It's an honor, actually, to moderate this session. We have great speakers today, and we're going to address peri-system disease. So optimizing gallstone management. Here's Todd's top five biliary calculus. So if you're developing a service or building a service, create right down a pathway for drain maintenance and stone removal, OK? Know your resources. Grow your resources. So drain, scopes, lithotripsies. See the patients in clinics. Set expectations. Develop a multidisciplinary network of known people that you know, surgeons that you have their cell phones, phone numbers for, surgeons and GI doctors. And your goal should really be to get as many drains out as humanly possible. If you don't set that as your goal, you're not going to have the impetus to keep pushing. Because remember, long-term drain maintenance decreases patient and probably your own quality of life, right? Because they get dislodged. It fills up your schedule. And then you're there late. So these are the seven parameters that I use to help guide me in efficient removal of drains. Today, we'll use this guide to efficiently, effectively talk about gallstones quickly. So stone location, we're going to talk about the gallbladder today in particular. Proper access into the gallbladder is the difference between a paved road and a cobblestone street in a car with no shocks. So you have essentially three options. Transhepatic drain placement offers direct access to the biliary system, reducing the risk of dislodgement. At the same time, the liver acts as a barrier against leakage, lowering the risk of peritonitis. It also provides a stable tract for procedures. Transperitoneal placement is better suited for patients with coagulopathy and avoid further liver injury. These drains carry a higher risk of peritonitis from bile leakage, a less stable tract with more drains prone to dislodgement, making it less suitable for some interventions. But all things being equal, access that gives you a mechanical advantage into visualizing the whole gallbladder, whether it's transhepatic or transperitoneal, probably when it's safe, you want to choose that pathway. Here's a happy case of multiple medium-sized calcified gallbladder calculi resulting in acute cholecystitis. Because bowel was in the way, needle entry was towards the neck of the gallbladder. And you can see here, sorry I didn't do an oblique on this one in hindsight, but essentially the drain is right up towards the neck of that gallbladder. And there's a big bunch of stones on the other side of it. Not a surgical candidate or anything like that. So she came for stone removal. And during stone removal, you can see the axis is right towards the neck. And because of the patient body habitus and the intercostal route, we're not able to torque this axis down to seed down. So we have to kind of flex the scope down and use lots of lasering to deflate the stones there. But that is sometimes even harder than this case reflects. So gallbladder access, upsizing equipment. So you have the drain in your gallbladder, and you need to upsize it. So in our pathway currently, this is a little bit different from the training, we go from whatever size tube they have, such as an aid fringe, to whatever size sheaths we can safely and successfully perform lithotripsy through. Ideally, we're losing access, dropping stones, or causing liver injury. I usually use balloon dilatation when the gallbladder is tight with access near the neck. So we'll stick a balloon in and dilate the tract, versus serial dilatation when they already have a 12 or 14 French drain with good purchase into the gallbladder. And then you can always use the, not always use, you can sometimes use the Amplatzer method, which is to push the peel-away sheath over balloon access. So here is just an example of how sometimes going a transperitoneal route can make your life harder. This drain is essentially wrapped almost completely around the gallbladder. It's partially inside the gallbladder, but it's largely outside the gallbladder. So we were able to, because of the Constantine co-blocking pigtail, we were able to maintain access while we got a stiff wire in, we ballooned up the tract, and we were able to use laser to remove those stones. So that's just access into the gallbladder. Let's talk about a little bit of medical optimization. So in clinic, I start thinking about optimizing them for the procedure. The big three medications you want to optimize, there's anticoagulation, antibiotics, and stone dissolution. Currently, we don't hold anticoagulation. We do give antibiotics. And today, we're going to talk about stone dissolution. So the goal with gallstone dissolution, although it's not required, and there's not a lot of evidence to support its use for these procedures, I always do consider it. The utility is to clear the sludge, mucus, and stone flakes, improve visualization, reduce complications, and prevent reoccurrence. So ursodiol or Actigol is essentially the drug on the market, which most people would use. It dissolves cholesterol-rich gallstones by lowering hepatic cholesterol secretion and converting bile into a cholesterol-solubilizing state. It's well-tolerated with minimal side effects. It's essentially all that mucus with the cholesterol stuck into it that you guys may see all the time, it gets rid of it. And so you can see the stones more clearly, and it improves drainage too. So if you get a little gallstones going down the cystic duct, hopefully they get washed away and you don't cause pancreatitis. My main fear and half of the reason why I do all this stuff is just to avoid the rare case of pancreatitis. There are many lectures at RSNA regarding fluoroscopy, so all I'll say is Allura. But cholangioscopes are a limited resource, so we have to choose our tool carefully. So cholangioscopes are designed to visualize the biliary tree and feature working ports for tools for biopsy, lithotripsy, and