Ian M Gralnek: Ian M Gralnek Hello everyone and welcome to episode three of ESGE's podcast Endoscopy Unplugged. My name is Ian Gralnek, past president of the ESGE and I am your host. With Endoscopy Unplugged, we're starting at the beginning, tackling some of the basics of GI endoscopy. Then further down the series, we will of course be getting into more advanced topics Today's podcast is titled ERCP Mastery, expert tricks for seamless CBD cannulation. And I'm very happy that my guest is Professor Torsten Baena, chief physician at the Evangelical Hospital in Dusseldorf, Germany. Torsten is a world expert in advanced endoscopy and has published widely in pancreaticobiliary endoscopy, both ERCP and EUS. Welcome, Torsten, to the podcast.

Torsten Beyna: Torsten Beyna Good morning. it's a great honour and pleasure for me to be here today. I'm really excited to talk about one of the most crucial and fundamental aspects of ERCP - the selective CBD cannulation. It's a step that often determines the entire outcome of the procedure.

Ian M Gralnek: Ian M Gralnek it's great to have you here, before we get started i just want to ask you how did you you choose to become an advanced endoscopist?

Torsten Beyna: Torsten Beyna After my basic medical training, more than a decade ago, I had the chance to move to Düsseldorf and work together with one of the pioneers in therapeutic endoscopy and in particular HPB endoscopy, Horst Neuhaus. We worked together for more than a decade and this was a great opportunity and chance.

Ian M Gralnek: Ian M Gralnek Yeah, I'm sure, I know Horst well and he's a fantastic endoscopist and he's a fantastic mentor. You're very lucky to have him with you for that period of time. All right. So let's get at it right now. let's talk about achieving a CBD cannulation and let's first talk about a general technique. So in your opinion, what most influences successful CBD cannulation.

Torsten Beyna: Torsten Beyna We are talking about the most basic, fundamental, and also the most difficult and essential intervention in ERCP, the cannulation. A high rate of safe biliary cannulation probably defines the good endoscopist. And here, we have to consider that here quantity breeds quality. We have to take care of our experience, of our numbers. So when I approach one patient for ERCP, it's very important that we are very clear about the indication. This is everything because we know that ERCP is more prone to complications. So be clear about the indication. And then we have some basic steps that we have to follow. First is patient position. I put the patient usually in a prone position or at least prone oblique position that provides a more stable position. We try to get a stable short position in front of the papilla. So I usually start the procedure only after I reach this position to have a papilla centered in front of my scope. Then prepare everything, have a look at the papilla, take care of the peristalsis and have everything in place.

Ian M Gralnek: Ian M Gralnek What do you use if there's too much peristalsis?

Torsten Beyna: Torsten Beyna So in Germany we have two options. We can use Buscopan or we use Glucagon. Both are very useful. Glucagon has the advantage that it's has not big effect on the heart rate. So this is sometimes more convenient.

Ian: Ian So you have your indication the patient is in a prone or semi-prone position. Everything's ready to go. Your scope is in a short position. The papilla is right in front of you. Your first line is, I assume you prefer a sphincter atome with a guide wire. Is that correct? As a non-ERCPist, I'm asking you.

Torsten Beyna: Torsten Beyna So this is true. So as we know, we should go for wire guided cannulation first because we can reduce the rate of post-ERCP pancreatitis. And then we have to consider also the papillary anatomy. Usually we have an S-shaped morphology of the CBD in the intramural portion or the interpapillary portion. So to have a sphincterotome that can be bended and an hydrophilic guide wire is in my eyes here the ideal combination to start with.

Ian M Gralnek: Ian M Gralnek Okay. And what if you, you say you start and you're just not able to get in and how would you sort of define, okay, this is a difficult cannulation, what's going on here and what should I be doing now to get access?

Torsten Beyna: Torsten Beyna So, luckily, we have very good guidelines coming from ESGE. So, let's go a little bit through this. So, we have a very clear definition of a difficult cannulation. We should consider a difficult cannulation to be trying to cannulate longer than five minutes, to have more than five contacts to the papilla, or to have more than one unintended cannulation of the pancreatic duct either with a guide wire or with contrast injection. So this is a 5-5-1 rule that we should follow.

Ian: Ian Okay. So what's your escalation sequence? You've tried the five-five-one rule, you've passed it, things just are not going right. So what's your next step?

