Cholangioscopy: What Interventional Oncologists Need to Know

Part 1 – Cholangioscopy 101 and Practice-Building

In the latest SIO Corner podcast, Junaid Raja, MD, MSPH, University of Alabama at Birmingham, Alabama; John Smirniotopoulos, MD, Georgetown University, Washington, DC; and Premal Trivedi, MD, University of Colorado Anschutz, Aurora, Colorado, join our host, Elena Violari, MD, RPVI, to discuss the ins and outs of cholangioscopy.

In this first part of the discussion, our experts touch on the basics of cholangioscopy and how to practice-build.

Listen to Part 2 - Further Applications of Cholangioscopy here

Transcript:

Elena Violari, MD, RPVI: Hello everyone and welcome to the SIO podcast. My name is Elena Violari and I'm an attending interventional radiologist in private practice in Chicago and I'll be your host.

Today, we're privileged to have several great guests with us. Dr Junaid Raja, an assistant professor of interventional radiology (IR) and associate program director of the IR residency program at the University of Alabama. Dr John Smirniotopoulos, an assistant professor of interventional radiology at Georgetown University, and Dr Premal Trivedi, an assistant professor of interventional radiology at the University of Colorado.

Thank you all for joining us today.

Today we'll be discussing a very exciting topic, which is the different applications of percutaneous cholangioscopy. I think there's a pressing need for innovation and of providing evidence-based approaches for the management of complex patients with indwelling biliary drains, long term. This is a very new and a very exciting topic, exciting space in IR.

Before we dive in, let's have everyone introduce themselves and please tell us a little bit about your journey in IR and the current state of your practice. Premal, why don't you start?

Premal Trivedi, MD: Sure, I'll take it away. I'm Premal Trivedi, currently Chief of IR, University of Colorado. My experience with percutaneous cholangioscopy started in a fellowship. I did a number of cases with Dr Harjit Singh, [MD, Johns Hopkins Medicine, Baltimore, Maryland] and they were really centered on stone treatment. It was obviously an additive tool in the IR space. When I was hired to come back to the University of Colorado, I had no plans to really focus on that area, but it became clear very quickly that there's a whole number of patients who had recalcitrant problems that meant that they couldn't get their biliary drain out. That's really where it started.

As you might know, we have a really robust transplant program. I think the university performed the first liver transplant in the country, at the University of Colorado, so a large number of transplant patients come through our program, and you can imagine biliary issues are pretty frequently encountered in this population.

What I've found over the subsequent few years is that we were able to navigate successfully these cases that were considered recalcitrant to all the techniques that we know how to do as an IR: using x-ray guidance, needles, catheters, wires, good operators that tried their best, and we had come up short. And for all of them, putting in the scope meant that you could either make a definitive diagnosis, there was a misdiagnosis, or you could definitively treat the problem and get the patient tube-free. And for me, the first year was this deeply rewarding series of moments where I discovered maybe this is one of the things I want to do for people because it's really rewarding, and it's appreciated by everybody around me.

Fast forward a few years, I think what we have is a pretty robust program where now the use of the scope is programmatically and structurally built in for biliary cases. We're trying to expand when and where it should be used, and I think we have improved both our diagnostic and therapeutic options beyond stone. We're doing stricture ablation and a number of other things that we can maybe talk about later on. This certainly become a fixture in the IR lab.

Dr Violari: That's wonderful and I'll move on to Junaid.

Junaid Raja, MD, MSPH: Thanks again for having me. Junaid Raja, I am an assistant professor at UAB. Very similar to Premal, I was initially exposed to cholangioscopy during my training.

Harjit Singh's kind of a grandfather trainer to me, in that Todd Schlachter [MD, Yale School of Medicine, New Haven, Connecticut] and Igor Latich [MD, Yale School of Medicine] were my main mentors. And, you know, there were different tools and techniques we used when I was in training. But when I came here to UAB, we had the good fortune of having already a good contract with SpyGlass and Boston Scientific. And it was very similar to Premal that as soon as I got here, we had a very obvious need. There are patients who need to get their tubes out. I think that's sort of been the biggest impetus for our field. We are able to do great work through our existing image guidance and sometimes the best image guidance is direct visualization and once we've been able to incorporate that into our practice and whether it's for stone disease or for post-transplant patients, post-Kasai patients, post–you-name-whatever pathology comes to mind, and it's been great that we've been able to expand the diagnostic armamentarium and as well as treatment, as Premal mentioned.