baskets. They're available in flexible and rigid forms, varying sizes, and used for stone extraction, diagnosis, and treating strictures and tumors. So the main differences between the two is flexible scopes are generally small-bore, for our purposes, small-bore endoscopes that are essentially designed to navigate small pathways and used in small, but they also have small working channels. But they are equally as good in the gallbladder. And over the next year or so, on the market, there'll be at least five, I think, new scopes now coming out with improved imaging and decreased price points. That's what's currently out there in the mainstream. So that should be good. The rigid, large-bore endoscopes are stiff, straight. They do offer nice maneuverability within the gallbladder and larger working channels for larger gallstones. They also tend to be reusable, but that is only sometimes cost-effective because they require strict sterilization and sometimes get damaged, whereas the disposable scopes, you do not have to deal with that. So lithotripsy modalities. Intercorporeal lithotripsy methods include mechanical lithotripsy, essentially with various baskets, electrohydraulic lithotripsy, EHL, and laser lithotripsy. Generally, everyone in the stone removal business should have a cadre of baskets at their disposal, at least small ones to use through three French ports and larger ones that you can just use through a sheath. Generally, a section will have either an EHL or laser. There's very few programs that have both, as the generators for these devices tend to be a shared resource with other departments. The three key factors in choosing the lithotripsy method is resource availability, resource availability, and resource availability. Essentially, if you don't have it, you can't use it. So take what the hospital will give you to a certain extent. Otherwise, choosing a lithotripsy method depends on several factors, including stone characteristics, size, hardness, location, composition, and patient conditions, comorbidities in their particular anatomy and complication risks. EHL uses essentially a spark, a high-energy hydrolytic shock that fragment the stones, and major limitations is injury to adjacent ducts. Laser lithotripsy uses a homeomylag YAG laser. It, again, annihilates water, creating a cavitation field and exploding the stones, but it's much more gentle on adjacent bile ducts. So when you combine these two, you can come up with a fairly good system for treating all the different stones, which we'll look at here today, a couple cases. So this is a very small calcified stone that absolutely causes havoc in this patient. This CT is pre any symptoms. This CT is when he comes in with acute cholecystitis from the stone. This CT is post partial cholecystectomy, which seems to be an ongoing trend, which shows essentially a blowout of the stump, and there's the stone still sitting in the residual gallbladder. And so we put a drain in, and the surgeons capped it, and he failed capping within 24 hours. So they had him get another ERCP, and they put two stents in, kind of what Megan was showing with her things. You put two round things in a round thing, and there's always space in between. But he's still fat. He came out with 20 and 30 cc's of clear mucus a day. I can give you the answer why that happens if anyone's interested. The surgeons and all the GI doctors knew. So we took him for a scope, and we can see viable gallbladder with a stone that was obstructing the proximal cystic duct. So when you see a patient coming back with 30 cc's of mucus, it's the residual gallbladder layer that's producing mucus. There's no bile in it, because the cystic duct's occluded, but that gallbladder will still produce mucin. And that mucin can blow out a stump or wherever they came across. So you have to just be careful with that. So we cleared out the cystic duct, and he did fine. We'll just go through two more quick cases. Large stone, large bore access into the gallbladder. We lasered it. We used this big basket thing, just because we were trying out new things and being impatient. Swirled it around there, got a bunch of stones out, stone fragments out. And then in the end, it looked great. Here is that continuation of the case I showed earlier with the stones in the gallbladder fundus. You can see here, we left a 24 or 26 French tube behind. With stones still in the gallbladder. So we brought him back. The CT was obtained for an unrelated cause. You can see the stones now are in the cystic duct, which was a problem. So we got through transcystic access with a buddy wire to remove those stones. And we were able to clear the cystic duct again. And we thought we were done. But when we brought her back, we noticed a stone in the common bile duct. And what happened on that one is that she has a large common hepatic duct. In hindsight, one of the stones had floated up into that common hepatic duct in the procedure before. We were scoping from the cystic duct and we didn't see it. And we didn't look at the cholangiogram closely enough. So she had a stone right here, which we lasered out without complication. And then at that point, it looked fine. Sorry, Nariman, I'm done. And then finally, when I first saw this cholangiogram, I felt a mix of excitement and being overwhelmed because they looked so beautiful. But it was a very, very tight gallbladder. You notice I kind of keep using that word. And so my plan was to just laser to free up some space, but some of them were small enough to fit inside of the small sheath. And so we attempted that because I figured, why not? And they got stuck in there. So then we had to laser them out of the sheath. We ruptured some baskets, not because of the laser, because of the stones. And we had to laser the basket a few times. So eventually what we did though, we were able to free up enough space because the stones were so hard, even with a 30 watt laser at