Torsten Beyna: Torsten Beyna So first, I think it's important that we start our procedure in a very structured way. We start with a sphincterotome with a hydrophilic guide wire, and then we approach the papilla, we cannulate the biliary orifice. Let's have a look at the papilla beforehand. We can see where the biliary orifice is. Probably the CBD goes into 11 and 12 o'clock direction and then we can align our sphincterotome towards the estimated position of the CBD. And if all this fails using a bended sphincterotome, what I usually use as a first cannulation step, then we have to go one step further. And in the end this is also related to the fact if I'm able to put the guide wire into the pancreas. So this is the first step. If I have the wire in the pancreas, we can use pancreatic guide wire assisted techniques. And if it's not possible, then we have to go for other techniques. So the third option should always be that considering the indication for ERCP that we consider to postpone the procedure for another day. This is always an option or let somebody else with more experience try to do the procedure. But depending on the pancreatic guidewire, we can go for pancreatic guidewire techniques or in case we don't have a pancreatic guidewire, we have to go for Pre-cut techniques usually needle knife pre-cut. So according to literature and also guidelines, fistulotomy should be preferred, but this is not possible in every patient, I think. I start with needle knife cutting upwards from the orifice if I have to do needle knife techniques.

Ian M Gralnek: Ian M Gralnek And with the pancreatic duct guide wire, some people call that a double guide wire technique. Is that correct?

Torsten Beyna: Torsten Beyna Absolutely. So we have a couple of options here. So once we have the guideway in place, we can also consider the situation if we have a difficult position in the duodenum, probably if we have a duodenum a juxtapapillary diverticulum in place, something difficult, I would already go for double guidewire technique when I have the guideway in the pancreas for the first time. If I consider that we have a good option to do a primary CBD cannulation, I will pull it out at the first time I see the wire in the pancreas and try to cannulate again. So if I have the wire in, we have more or less a double guideway and this is my preferred technique. in case we don’t have a very small type 2 papilla, then I'd leave the guide wire in place and cannulate alongside with a sphincterotome and another guide wire into 11 and 12 o'clock direction because now using the pancreatic guide wire, the intramural and the interpapillary part of the papilla is straightened and this usually leads to a very high success rate. And if we have a small papilla, we have the option to do a little bit of trans-pancreatic cutting, somebody may call it sphincterotomy, I call it septotomy because we just want to open the septum between the pancreatic and the biliary orifice and cannulate after that. These are the options. And the third one is that we put a pancreatic plastic stent that we have to put anyway because once we have the wire in place, we have a high risk situation of post-ERCP pancreatitis.

Ian M Gralnek: Ian M Gralnek Right. So let me backtrack maybe a little bit. So before you start getting into trouble, what do you notice about the papilla or other anatomical features that may say to you, ooh, this is actually going to be difficult, and this is not going to be a straightforward CBD cannulation?

Torsten Beyna: Torsten Beyna I think the first step that we have to consider is the patient itself. If we are dealing with a patient that has a high risk of complications, for example, young female patients with a small papilla, we have to be aware that the risk of complications is much higher, in particular for post-ERCP pancreatitis. Then the second step is if we can reach a very good stable position in front of the papilla or not, if we are dealing with a stricture, for example, tumor infiltration, or a juxtapapillary diverticulum. Then the papilla itself according to the Haroldson classification, usually type one papilla has high success rates, but type two and three, so the very small, tiny papilla and also the protruding ones with a long intra-duodenal segment, in whom, according to literature, we can predict around 50 % difficult cannulation and 10 % failure of cannulation and this usually also goes hand in hand with increasing complication rates. These are probably the points we have to consider beforehand.

Ian M Gralnek: Ian M Gralnek So let me just briefly summarize. So if you're having difficulty and you need to go to like step two, step three. So your step two is the double guide wire technique. Your step three would be a needle knife or a pre-cut. And your third one would be a trans-pancreatic septotomy or fistulotomy. Did I get that right?

Torsten Beyna: Torsten Beyna Yeah, I prefer the needle knife only when I don't have the pancreatic wire. Sometimes it's necessary to put a pancreatic plastic stent and then you could go for a needle knife, that makes it safer because you already have the prophylactic pancreatic stent in place.

Ian M Gralnek: Ian M Gralnek Tell me a few things about how do you minimize, especially in these more difficult cases, pancreatitis risk. You've talked about that you should be placing a pancreatic stent. What else can be done by the endoscopist?