Like everything else, there's an adoption period which can be a little challenging for certain people to arrange logistics and make sure that everything's teed up the way that they want. But once it's up and running, it's just like pulling another wire or catheter, having that integrated setup is just tremendous. And it isn't a question of, do we need to have this out of the other setup? It's, what's best for the patient? How can we really positively impact their care? And we've been really fortunate. We've grown exponentially in terms of our cholangioscopy service over the last 2 years, and that's how we got into it.

Dr Violari: That's awesome. And I'll give it away to John.

John Smirniotopoulos, MD: Thank you also for having me. I'm John Smirniotopoulos, I'm assistant professor of radiology at Georgetown and MedStar Washington Hospital Center. Like everyone here, I got into colon jobs to be during my fellowship. At the time, Alex Kim [MD, FSIR, National Vascular Physicians, National Harbor, Maryland], who was at Georgetown and Emile Cohen, [MD, Georgetown University]. We started playing around with the original SpyGlass, the really long one, prior to the [SpyGlass] Discover but then using it to look at biliary strictures and

When I took my first job back at Cornell, where I did my residency, I had familiarity already with using a scope for more malignant issues. And it was interesting because I started my first job in August of 2020, so COVID was pretty rampant. All the cholecystostomy (coley) tube numbers have gone up, at least I felt, at the academic center. And we had a lot of patients that were returning for persistent coley tubes and coley tube checks and exchanges. And so, we were trying to figure out what to do with these patients and as you guys were mentioning, how to get them tube-free. Prior to SpyGlass Discover, we were using disposable cystoscopes to identify the stones and using different baskets and SpyGlass allowed us to then, once we got it on board, have different tools through it, but beyond that we just got familiar with using a scope in general: how to navigate it, how to get your access, what equipment you need.

When I came back to MedStar in 2021, a lot of this was already in place. Some of it, I asked to bring in. But once we had familiarity with the equipment we needed and the setup and even simple things like how to get the image on your angio[graphy] screen so you're not necessarily having to work off a separate monitor, those things became very natural for our team.

As both of these guys have mentioned, it's now not a laborious task to bring in a cholangioscope. It's just part of our regular armamentarium that we have ready to go. And it's been well received not only amongst my colleagues who are also picking it up, but amongst the other specialties we work with. For example, we have a very robust hepatobiliary service, and we have multidisciplinary conferences with them. The cholangioscopy becomes a very regular point, “can we do this with an antegrade approach using the scope to treat a stricture? To treat a stone?” I got a consult this afternoon for something just like that. It's not even so much a competition with other services, like gastroenterology, this is really collaborative. The way that everyone has started to approach this, and at least the way I'm seeing it now with 2 institutions, is that it is more collaborative, not so much competitive in terms of trying to really help a patient population that is now growing in its use.

We started with stones, we moved on to strictures, and we keep finding more and more uses for it and hoping that we just keep treating more and more patients.

Dr Violari: I feel that, as you mentioned, as opposed to many things that we do in IR, where sometimes we kind of run into competing specialties, with cholangioscopy it sounds like you really are solving problems that your GI colleagues or your surgeon colleagues cannot solve. Most of the cases are complex and come to you as a complication after surgery, or after failed endoscopic intervention. It must be a lot easier to build this practice than other practices in IR, correct?

Dr Trivedi: I might take an opposing viewpoint there, just because my lived reality was a little bit different, and I hope that my GI colleagues will forgive me for saying this out loud. Certainly, for me, there was a degree of trepidation: who is this person who's wielding a scope? Do they know what they're doing? Why are they doing it? I think that's pretty natural, right? If you found out that someone was doing angiography in some other part of the hospital, you'd want to ask questions. I think it was retrospectively fair.

It involves some conversations, again, a period of anxiety, but it subsided very quickly. And actually, I would say one of my, what I consider my early wins or crowning achievements, was one of the same people who had a degree of trepidation started referring patients. These are my GI colleagues who said, "You know, I can't get there retrograde. Could you want to try antegrade?" It clearly demonstrated that, one, there's a degree of trust in the IR doctor handling a scope to do basic things, right? We're not going to do complex diagnosis. And that there's a real system of collaboration. And that's when really the fruitful collaboration started. It wasn't always easy.

Dr Violari: Yeah, did you all have the same experience?

Dr Raja: Yeah, I think so. I think there are always going to be partners and there are going to be people who are very skeptical. And we have our fair mix of both.