full power, it wasn't able to annihilate them. We went up to, I think, a 28 French sheath and we were just able to then pluck them out one by one. And it turned out very well. There's one stuck in the proximal cystic duct, which we were able to pull out. And that's it. Thank you guys. Thank you so much. Thank you so much, Todd. That was a wonderful talk and amazing cases. All right, I guess it's my turn. All right, so I'll be talking about the rule of RFA and actually malignant biliary obstruction technically. So when a patient with malignant biliary obstruction presents to the hospital normally in a setting of pruritus or hyperbilirubinemia or technically cholangitis, normally like in these patients, if there's not any contraindication, they are routed to a GI service. And I mean, back up until 1990, I would say, like, I mean, there was a tendency in utilizing plastic stents. However, later studies sort of showed metallic stents would have a better outcome. So since, like, 1990, there hasn't been a transition in practice. Also, in the meanwhile, like, I mean, we started developing sort of covered stent. And if by any chance this ERCP failed to cross, so normally this patient rerouted to interventional radiology service to undergo percutaneous biliary drain placement and eventually, like, a stain placement, which I'm glad actually Megan covered it very well, so it made it easy for me. So with this in mind, so what do we need, like, in the biliary ablation system? So these stents are great, but historically and overall, like, I mean, research have shown they have a limited life expectancy in terms of patency. So the median overall, like, I mean, patency, like, I mean, normally is around 120 days because of the tumor ingrowth or epithelial hyperplasia or biofilm development in the sludge. And all the studies actually have pounded on that. If the patients, like, with this biliary obstruction, as Megan mentioned, they come back with current or ongoing biliary obstruction, these patients are at a higher risk of sort of mortality and morbidity. Therefore, like, I mean, research been going on to find to tackle this issue. Some, like, I mean, strategies implanted, such as new generation of metallic stent or photodynamic therapy, or even intraluminal, like, I mean, brachytherapy, which is more common in Europe. And like, I mean, as a new achievement or approach, so we have started utilizing endobiliary RFA to decrease the tumor load and hopefully, like, delay the occlusion. So historically, like, all of us, like, are familiar with the ablation system in practice, like, using either microwave system, oscillating sort of ions, or using a regular frequency system to oscillate electrons to solve coagulative necrosis, or even cryoablation to rely on Jules Tampson rule and expand the gas and cause, like, freezing in the area, or even non-thermal approach, which is, like, IRE or PF nowadays. But, like, I mean, neither of them actually work in biliary system because we need something that accommodate the tortuosity of the biliary system or endoluminal ablation. And meanwhile, like, I mean, a lot of times, these rigid systems are designed for percutaneous approach and normally, when we wanted to access any of these areas, so there's a limited window, either because of the structure leaves in that area, or, like, because of the structure actually blocking the window into that area. So therefore, like, I mean, investigation started on developing sort of thin, wire-like and flexible ablation devices. And the researchers came up with this bipolar approach systems, and technically, RFA was one of them, like, I mean, based on the rigid system, they come to the conclusion they can utilize bipolar approach to do, like, sort of this flexible system. And IRE is one of them. Like, I mean, we don't have anything on the market, IRE-wise, but there will be more. So the first catheter introduced to the market is called Habib. This is, like, a French system, so it's developed originally for endobiliary or endoscopy approach. However, we utilize this, like, I mean, actually percutaneously nowadays. So technically, so it utilizes both settings, but IR and GI. So it provides an ablation zone length-wise up to 22 to 28 millimeter, and width-wise is about, like, seven millimeter to 11 millimeter in general. So next to that, a Korean, also, like, company came up with this device called Endoluminal Bipolar Radiofrequency. So it's called, like, Star Made America. So this is a seven-frame system and originally developed for percutaneous. Habib was originally for endoscopy, and this is for percutaneous approach system. So both of them are good devices and can be used, like, alternatively for different applications. As I said, in terms of indication, all of them were developed for malignanbly obstruction to avoid a stone occlusion. However, like, I mean, when anything comes in our hand, as you guys know, IRs are creative, so we start utilizing them in different locations, like off-label, so, and then we'll talk about them, like, down the road after we'll go through the evidence. So once the patient comes in, like, malignanbly obstruction, so before I decide about utilizing them, I make sure, like, the patient's on liquid, like, I mean, a diet at least for 12 hours, NPO for eight hours, pre-op antibiotic, anti-emetic, all, like, I mean, critical components and we can have them on board. For these patients, I normally get, like, I mean, deep sedation, or even general anesthesia on the board. It's not, like, I mean, bleed replacement that we do, like, or exchange that we do it under moderate sedation. Three hours post-op observation, definitely I examine them at the bedside for peritonitis because of the risk of, basically, perforation, and on top of that, I definitely, like, other patients, I get a CBC to make sure there's no bleeding because of higher risk of, like, bleeding. In terms of evidence, of course, when