tube and the size that you place and it's also

interesting like I said every now and then you're gonna see that bleeding arteries are actually not liver arteries and you can't bleed from the GDA internal memory from other procedures intercostal artery from where you put

your tube first needle through the liver through sorry through the ribs itself it's actually access site rather than your internal parenchymal your liver so it's actually important to also do sometimes it a water gram check the

intercostal artery because you'll miss it by doing a celiac or teragrams hepatic artery gram and don't understand why the patients still bleeding and here's just example of what a pseudoaneurysm does when we remove the

chief we can see the image on the right the blue tube has mean withdraw back and they you can see quite clearly there and sorry the pseudoaneurysm of the paddock right re and like any other immunization is important to go front door back door

implies across mainly because the liver architecture has a rich collateralization that will feed before and after and like I said the lake complication zone was or derived and related to tube maintenance and tubes

catching on to things in dislodgement and so these are just really you know your whoever answers the phones whether it's the physicians on call they have to manage with maintenance of these tubes and really just keeping these tubes open

as long as possible it's amazing how long some of these tubes do last in particular in benign but Lewis structures so management of these is really or expectant and the right advice and frequently just need to

get these tubes changements they're clogged sufficiently the difficult ones

and what makes things complex is when the Louie system is inhospitable to the easy procedures when the ducts are dilated I think most operators find this

really relatively easy to get a tube in but once it's under lay that it really makes it tricky you either have a disease of the Blooey systems such as sclerosing cholangitis in flammond ich ins of the power duct architecture and

the wall itself all surgeons have gone in in misadventure transected cut the wrong duct and so cholecystectomy is are frequently the most common ones we misidentified and right posterior duct inserting below

and they cut that or even cancers is there not sometimes Calandra carcinomas such as cat skins - matrix of the ones right at the middle of the tree those ones make it challenging to sometimes get through sometimes they're so severe

in the severity of a structuring that it's it's very difficult to get through and sometimes we have to use sharp organizations and then like I said post surgery and with the advent of your gastric sleeves and gastric bypass

surgery this has become a much more common place and so frequently I think bluie interventions are on the rise again whereas I think they went out of favor for a few years in the 2000 mainly the GI became so aggressive with a

slanting Denova stenting and middle stenting then and bluie disease came down somewhat in high AR but this is all on the upswing again now with much more patients with with a bariatric surgery so in terms of intervention and your

your procedures in the room for difficult access and again a unviolated Ballou systems is actually not that insignificant even very experienced operators is going to be the most challenging procedure of the day and

it's vital to actually know your options and for we will actually a pacify the blue system with anything that has yellow stuff so frequently surgical drains that are adjacent to the leaking site sometimes we will check them and

sometimes you just got to be careful not inject too much sometimes their pacifiers and obliterates a field so much so you can't see anything your procedures pretty much done I also use known in distance gee I frequently would

be the first group to go in and try address below a leaking and they'll plate in the stands even though it doesn't cross the leaking site or it's inadequate for a decompression so we frequently would just stick the

indistinct directly and start our procedure that way so we know we're going through deliver through some bad structures but you we use a very very small caliber needle and stick the in distinctly and then once we use that

sometimes we'll place a wire knowing the fact that this is not our final track to a destination we'll put a wire in and then put that into any peripheral duct and then stick our skinny wire and so that's another way another way is

actually once you original PTC's been obtained with its optimal not will use mix lidocaine jelly with contrast media and mix it and make it a real thick slurry and that sometimes is a really good way to keep

the contrast from making out really really quickly he sounds quite logical but it's actually a very cute trick so that's another thing to consider every now and then you can actually use gas because it doesn't dissipate so if you

take co2 and there's at large dilated ducts you can actually put co2 and visualize that very nicely particularly specifically in the left lobe of the liver tends to dive into Phi the ventral left duct very nicely with gas but

sometimes it's not always easy if it is gas filled intestinal tract and then use control actress and I'll show you what that looks like on a picture and then high-grade lesions every now and then we have to use sharp aura colonization and