But to Elena's point, when they have had failed ERCP [endoscopic retrograde cholangiopancreatography] or they've had a complex anatomy and they know they can't get to it endoscopically, it's been nice and easier when they say, "Hey, can you go antegrade and take a look?" Some of the challenges that Premal mentioned, yeah, for sure, there are times where they're like, "Well, why would you go that way, when we can attempt this, that or the other, from an endoscopic approach?" And a lot of times they attempted it and were not successful and it ended up back on our table. Being team-oriented was just really important.

And I'm sure we'll get to it at some point, but the concept of doing rendezvous procedures in conjunction with GI colleagues has really been great in terms of fostering trust and fostering collaboration. Hey, we're not out to steal lunch money, right? We just want to do what's best for the patient. We want to help patients as much as we can. And we have a role, they have a role, and we have a role together, right? Multidisciplinary conferences to discuss some of these challenging biliary cases are awesome. We have them here; John says he had him at Georgetown as well. Yeah.

Dr Violari: And that was my next question. With all the imaging modalities available in IR, why should we also be using endoscopic guidance? What do IRs bring to the table in this arena that GIs and surgeons cannot bring? Go ahead, John.

Dr Smirniotopoulos: I think one of the big things, like we're saying, is an antegrade approach, right? If you take the gallbladder by itself, most of the GIs are not visualizing the gallbladder lumen unless they're doing like an AXIOS stent or something like that. For gallstones and patients that would never go on to have surgery, which is where I think a lot of us started looking at the scope, it became a large patient population for us to treat. Because surgeons, at least our surgeons, said no, there are too many comorbidities, whether it's cardiac or whatever, it was more of the anesthesia comorbidity that was there, or needing to convert to open from a lap chole [laparoscopic cholecystectomy]. The patients would have a chronic tube, and the GI could put in a CBD [common bile duct] stent, but it wouldn't really treat the stone. So, this patient, theoretically, has a 20% or 30 % risk of recurrent cholecystitis when the stone is in place. That opened things up.

Once we started doing that and doing it well, then we started looking at things also differently, right? The biliary system, you can go from peripheral to central looking at the scope, visualizing it. A nice example that I like is, we had a patient, again, outside hospital transferred. They had a lap chole and unfortunately, there was an issue with injury to an artery, and there was devascularization of segment 7. There was a drain that was placed, a biliary drain, and it became a longer discussion because the stricture never really healed, and it was a long-segment stricture. And so the hepatobiliary surgeon say, "Can we identify what's healthy, what's not healthy? Because I probably have to do a resection and do hepatico-j [hepaticojejunostomy]?" And it would determine, can I just get away with a segmentectomy or do I have to really do something more elaborate like a triseg[mentectomy].” Which is obviously— This was a relatively inpatient, so that would be a much bigger surgery. I said absolutely we'll go ahead and look at the scope. We were able to identify from peripheral to central where the structure was and probably more importantly where it wasn't, and the transition from injured and non-functioning biliary duct to normal healthy duct.

For our purposes, unfortunately, therapeutically, we tried a lot of stuff that didn't work. But from a diagnostic standpoint, it really helped out, in terms of surgical planning. And this particular case spared some healthy liver. But I think it really added a role that maybe couldn't be performed by ERCP, just due to constraints of the scope length and the approach of it.

Having an antegrade look at things in an area that maybe wasn't literally visualized under endoscopy is nice and helpful, at least from our end.

Dr Violari: That's a great explanation, a great example. Premal, would you like to add something on that?

Dr Trivedi: Yeah, you can tell I'm eager to build. And I agree with John, and I'd say in retrospect, if you don't have scope technology, you are limited in diagnosing biliary problems. And quite frankly, the vast majority of our history, what we know about biliary disease, is fundamentally limited. We're using x-ray pictures.

What's particularly challenging with bile ducts is they're small, flow is slow. There's a degree of subjectivity and interpretation to begin with. I'll ask you, when you see a narrowing, do you know what the narrowing is? When you see a filling defect, do you know what the filling defect is? I think we've made a lot of assumptions in literature about what that represents. When you look at the same population, with the addition of a cholagioscope, plus traditional fluoro[scopy] images, you get more than the additive information of the two modalities. I think they work really nicely together.