we introduce a device in the market, like, the first study we do is a pilot study. This was a pilot study done back in 2011. So we looked at 22 patients with malignant obstructions. So they looked into immediate and 30-day safety and 90-day biliary patency, and only one patient failed within 30 days and three patients within 90 days. So they showed this is safe and technically feasible, like, I mean, to be utilized for malignant biliary obstruction through the endoscopy. The second study, like, I mean, following this, it was sort of, like, I mean, an opportunistic study, retrospective analysis of 10 patients, and again, they emphasize on safety and feasibility, so. But then it comes, like, sort of like another study with more evidence from 2015. So where they looked into 23 patients compared to 46 controls, and they did try to actually see what sort of benefits this could offer to the patients. So nine out of 23 patients met the end point of the study and 14 out of 46 controls. So they compared RFA versus, and stent versus just pure stent. So what came up actually was interesting, like, I mean, beyond patency, they showed actually utilizing RFA offers more median oral survival for these patients, about, like, 20, 26 days, versus, like, I mean, 120 before in general. And they actually sort of concluded that using RFA within 90s and 180 days sort of offers, and is an independent predictive factor for survival. So moving forward, like, I mean, after this, like, a more, like, I mean, registry type of a study came out, and this also showed, like, positive results. So what they did, they not only actually concluded with that, they also compared, they grabbed a sort of comparison group from a stereo registry. So compared the patient who underwent ablation and stent versus a stent, like, I mean, and they found that actually same thing, similar to prior study, using RFA in a combination of stent sort of offers oral survival benefit for these patients, and the patients who are suffering magnum belie obstruction and setting of pancreatic cancer or cholangiocarcinoma. And on top of that, obviously, like, they showed that the patients who undergo RFA ablation, sort of, like, I mean, they benefit structure-wise as well. So there's a sort of, like, I mean, longer patency in stent. All of them were good. I kind of felt like we decided to, like, do a good study, sort of level one evidence. So, which was done, like, I mean, back in 2020, and it was a randomized multi-center, like five centers in Germany, and they enrolled 66 patients. So they had two groups, RFA, stent, and stent, and unfortunately, the result from this study was negative. So they did not, I mean, although technically, both RFA combination to stent and stent alone was feasible, but in general, like, I mean, neither of them, like, I mean, there was no benefit in utilizing RFA, even trying to actually stent these patients. So in terms of oral survival, also, they did not show any evidence. So these are, like, for endoscopy approach. And when it comes to percutaneous approach, which actually fits with the radiology, actually, filled in interventional radiology mostly. So the evidence started coming out around 2015 with the first study looking to 46, and obviously, as a first step, they showed it's safe and feasible, which was fine. Actually, also, they showed, I'm gonna go back here, they showed also stent patency is better than the median literature-proven, like, sign, which was 120 days, so the stent patency was 49 days. In terms of oral survival, like, I mean, they said they may not actually offer benefit. And then after that, like, this followed with another study on 21 patients. They looked into 30 days and 180 days stent patency rate, which was, like, 75, like, and also 34% in general, and they just conclude it's safe and feasible. But the most strong evidence, which is also retrospective in the field of, like, I mean, IR and also percutaneous approach, is this study on 150 patients. So it was also retrospective. I agree, like, it's a limited sort of evidence. It offers limited evidence. But in general, they did design the procedure. They had two groups with RFA and stent and stent alone, and they showed this actually utilizing RFA, not only decreases the number of the intervention and number of the stent utilized, but also is associated with higher rate of patency. So when you look into the numbers, it was, like, seven months versus, like, I mean, 11 months. So those are all a percutaneous approach. Whenever I'm discussing about utilization of RFA, that's the reference I normally rely, so to discuss, so. And off of those indications, so in looking to that, so, like, I mean, there's some publications to show actually this RFA may benefit the patients who are coming back with residual disease and setting off, like, I mean, sort of endobiliary adenoma after papillectomy. And they showed actually, like, I mean, this could be, like, I mean, RFA ablation plus stent could be considered as an alternative to surgery. And obviously, for benign structure, so it's one of the common, like, I mean, things that we do in our practice treating these patients. So there has been two publications in this field, one with a smaller sample size. They grabbed 21 patients, all of them under vambinery drain, PLASI, which is a traditional treatment we offer to these patients, and upsizing them and intubating them for three months or six months based on the institutional protocol. So, like, I mean, eventually out of those 21 patients, six patients were resistant, and they could, I mean, the researchers in the study, they could not actually extubate the biliary drain. Therefore, they utilized RFA with, like, protocol of 90 seconds, like, I mean, the protocol, like, kind of copy-paste there, and 10-millimeter balloon PLASI, and eventually 14 French biliary drain. And actually, they were able to, they were able to remove the catheter and extubate