Torsten Beyna: Torsten Beyna As I mentioned before, dealing with a young female patient, sphincter dyskinesia and small papilla, these are more or less red flags for me in my practice because I know here we have to stop earlier and follow the guidelines to early escalation of our therapy. So importantly, if we have difficult cannulation and recurrent passage of the guide wire to the pancreas, we always have to put a pancreas stent. And then we could also consider fluid therapy so there are a couple of options. Usually we don't do high volume hydration of our patients, but we know that hydration, giving more fluid than we usually do, can reduce the PEP rate. But we do it in particular if we cannot give the patient rectal indomethacin, the backbone of our PEP prevention strategy. So we give it (NSAIS) to all our patients that don't have any contraindication.

Ian M Gralnek: Ian M Gralnek Right. And you give that routinely prior to starting the ERCP, correct? The rectal indomethacin?

Torsten Beyna: Torsten Beyna Absolutely. So we know that it only works if we give it from the rectal route, this is our routine that we follow in our practice.

Ian M Gralnek: Ian M Gralnek Okay, so let me switch a little bit. Now what about the patient who has altered anatomy? How do you approach those patients?

Torsten Beyna: Torsten Beyna So nowadays we have a couple of options and these depend a lot on what the altered anatomy is. First is that we have to be clear about the surgery that has been done before. So we should have a look at the reports beforehand. So usually in daily practice we see patients after Billroth II resection on the one hand and the other ultimate situation is that we have Roux-en-Y gastric bypass. So usually in BII patients, we can go for endoscopic transluminal approach as a first line approach because we know that we can, in most of the cases, reach the papilla with a standard side viewing duodenoscope. Sometimes it makes sense to start with a gastrostrope, a forward viewing endoscope, beforehand to have a look at the anatomy, but then most of the cases we can reach it. And then we can use standard instruments, standard cannulation. The only difference is that we see the papilla from the different side. So we have to consider this when applying therapy. So and then the standard Roux-on-Y reconstruction, we still high success rates of device-assisted enteroscopy, ERCP using double balloon, for example. But depending on the overall situation of the patient, we can consider already here to go for EUS-based techniques or percutaneous access. EUS guided transmural approach. The EDGE procedure is nowadays first line. So a lot of things to consider beforehand.

Ian M Gralnek: Ian M Gralnek Can you explain to the listeners the EDGE procedure, what EDGE means and what it is?

Torsten Beyna: Torsten Beyna So after the advent of the lumen-opposing self-expandable metal stents, we now have the option to reach the excluded stomach from the stomach remnant or from the adjacent jejunal limb. So (EDGE) this is a two-step procedure. Usually we create an EUS-guided gastro gastrostomy or in cases if we don't have remnant stomach anymore, in patients with other anatomy, we sometimes do gastroenterostomy for that. But in EDGE procedure, we do a gastro gastrostomy, put the LAMS stent in place. If we go as a single step procedure, we have to suture the LAMS to the gastric wall to avoid stand migration.

Ian M Gralnek: Ian M Gralnek are you actually suturing it or are you clipping it?

Torsten Beyna: Torsten Beyna Nowadays, we do both. Sometimes we suture it, sometimes we use the stent-fix clip. The most important thing to consider is before you go back with your scope, put in a safety guide wire to save your access. Even if the stent migrates, you can just put another one over the guide wire. So, and this is the first step. Now we dilate the stent or we wait for at least two weeks and then we come back with a standard side-viewing endoscope, pass through the new gastro gastrostomy and then can reach the duodenum in the more or less normal way and perform a normal ESCP here. This is very convenient and a safe procedure nowadays.

Ian M Gralnek: Ian M Gralnek Okay, great. That's a great explanation for the uninitiated. So are there other times when you're going to switch actually to EUS-guided biliary drainage? Can you tell us about that?

Torsten Beyna: Torsten Beyna Yeah, so I think nowadays in hepatobiliary pancreatic endoscopy, ERCP and EUS are no longer divided. Both should be provided by the same person in the same room in the same setting. I think this is important development in our field. We see also we have the option in case we have an accessible papilla, we can go for EUS rendezvous procedure. So in our centre, we have the option also to perform percutaneous biliary drainage for rendezvous. So we can use EUS for rendezvous procedures in case of failed biliary cannulation, but in inaccessible papilla, we have the option, to use a gastrointestinal anastomosis to make our way to the target site, what usually is the papilla or the bilio-enteric anastomosis, but we also have the options of antegrade interventions. For example, in patients in whom we were not able to drain the left side of the liver, for example, in cholangiocarcinoma, we can do a palliative hepato-gastrostomy of the left side, but we can also perform it in patients with benign disease. After complicated surgery, for example, stricture of the bilio-enteric anastomosis, we can do hepatogastrostomy from the left side using plastic stents, using multiple plastic stents, like the multi-stenting concept from the antegrade approach. And nowadays, we also see that in case of distal biliary obstruction, most of the cases in malignant disease, we have the option again with the lumen opposing metal stent here to perform a EUS-guided choledochoduodenostomy. One might say that this can be easy. I think it's not so easy and should be done only by experts in the field. You do a Choledochoduodenostomy using LAMS only if the bile duct is dilated large enough. At least 15 millimetres I'm not sure if the LAMS stents are here the final and best option, but we have now the option to do so.