The other thing that's striking here is that all these examples that John's throwing out, which are really impressive, these are all things that we have run across in the last few years. Which tells you these are not particularly “zebra” problems. They exist out in the world. We are just fundamentally limited in our technology to accurately identify them and treat them in other places. Looking forward, we really need to look at this as the biliary disease and treatment platform of the future. We need to bring this into IR in order to take adequate care of our patients.

Dr Violari: I totally agree with you. As we all know the ultimate goal, for this patient, is biliary drain removal and biliary drains can have a significant impact in the physical and psychological aspect of a patient's life, so getting drains out as soon as possible is very important in improving this patient's quality of life, especially cancer patients.

How do you think this equipment helps us achieve this goal more quickly?

Dr Trivedi: I’m going to say one little thing which is, you start with accurate diagnosis. Frequently you have patients with, again, a biliary narrowing and some types of strictures look malignant. What we found is that there are other types of strictures that don't look malignant that are malignant, and there are strictures that look malignant on cholangiography that look not malignant by cholangioscopy. So, step one, make the right diagnosis. I think cholangioscopy can help right away.

And I think Junaid probably has some thoughts on the treatment.

Dr Raja: Yeah, for sure. I agree. I think it's not just accurate diagnosis, I think it's a complete diagnosis and I think it goes hand-in-hand. Being able to delineate malignancy versus benign disease is important, but it's a fairly large territory. It's a small organ with small ducts, but there are different areas that can have different diseases.

I think PSC [primary sclerosing cholangitis] patients are prime example of that, where you can have both mixed, benign and malignant disease, you can have various areas that have other functional changes. And by functional, you can see that much more clearly with direct visualization than with cholangiography, as was previously suggested. I think we're going to start talking about ablation at some point, and that's a great place that we've been able to grow here. I think it has a very important role for the future. I’ll leave it there in case someone else has other comments on this question.

Dr Violari: John, do you have a comment?

Dr Smirniotopoulos: Yeah, I completely agree. Making the diagnosis and knowing how to treat it— It's interesting because, as Premal mentioned also, you look at cholangiography and you see a stricture and not know what it is. To add to that, sometimes the cholangiography may mask or overexaggerate the disease and the duct. And that may actually very much influence your treatment, whether you're doing a stricturotomy, ablation, or just a balloon, or whatever you decide to do.

It's interesting because I've seen a number of strictures where you inject contrast the first time and you think it's a certain length or certain size, involves certain ducts, maybe doesn't go to a confluence or maybe it does. And then I put the scope in, and it absolutely will help me so much, because it will either confirm or just completely blows away what I saw on cholangiography. Usually they go pretty hand-in-hand, but it helps tremendously. At a very minimum, you can confirm what you're seeing on fluoro[scopy], but it's definitely helped me in times where I'm finding things that I didn't pick up on fluoro[scopy]. Or I go in there and say oh, this is actually not as bad as I thought based on the on the fluoro[scopy] image.

I agree that this is not only an adjunct tool; I don't think you can look at it like that, I think it's becoming an essential tool for us. Especially as we're getting more and more experienced with the visualization, diagnoses, pathology, and that nature, which credit to Dr Singh for spearheading a lot of this. Part of the atlas that he's been working on is to really help push that out, to identify those pathologies that you see in the scope, so more interventionalists will have a better recognition of it. So again, this becomes more widely adopted.

Dr Raja: I wanted to add something there. I think an important parallel to a different disease process is how intravascular ultrasound (IVUS) has revolutionized deep venous disease management, and similarly, you can make a similar argument with ICE [intracardiac echocardiography] and tips TIPS [transjugular intrahepatic portosystemic shunt], but I think IVUS is a better example here. Where historically we referred only to either external ultrasound or to venography. And IVUS has redefined 3D visualization, has redefined defining the extent of disease. And very similarly to John's point, when you put a scope in, it tells you so much more information than just a 2D image.

Dr Violari: That's awesome. Tell us a little bit about the technology needed to do these procedures. What equipment do we need to build a cholangioscopy practice? Are there different systems? Do you all have access are reusable scopes at your institution or disposable scopes? And for someone who's looking into building this practice, what's the most accessible tool that he can start using?

Dr Smirniotopoulos: Premal, do you want to take this? Because you and I have had discussions about the disposable scopes, and I know you have some thoughts.