the biliary system, which was very interesting. And to follow this, like, in the most recent, again, as I said, like, I mean, these are mostly retrospective study, but these are the major studies that we have to how to utilize RFA in benign strictures. It was, like, a similar sort of design, like, you study retrospective analysis of 15 patients. Benign biliary strictures, all of them actually were benign resistant to extubation, so they had biliary drain, they could not extubate them, same thing. So, like, I mean, they utilized RFA in these patients, so it was technically drain placement, RFA, and then PLASI. And clinically, like, they were successful in 87 patients, like, and they were able to actually extubate the biliary system. And lastly, there's some, like, I mean, reports around, like, I mean, off-label use in the portal system, when the patient presents with portal vein traumas in the setting of HCC. Off of this, to wrap this up, so like I mean, those are our RFA, but newer technologies are coming up. Like I mean, one of them, like I mean, was sort of self-expandable, like a stand base, and there will be radio frequency ablation and other devices. IRA, they're all like utilizing animal and we are waiting for clinical data on them. When we do this RFA, obviously, so it's an intervention heat base. There's some complication associated with it, but most concerning was a thermal damage may result in perforation or like sore dystriction, biliary system, hepatic infarction, either because of the adjacent damage, because this is a heat-based thermal ablation system, or because of the arterial damage. Infection in particular, if anyone tends to use RFA immediately when dealing with obstructed system. So normally, we let it to actually cool off. And bleeding because of mostly, like I mean, injury to the vessel. And pancreatitis, of course, when we do this, or sort of actually proximal ablation, there's a chance of inflammation in pancreas and causing pancreatitis. And it's generally the complication. All right, so take away is like, I mean, honestly, based on all evidence like provided from the oscopy side, there's gray zones, or there's a sort of positive like strong literature, but only one literature showing actually lack of benefit in using RFA, but other studies like showing benefits. So there's still some investigation going around. So my recommendations is always like, I mean, because of the heterogeneity in data, try to like, I mean, use this based on like, I mean, the case we're dealing with, and then adjust for clinical judgement, like I mean, so it's not like a literally, legitimately can say, oh, this is where we have to use like I mean, RFA. And on top of that, like I mean, in general, like I mean, shown like in patients, pancreatic cancer and cholangiocarcinoma, it not only may improve the patency of stent, but also may improve in general, the oral survival of these patients. And of course, case-based off-label use, in particular, with benign stretch. All right, with that, that'll be end of my talk. Thank you for listening. All right, so. Thank you. So it's a pleasure to invite Dr. Habibullahi from MD Anderson to come and present to us, like I mean, and discuss gallbladder intervention for acute and chronic cholecystitis. Good afternoon, everyone. Thanks for joining us today. Before I start, I would like to thank the other presenters in the session. They could have not done a better job setting the stage for my talk. So acute cholecystitis is an acute infectious inflammatory syndrome that occurs mostly in patients with gallbladder. And I'm sure all of you guys are familiar with this. Chronic cholecystitis, on the other hand, is used to describe chronic inflammatory changes in the gallbladder wall that's seen on histopathology. It doesn't really correlate very well with the symptoms, as most patients with chronic cholecystitis are asymptomatic. But obviously, if you follow them enough, up to 20% of these patients will become symptomatic down the road, and they will require some intervention. And the treatment of choice for both of these conditions is cholecystectomy. So if you look at the literature, obviously, other than the treatment of choice, there's really not a lot of consensus going on around on how to manage these patients. So at Auburn Institution, what I did, I put together a working group, including all the stakeholders who take care of these patients. In this group, we came up with a management algorithm based on evidence and consensus among the panel members. Obviously, treatment of choice was cholecystectomy, as I mentioned before. And per our surgeons, a good surgical candidate for emergent cholecystectomy is somebody with not a lot of inflammatory changes around the gallbladder and non-hostile abdomen, absolute neutrophil count of about 1,000 or more, and a functional status or ASA score of three or less. In this algorithm, we also included a non-operative pathway. Our surgeons prefer to operate on these patients when they don't have a cholecystostomy tube. So in order to minimize cholecystostomy tube placement, these patients, if they're not a candidate for cholecystectomy, they will receive a trial of 24 to 48 hours of antibiotics. If they respond, their diet will be advanced, they will be discharged and sent to the surgery clinic to be evaluated for elective cholecystectomy. If they don't respond, then we will give them a choletube. So what happens after these patients get a choletube? If you look at the literature in IR, unfortunately, there's not a lot of agreement among all of us in terms of how to manage these patients. In a study, the researchers looked at National Readmissions Database and found that there's about 181,000 patients and 181,000 admissions every year for acute cholecystitis. Luckily, 98.3% of these patients undergo emergent cholecystectomy and only about 1.7% of them get a choletube. But when they looked at the