Ian M Gralnek: Ian M Gralnek You brought up something I think really important. You said now today, a person who does ERCP also needs to be facile in EUS. And I agree with you 100%. You have to be able to do both. I'm going to take it a step further. Do you think we've reached the point in advanced endoscopy training? This is a little bit off of our subject, but still related. That when somebody's training in advanced endoscopy procedures, have we gotten to the point where there's sort of division between you're either gonna really do your advanced endoscopy training in pancreatic biliary, including ERCP in the US, and then there'll be others who will be more focused on luminal resection techniques and luminal advanced endoscopy. Have we gotten to that point?

Torsten Beyna: Torsten Beyna So the answer is a little bit difficult for me because in Germany we don't have that yet. But I would strongly recommend that the development would go into this direction because it's getting so specialized on the one hand, luminal resection technique, ESD and so on. This is really challenging. And on the other hand, we see we have a complex field in the HPB field where first, of course, we have the ERCP training, you have to learn, of course, how to cannulate during ESCP, but also how to handle guide wires, how to handle stents. And these are very important steps when you proceed to interventional EUS because usually the first step is only EUS, so the puncture of the duct to put in the guide wire and from there it's more or less ERCP and sometimes vice versa. So I think the development should go into this direction and the training of EUS after you are able to do a very good diagnostic EUS procedure that's still very important to have a good overview, a good orientation. How to use your echo-endoscope and also how to do FNA, FNB. This should be included in the training and then the training should go hand in hand.

Ian M Gralnek: Ian M Gralnek Yeah, I agree because we got to the point, like you say, things have become so sub specialized really that if you try to learn everything, there's a saying in English that you're jack of all trades, but master of none. And I think we are at that point, that division. Torsten, this has been a great podcast. Your knowledge is incredible. And you do a great job of explaining these difficult procedures in very easy language. But before I let you go, I do want to ask you. What are you doing in your free time when you're not doing the ERCP and do you follow sports teams? Do you play sports? Tell our listeners what you're doing.

Torsten Beyna: Torsten Beyna I'm also very much into sports, so I like to do it and follow it. As endoscopists, we sometimes forget that our job is physically really demanding and we do long procedures, sometimes in awkward positions and do fine motor work. So ergonomics really matter, so for me staying fit is part of being able to do endoscopy and this job very well. And so I run on a regular basis. I take my running shoes as you know everywhere I travel and I love playing tennis. I love playing football and go skiing to keep my shape. But more importantly also to it keeps me mentally balanced. And also I love to watch soccer, and also American football.

Ian M Gralnek: Ian M Gralnek Oh really? Who do you follow?

Torsten Beyna: Torsten Beyna I follow the Kansas City Chiefs quite frequently and so Prateek Sharma managed to bring me into the Arrowhead Stadium. So from that moment on it was the Chiefs.

Ian M Gralnek: Ian M Gralnek And your Kansas City Chiefs are not doing that great right now i think they're six and six and they're close to being out of the playoffs which is a big deal

Torsten Beyna: Torsten Beyna Absolutely, absolutely.

Ian M Gralnek: Ian M Gralnek But they're doing better than my Minnesota Vikings, because my Minnesota Vikings suck this year. And it's been a pain to watch them. Listen, Torsten, thank you again for being here. It's been great having you here. It was a great podcast and have a great rest of your day. Bye bye now.

Torsten Beyna: Torsten Beyna Bye bye. Thank you so much for having me.

Ian Gralnek: Ian Gralnek Thank you for listening to this episode of Endoscopy Unplugged. If you found this podcast useful, please subscribe wherever you get your podcasts. To find out more about the European Society of Gastrointestinal Endoscopy, for example, to browse our scientific publications, interact with our online learning portal, the ESGE Academy, or to learn about becoming a member of ESGE, visit our website, www.esge.com. And of course, your feedback is always valuable to us. So send us your thoughts via podcast at esge.com. Thanks for listening and join us next time.