really the packing of the wire and your who should be your Russia sheet a needle from a tip set every now and then we will use a cardiology transept or needle the skinny a needle and really that sometimes with a high-grade multi

sclerosing agent of sclerosing cholangitis sometimes that is the only way through and sometimes we will use even rfy and drove our way through with high-power so this is a little bit what what it would look like if you had a

lack called a transaction we couldn't specify the billary system from about 30 passes of a routine and ptc axis that we should be stuck a central duct we pointed the wrong way contrast we float much faster than we could to get a

second axis so we just put a wire and it immediately then we actually stuck our wire and used our wire to get down and this is a cute way of getting using just a structural element even though you don't actually managed to keep contrast

in there to allow you to identify here's an example of a patient who had a Whipple procedure and a surgical master moses leak and it was under laid it difficult to pacify patient also has rapid respiration so some of these

patients are from the ICU they breathe very very high frequency and it's actually very difficult unless you get general anesthesia sometimes the risk outweighs the benefits of putting people under

for some of these that we will just as soon as if get pacified the blue system put a wire and again another example where we stuck a wire then we actually use that to gain a second axis and pacify the other system left atrophy

this is a patient with a very very small left lobe and we use the right axis it's a very acute angle from the left hand side we actually spin just stuck put in a snare and we stuck a snare we pull the wire out from the left through the white

and out the skin and then pushed it down using a stuff and that's why I'm taking your snare from Lord lift out the let right and then put in from the right hand side up the skin then you push that all the way through into the right hand

side and how you have power lateral axis so just there are some cute tricks that you can do to and make your procedures more successful and this is the other way you may do it sometimes you can only get to the lift system from the right

the hilar cholangiocarcinoma here high central high low lesion we could get our CAFTA from the right to the left that there's no way we could get from left to right so all we did was stay our Y from right to left and it comes out the skin

and then using a peel away she you put the wire down from the right hand side then you said she go from left access all the way up the skin on the right you exchange being glide wire put it in the pillow sheath and the right stolle

feeder that aren't all the way and you pull your pillow as sheath and now you have left access and right axis and sometimes it's the only way to get our lateral axis this is commonly found when surgeons require bilateral tube for a

cholangiocarcinoma classic in Palmyra section where they use the Blooey tube to feel their way up and look at the end of the tumor and so sometimes we do

actually do something more than just drain and even though the drain is

frequently the most important part of biliary disease and we sometimes do also get to treat and and do more things with and intraoral you actually now also help them identify the conduit of the below a tube is actually very helpful we

actually can do IVIS we can also do intra Patek Carranza how Skippy and I'll show you what some pictures of that so it really is it just a conduit to get you into the blurry system so intraoperatively like a

you know Whipple procedure it's critical to get this tubing for our patients our surgeons actually use this axis a lot to pave the way for the sort of complex surgical resection of part of the budget system gall bladder pancreas and rehook

up the patient so that they have sort of the setting and almost always postoperatively will actually be Batum and the surgeons will leave a team in to maintain access and artificially hold open this new surgical nest the mostess

in an open position for as long time as

possible even though the you know strictures actually most likely are related to the malignant frequently in large centers like the Asura actually we see more benign strictures and malignant

strictures mainly because of the post-operative and perioperative complications so strictly speaking the incidence of reduced riches is actually flipped sometimes though we do actually have to help and some more patients now

particularly in the GI Sims I think in the ten last ten years GI now places metal stents almost routinely there's almost there are people still placing skinny in those things are two plastic calibers things

but the advent of retrievable removable metal stents has really changed and so now we will place dancing much frequently in that the wall stent is actually the pre derivative of the wall flex which is the Justin that can be

removed it's got a little barb that removes it and it's what they will do is retrograde put these up and then six weeks later or even up to nine months go in and retrieve it and pull them out completely so they certainly and the