follow-up, out of the patients who get a choletube, only about 40% of them will end up with a definite cholecystectomy. So there's a lot of patients that may benefit from the interventions that we do. Other studies have also shown that if these choletubes are removed without any intervention, there's very high recurrence rate among these patients, usually in the range of 30 to 40%. So at our institute, after these patients get the choletube, we bring them back at four to six weeks after the intervention and we do a choletube check. In this study, we are looking for the presence of stones. If we don't, we're not, or they have that information. The stone burden and also the patency of the cystic duct and CBD. And based on this, if the patients don't have any stone and the ducts are open, they will undergo a capping trial. If they have any stones, they will automatically be referred to surgery to be evaluated for elective cholecystectomy. So as you can see, now we have two groups of patients that may benefit from additional IR interventions. Patients with a catalyst cholecystitis who failed their capping trial, and patients with catalyst cholecystitis who remain to be poor surgical candidates despite the choletube and receiving the antibiotics. Obviously, in the past, all these patients would come to us every two, three months for choletube exchanges, but with increasing adaptation of biliary endoscopy by IRs, now we have solutions to offer to these patients. Several applications have been described for biliary endoscopy. In my practice, I mostly use it for cholecystoscopy, gallbladder, and biliary lithotripsy, and stone removal, as well as doing some endoluminal biliary biopsies for patients in whom endoscopic or percutaneous options are not feasible. IR-operated cholecystoscopy, lithotripsy, and stone removal obviously is a promising option for these patients with gallstones. There's an old body of literature around this, but more recently, Patel et al. published a study. Describing 13 patients who underwent this procedure with 100% technical success, although a couple of patients in their series required multiple procedures. And in this study, they used a combination of rigid and flexible pediatric scopes to achieve stone clearance. And in terms of the outcomes, only one patient in their series came back with acute cholecystitis three years later. Nowadays, obviously, the other presenters covered this really well. There are a couple of disposable small-bore endoscopy systems available to us, including the spyglass discover. This has really made it very simple for me to do these cases. Obviously, interacting with GI and borrowing the equipment is not very easy. This scope is 65 centimeter long, and it can be introduced into the biliary system through a 12-frame sheet. And it has a working channel that could accept different tools, including a biopsy forceps, basket, and electrohydraulic or laser lithotripsy probe. And honestly, this has been a game changer, at least for me and my institution. But if you do a few of these cases, you will quickly realize that pulling the stones out of that 12-frame sheet is not an easy task to do. So in my practice, I had started using 14 and 16 French Pilebaix sheets to kind of go around that. But this paper was published last year at JVIR, and they showed that a mature access into the gallbladder, you can safely upsize it to 24 to 30 French and use it for single-session stone retrievals, which is really ideal for the patient. So this is a case that I did a couple of years ago. This is a seven-year-old gentleman with history of advanced metastatic pancreatic cancer, choletiosis, CBD obstruction, managed by a metal stand placed endoscopically. He presented with acute chole and required a chole tube placement. So in these pictures, to the left, you can see the extent of a stone burden in the gallbladder and cystic duct. In the top middle image, you can see my safety wire that I placed in the duodenum and the scope that's inserted in the gallbladder. To the left, I have also provided a white light image of the stone that you can see with this scope. Middle bottom image, you can see the cystic duct after I removed all the stones, and you can see how clear it is, and there's a nice flow of contrast into the duodenum. So I basically did this patient under rent-a-capping trial, and we were able to remove the tube. He went on to live another year without a chole tube after the treatment. So this is a picture of the patient another year without a chole tube after this procedure, and he was very appreciative of this. But what if the cystic duct is severely narrowed or occluded? Is there anything we can do for these patients? There's a recent study reporting a relatively small number of patients who underwent dual cholecystododenoplastic stent placement for internalization of the chole tube. The technical success in this study was 76%, and they had generally very good outcomes with 77.1% one-year patency. I think this provides a very interesting concept in the patients who are not candidate for surgery otherwise. What if this doesn't work, or you don't really have access to these stents? Is there anything else that we can do? This is a case that I got from my colleague, Nariman. So this is a 56-year-old male, bit chronic cholecystostomy-dependent cholecystitis. The stats post multiple failed attempts. So what they did was they brought the patient for a cholecystoscopy-assisted lithotripsy and a stone removal, and within the same session, they did a laser cystic duct ablation. Six weeks later, they were able to confirm that the cystic duct is occluded, and then at that point, they performed gallbladder cryoablation, another novel procedure to help these patients, and they were able to remove the tube on the same session, and the patient did really well afterwards. A question that comes to mind is that, I'm sure you all have heard about gallbladder cryoablation. What this case kind of points out is that, is doing an ablation on the cystic duct is necessary? If you look at the preclinical and clinical study from studies that are available from gallbladder cryoablation, on the animal study side of it, the researchers were able to show that at four to six weeks after the gallbladder cryoablation, they identified cystic duct fibrosis and occlusion in the animals. In the clinical side, under phase one study, five out of their six subjects underwent a high-dose scan at about a month after the gallbladder cryoablation, and in none of those patients, there was any evidence of gallbladder filling, which may imply that the cystic duct was occluded in these patients. So I think when you're doing the gallbladder cryoablation, based on your planning, if you're including parts of the cystic duct, or at least a pre-flow part of it, you're probably gonna achieve cystic duct occlusion. So you may think about omitting the cystic duct ablation procedure, although it's a very elegant procedure. And finally, I would like to talk a little bit about the chemical data for gallbladder cryoablation. The results of the phase one study on seven subjects was reported in 2020. The technical success rate was 86%. In one patient, hydrodissection was not successful, so they aborted the procedure. There were two major complications in this series, one bleeding and one collection that required drainage. There was really no mortality. All the patients symptomatically improved after this study. And on imaging follow-up, four out of the six patients, they had partial or complete involution of the gallbladder. One-year survival was 67%, but obviously these patients are not dying from the intervention or the cholecystitis. They're just very sick patients to begin with. Despite all these advances, I would like to point out that there's still many gaps in our knowledge about these patients and procedures, and future research should focus on these knowledge gaps, and hopefully we will have answers for some of them. In summary, there have been promising advances in the availability of percutaneous image-guided interventions to manage patients with acute and symptomatic chronic cholecystitis who are not good surgical candidates. I believe further research through prospective studies and national registries could help us identify the ideal treatment for individual patients. Thank you. My charge was to talk about sort of extreme biliary cases, but I like to sort of put things in a cohesive group. So really what I'm gonna talk about mostly is extreme biliary leaks. Now you've seen earlier today from some of the excellent talks that bile leaks are not uncommon, right? In fact, we have this nice schema or a classification system because we know they happen relatively commonly after postcholecystectomy, but they also happen pretty commonly after hepatic resection, and they can be in several places. They can be at the anastomosis, they can be on the cut surface of the liver, or they can be due to isolated ducts, and that's what I'm gonna focus on here today because I think those are the most complicated ones that we wind up treating, and this is an algorithm that I pulled from annals of gastroenterology surgery. It might be a little hard to read, but essentially you have postoperative bile leaks that can be divided into non-isolated biliary leaks, which are pretty easy to treat, and those that are due to isolated ducts, which are a lot more complicated. So our role typically is to drain the myeloma, divert the bile, those are pretty straightforward, but what's really a little bit more complicated is to try to come up with an exit strategy, so it is a long-term solution here, and it's either to reestablish biliary continuity, which sounds easy but can be really hard, or to obliterate the leaking segments to stop bile production. So I'll start with my first case, and this is an example of what we call a percutaneous rendezvous, and essentially a rendezvous is where you have two separate access sites to try to make something communicate that had not been previously. So this is a patient who had metastatic colon cancer. He had a partial hepatectomy, and what we use very commonly at Sloan Kettering, a hepatic arterial infusion pump, and he had had this bile leak for several months, actually, before, whoops, sorry about that, before I met him, so by the time I saw him, he was pretty frustrated, he had this strain that had kept getting changed, it continued to drain bile and was looking for a solution. He had had an endoscopy, which I think is probably the first line of treatment here. You know, they went in, as you can see, they were able to access the common duct here, but there was no continuity with the intrahepatic bile ducts. In that case, what we often do is to go in and drain the intrahepatic duct, and as you can see here, we had a hint from a CT that I didn't show you, that it was the segment two duct that was probably the issue here, and when we get in, we inject it, and again, we only see filling of this biloma, with, again, no visualization of the distal duct. So what did we do? Well, we left him with a couple of drainage catheters now, one going from segment two into the biloma, you know, the second being a biloma, and we sort of put our heads together and said, what can or should we do? Now, initially, the plan had been to do a typical rendezvous, where gastroenterology gets access, you know, and we can achieve sort of through anthrax just like that. There was some complication that they weren't available, and we knew that the common duct, again, dumped straight into this leak, so what we decided to do is essentially a percutaneous rendezvous. We took this 21-gauge needle, and we accessed very centrally here, you know, the common, high common hepatic duct. Through that, we were able to put a wire into the collection that we then snared from the segment two