number of build with stains placement in G and IR is reduced somewhat because how aggressive gr has become but certainly will place these and particularly patients who are in the palliative stages of care and although these

applications we've used in many other ways so your goal is to get the same team this just happens to be a patient with unresectable head of pancreas cancer you can see the obstruction in the distal CBD just below the cystic

duct there's non pacified area you can see on the calendar gram as well as the celiac artery gram you can see how the portal vein sensor strictures of his patients unresectable will go in there in place

that metal stent you first place your guide why follow that up with a stent that cross bridges from open to open and open this up and we use stands between eight and ten millimeters in diameter and nowadays even covering the

cystic duct is not such a big deal and nowadays cupboards things are probably more in favor now even though the data the data actually doesn't support covering over uncovered and the data for both is actually extremely marked be

similar and it's not compelling and because of the price difference I think visit again a probably a swing back to I'm not standing every CPD stains with covered stands but no question at least from operators point of view in my point

of view it makes whole wholehearted sense to allow the tumor no interest disease to grow through but yet the outcome is still not clear that it's a favorable and cost-effective to do covered stains entirely and we actually

will place up to three drains sometimes you have these complex cancer patients with multiple strictures where almost all the segments are excluding in a extremely sick or they need their bilirubin's to come down for four to be

eligible for cut medical oncology chemotherapy and this is the selling of metastatic colorectal cancer and so that will put three up to three tubes in the right lobe before will give up and say that there's not much more decompression

we can achieve so four tiers is that probably the maximum will place in for multiple site so like I said you know malignant brutally strictures and this data and I'm not going to because it's sort of a moving target

when Gore came with the first covered stand purely because of the fabric that they have gore-tex like what's under jacket and clothing and was interesting it's one of the most improbable fabrics and the reasons why Bill Lewis stands

accrued is not so much that it's overgrowth of tumor but the in growth of bio and in growth of bacteria actually will cause a non-covered stain suit include earlier so the advent of gore and making a stent that made a big

difference and it's covered same it does to change quickly the ease at which patients could be stent in the new system so when they came on the market was really helpful and there's just example of how you can go from occlusion

all the way to having natural passage about now back into the small bar and the utility and the importance of bile salts power fluid in your GI tract is critical for absorption in almost all your metabolic

function so having this drain out externally is really not advisable so getting a natural pathway flow of bio into the GI system is extremely important but I believe strictures and

this is just happens to be a biliary

other classification system with bismuth how where the injury occurs and this is really germane after surgery so you'll see most of these actually after misadventure with bluish surgery and and like I said the most common ones

actually after laparoscopic surgery but we have barrier so we have oncological have two extremely complex three sections of the liver now and and we the advent and certainly rise are more balloon complications this is an example

of what we might do in the complex setting this patient had explorers in cholangitis primary cylinder current charges received a transplant and the transplant liver had a recurrence and with recurrent explorers and cholangitis

there was just no way we could cross it but even with a long-standing billy we drain frequently if you drain most obstructed systems a day or two passage across an inflamed structure it makes it much more easy and you will see their

people get brought back for their secondary tube with laryngitis sometimes this is not possible so we actually have made attempts to cross this there's no other way so we happen to use a sharp organization so we happen to use a

transept own needle and use a sharp needle go breakthrough sometimes analysis of the CT scan is a very important you really want to know what's between your one side and what's on the other side and the more even more fun

thing to do now is using our rfy off-label and we'll burn our way through and create the track that actually has a much better patency rates and even sharp organization your allow essentially coring of sort of in chronically

inflamed fibrotic tissue and allows you a chance of keeping this open it's just example of how you benchley burrow through with a shop another case with a sharp needle creating a track really that's not

natural because this is obviously a transplant patient and it's the only way through even done what we've done is stick the intestine first and then put us in a punch our way through polio stay out and

then thereby restoring the the track and they are sort of you have to be just really created with biliary disease when it comes to chronic obstructions or high-grade obstructions so like I said with benign the disease frequently it's

post-operative and so they will present in multiple different ways and most of the times they're just leaking in the intraperitoneal ich you you're you essentially peritoneal cavity will reabsorb it so patients get jaundice is

essentially it hi arrays but Rubens and you'd really can diagnose in many ways and really just dealing with this can be problematic and then so we've been dealing with bluish structures and and oh sorry benign Ballou strictures

post-operative benign Ballou strictures in a more labor-intensive way we actually leave tubes in for six months which is probably a little more than most people must be not a benign the Lewis structures are managed with three

months of stinting with a minimum of twelve French tube so that's a reason why some of these patients will get kalanchoe pasties multiple bluie a drained Rhys tenting it and tube exchanges and changed up this way and

then this is just happens to be the British is worth a typical we will get access cross the stricture kalanchoe plastic stretch out this benign structure and then place a tube in for as long as you can to keep it open and

fro asses of between three and six months there's a classic example someone who obstructed that they said this looks very smooth it doesn't look ugly and looks okay doesn't look like a cancer we sometimes what I so biopsy if it has any

suspicious appearance and then get across you can see even with a balloon how tight the structure can be with a high pressure balloon and there after placing achievement for again three to six months we actually err on the side

of caution almost our patients have six months of intubation which is quite long difficult and this is our experience what we do then is when do you remove it to actually have a sort of a step-by-step process we have a it's not

really medical clinical trials actually just if a flow clinical trial what we'll do is get the tubing bring a patient back and we actually cut the tube so there's only the access through the parenchyma of the liver is preserved but

nothing through the structure we will cap the tube is since you can maintaining access and see if the patient doesn't make sure that doesn't get fever the stricture is maintained and then we'll bring the patient back

after a week to do a balloon whiticus test that's really just a modification of a urinary radhika test we're going to take pressure measurements after slow contrast injections to make sure it remains the

patency and for us the data suggests we can essentially and predict over 90% who will be staying free if they pass the Whittaker test in keeping the monetary reading less than 20 centimeters of

water and really it allows us to manage these because of how many patients have what procedures at our institution we have a large volume of patients that we actually follow and it's a you know our fellows think it's the most common

procedure Billu intervention had this is actually not that coming everywhere else and this is what I believe tests we have a pro forma that we fill in and the contrast has been ejected in

certain rates per minute and so this test takes about 30 minutes we make sure that there's the predictive value of in less than less pressure building up over higher high contrast injection rates will give us a great prediction of no

longer needing the tube and then stone

management is probably as we move into more complexity we actually manage quite a lot of blueish stones as well we don't have surgeons go in and cut them out we'll actually get the rid of them so

this is residual stones either after laparoscopic cholecystectomy where they drop a stone into the cystic duct or into the common bile duct even worse if they cut it off or frequently what you've seen now and we've sort of it

much more increase numbers of scope cases by IR is related to gall bladder drains so placing our colleges ostomy tubes is frequent frequent in sick patients they don't get surgery almost staying over and so we actually will go

use that axis put a scope in and work on stones and get rid of the stones entirely and then remove the tube rather than just draining the gall bladder so the incidence of stone mentioned for us the

section that I said it's post surgical it's actually not uncommon at some stage of most patients live once they've had blue enteric rear nasty Moses will have about 10% of a stone and some of them were

extremely symptomatic so we put contained easily manage these so we'll get rid of the stones either basket art or push them out or break them up with a with a laser and so this is something we've been doing for quite some time

over 20 years it's just example of what might be looked like this is a 50 yard after a Whipple procedure for benign mess and you can see here's the stricture here we plasti and then we got a Fogarty balloon push push the out I'm

not sure if you can see the filling defect previously but the that round bulb was filling defect right of HJ is just your stone and so sometimes you guys would make sure to push the stone art did you last see it out and then

with a balloon sweep it out and the stone can be passed in the GI tract perfectly very easy and you can see now there's no filling defect and the Kalonji gram is now non dilated and so we actually managed to use with scope