access, which now gave us through and through access from the common duct, you know, into the segment two. You can see we left a safety here wire. And from that, we're now able to, in this sort of, this is gonna jump around a little bit. Maybe it's gonna play, maybe it's not. Now we've established, again, continuity. I don't know why this isn't playing, but we were essentially able now from segment two to, oh, there we go. Is it gonna play? That's okay. We were able to now put a sheath in and access the common, yeah, I don't know why it doesn't wanna play. There we go. Slowly, slowly, we were able to put a grebset in here and reestablish continuity. Afterwards, let's see if I have to do over here again. It looks something like this, and now we have an internal external biliary drain. We can still see this leak here. You know, there's clearly a stricture in the left hepatic duct, which is why bile had been leaking. Fortunately, oops, sorry about that. Fortunately, eventually, I have to do it over here. This is so weird. You know, the abscess cavity dried up. Once we had drained the bile, we had ballooned the stricture and were able to take that catheter out. He actually is doing well. I just saw him a couple of months ago. He's continuing to do well. And I would say, if in retrospect, you know, I had one thing here to avoid complication, you know, we put a 21-gauge needle in that common hepatic duct and we got away with it, probably it would have been smarter to reschedule and do it with endoscopy. This is sort of the other end of how to treat isolated ducts. This is similar story because this is almost all of the patients that we see. Now, a 51-year-old male, had colon cancer, had a resection, had this drain placed anteriorly, sort of through some of the costochondral cartilage that was terribly painful for him, but he had continued to have, you know, high output from this drain. We actually brought him in and did a little sort of study to see if it communicated with any bile ducts, and the cavity was just so large, we really didn't see anything. Here, I would say, you know, it probably makes good sense if you're really looking for communication with the bile ducts to really let it drain for a while first, you know, certainly seeing no ducts here didn't exclude that possibility. We resited the drain for his comfort, and when we did, you know, we did an injection, and now we can see that there's clear communication, you know, with the interhepatic duct, and if we let this study carry out a little bit, it would look like this, you know, a pretty big cavity, and, you know, fairly sizable segmental ducts here that did not communicate with the common duct. We actually talked to our surgeons because it really looked like there wasn't that much distance between, you know, the duct, and we could see the stent here, so we were considering trying to, you know, reestablish continuity, but there were some big vessels there. He had already had a complication, so our surgeon actually just wanted us to sclerose these ducts. Now, we didn't want to necessarily do it through the abscess cavity because whatever you use, whether it's sotradectal glue, alcohol, which is what we used here, you know, essentially, you can just dump it into this collection, and you don't sort of guarantee that it's gonna get back into the bile ducts, so what we did was use the filled ducts here to place an internal external drain. Again, you can see how close it was, you know, to the duct, very tempting for us to try to reestablish continuity, but what we were able to do was essentially put this duct drain in, we let the bile drain, and ultimately made sure we did, now again, another cholangiogram to make sure that we didn't see any communication with the central ducts. We can sort of see the ducts, you know, in the liver that we were gonna sclerose, which we did, let's see, and afterwards, you know, it looked something like this, so essentially, we had obliterated, you know, that right anterior liver, and he actually continues to do quite well. I'll show you one more very quick case. Another thing that we're seeing more and more commonly are these infected intrahepatic bilomas, so these patients who have stents, who have drains, who have some sort of bilioenteric communication are living longer and longer. This is a patient who, as you can see, had a portal vein embolization, had an indwelling endoscopic stent, and developed a biloma in the liver. Unfortunately, as you can see, they weren't resected. Well, you can see the biloma, which we drained. Sorry, I don't know why this doesn't, let's see, so we drain the biloma again. The first time, you know, when you initially drain these things, you don't often see the communication with the biliary tree. They really have to sort of shrink down to size in order to see it, you know, something to be aware of, so don't get lulled into, you know, thinking that this doesn't communicate with the biliary tree. You know, we brought them back a couple of weeks later, and now when we inject, we're gonna be able to see the communication with the biliary tree so that we can, oh, let's see, sorry, so that we can now convert this catheter, you know, from a biloma drain into an internal external drain. We push out that endoscopic stent, and we have, you know, complete drainage through that access and a more stable purchase. I know I'm running over a little bit, so I'll just summarize here that iatrogenic bile leaks, mostly related to surgery, but sometimes related to things that we do, right? These occluded stents, occluded drainage catheters, they're pretty common. Non-isolated biliary leaks, which I didn't really show you, can be treated with simple drainage and diversion, but these isolated biliary leaks are much more challenging, and you either have to reestablish continuity or obliterate the affected segments. Thank you.

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