than this is what a scope looks like as actually originally a pediatric nefra now there's actually this disposable scopes that urology uses and we actually have a disposable we've switched over we own two of these scopes separately and

this is a little costly to manage and also to clean as I share biggest challenge cleaning scope so we've gone to a disposable scope now which is in the order to other inventory that you manage so it's actually becoming much easier so we use this the access point that we have you can see using a basket in Palmas or stones are whether it's in the blue system or in the gall bladder and this

is just example what might look like this is just a woman with you know history of a power back injury and she had a gallbladder misadventure and required a HJ but now she has a stricture

and like I don't know if you can tell but the HJ is narrowed there is filling defects not only on the right but the left so you couldn't see this filling defects sausage like filling defect on the left so what we would do is go in

put a wire from right to left and then we put a scope I'll show you what that looks like and you can see and unfortunately our packs doesn upload in download images all that great it actually looks much better on the scope

and we can see the stones real time so you can the utilization of a scribe is actually very very similar to using tip deflecting wires or if any of you interventions use tip reflecting sheets

is exactly the same 180 degree deflection up and down and the pyro rotation you can have for cotton coverage and so scopes are defined by how much they cover in your field in front of you and our fellows pick this

up extremely easily it's actually very very a natural progression from trans fluoroscopic guidance to trans endoscopic intervention and so we actually cleared the stones aren't entirely in to session so we use a laser

night I think I have images and the videos didn't load that easily but it really is like star wars you can just put the laser right up against a stone put the energy on energize it with a generator and break up the stones I mean

this is what the stones look like this is a can see they frequently if they black they tend to be have probably chronic infections and this and you can see on the low image back here and on the wall and that's really just from

inflammation even sometimes the intervention the red bright light is our laser and we will see by the scope we'll have the laser go right up to the stone with the contact with the laser light understand then will energize to

generate and break the stone up and

sometimes even you can see things that you would never be able to see in this card sorry fluoroscopic e with the PTC this is a patient after surgery somehow had I'm on going obstruction that we

couldn't resolve with the tube we put the scope in you can see how much debris there is in the CBDs wall or stones and when you look they they are black white black and orange stones but then we saw the sort of blue structure we obviously

that wasn't unnatural so we actually use the biopsy forceps to grab it and pull it out and then we put it on the table it actually happened to be the surgeon had accidentally hired the CBD off and so we actually resolve the blurry

obstruction by pulling this surgical ligature which had not been intended completely out the body so with the hardest scrub I don't think we ever would have known we would have never been able to diagnose it and probably

would have had to go into a fairly difficult surgery to have that resolved and so not only had the surgical bit literature being tied around the combo duct but it eroded right through the wall and that's why

see in on the in the luminal side so it's interesting that you would be able to see this and for IR to be doing this from the flank from the side in fact real close to where the pathologies versus GI going from the mouth through

the stomach up the room up through the CBD and so you can imagine how much more mechanic advantage in how close we are to the pathology and this is a natural extension what we do certainly the GI you know fight us sometimes for even as

using scopes but I think much as Vassar surgery GI and surgeons use the techniques and and equipment that we have I think it's time that we used to do the same with them and you can see it just happens to be another type of

structure and see the debris is from ischemia and then you can resolve a completely and get rid of all the stones and ultimately if this patient got his tubes removed filling defects from other benign sources so you would never know

that these are polyps because on filling defects or filling defects and we try biopsy these sometimes they tell us you don't have a you know cancer it would be hard to know if these are inflammatory polyps and you only see them when you do

a scope and you can see these fronds and causing a filling defect and it would be impossible probably to manage this until the patient is open and biopsy taken and even more bizarre is other inflammatory masses so this is a pseudo mess really

by inflammation you can see this scope image of this crazy paving and I told you biopsy it you would never know so just really just in the context of time I just want to summarize I know time is up but thank you very much for

opportunity to speak to you but I think I are and I are sweets are now doing more more Ballou interventions of increasing complexity thanks very much [Applause]

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