Dr Trivedi: Yeah, I'm really eager to hear about everybody's perspective. What I'd encourage people to do is just look locally, the challenges are local. Some people have a scope that's available in partnership with urology or gastroenterology, and that might be reusable. Whatever technology you pick up for the first time is going to seem challenging. And it's good to start with a collaborative program, irrespective of what that scope looks like. Having some buy-in from a GI doctor, from a transplant surgeon, from a urologist is only going to help you with advancing your skill set locally where they can provide some backup. That’s step one.

Step two is thinking about, what is the path of least resistance? As I mentioned, maybe that looks like a reusable scope. If it does —for me, it didn't— then, think about what type of disposable scope is easiest to use. For me, I'm still using simple technology compared to these 2 on the podcast here. I primarily use a disposable ureteroscope for almost everything. And that really is reflective of, I would say, trouble articulating a rationale for a higher level of technology that costs more money to a system that is clearly seeing that we're successful with a cheaper scope. That was my learning curve: I didn't have a pre-approved SpyGlass to pull from, but I did have a close collaboration with urology and transplant surgeons, and they were using the ureteroscope. That’s what I use, it does a perfectly good job for basic visualization, for stone treatment.

And then, you asked what is adequate starting technology? You need, I would say, baskets, you need forceps, that's simple stuff. And then you need an approach to treating stones. Without getting too much into the weeds on that, there are multiple options for treating stones too. But I would say that is level 1 technology. Figure out a partnership, figure out what type of scope is least resistance, and then figure out a basket source, a forceps source, and then figure out whether you're going to use laser or some of the other technologies for stone treatment.

All of these things, by the way, you can pick off a menu out of a number of different vendor options. You can have it in a cohesive platform with Boston Scientific, or you can kind of put pieces together on your own, which is what I did.

Dr Violari: That's awesome. What are your thoughts, Junaid?

Dr Raja: I think that's great. When I was in training, we used a ureteroscope as well. I think there's merit to that for sure. For us, like I said, we already had an established relationship with Boston Scientific. The other part that was great is the lower profile catheters that we're able to use and scopes we're able to use at times. The [SpyGlass] Discover that we ended up using, it's about 10 and a half French. And some of the biliary drains we put in are 12 French or 14 French, and that's ample size. Whereas some of the historic scopes, and I'm sure the newer uteroscopes are lower profile as well, would require additional tools. I think it's really important, to Premal’s point, to think about the full bundle that you're going to need.

I think one important part is the sheath. If you are doing just gallstone disease and you just need access into gallbladder, it can be a little bit less challenging or cumbersome in figuring that out. But if you are trying to treat a fairly central bile disease or to diagnose something there, and your access is peripheral and low., being able to have a braided sheath, being able to have something with more support is important, even as you access and guide your scope through.

I agree with what Premal said in terms of, you need to have your scope itself, a basket, forceps/brush/whatever you want to biopsy with. And then EHL [electrohydraulic lithotripsy], laser, whatever your tool is for destroying stones. But I do think a good sheath is something sometimes I overlooked in very early practice and it's something that I've learned to value very much.

Dr Violari: How about you, John?

Dr Smirniotopoulos: Yeah, actually, I love the sheath point, because I completely agree with that. And we work with Boston [Scientific], too. Very early on, they have that 12 French sheath that they'll recommend using, it came from their peripheral line. I'm not a big fan of it. For a couple reasons, especially if you're talking about biliary, not gallbladder, but biliary, because you need to sometimes make curves, especially if you're coming from the left, you'll make some exaggerated curves, it's not very radiopaque. But they, in my understanding, weren't really sure what other sheaths to pair it with, and this seemed to fit the scope size, but I now use other sheaths that I like a lot better. That's actually an incredibly important part. Even if you're thinking of gallbladder, if you're going to go through the cystic gut, transcystic, you also do need to have some support there.

For scopes, so when I went back to New York for my first job, again, we didn't have SpyGlass Discover yet, it wasn't available to us. So we were using the disposable ureteroscopy and cystoscopes. And they worked fine. Then we wanted to try SpyGlass Discover, and we tried that and it worked fine, but different. And I think to a Premal’s point, whatever the path of least resistances is, is probably going to matter quite a bit.

SpyGlass Discover was originally designed with surgeons in mind, and then more IRs started adopting it. However, at Georgetown and MedStar, there were already discussions with surgeons to use it intraoperatively, and they did cholecystectomy, they used to sweep the cystic duct and CBD. So, from a cost perspective, there's a cost of renting or buying a generator and then if you have more than one group that's going to do that, if they share it or if you can buy more than one generator then reduce the bulk price, that actually became —this is getting to the degree of purchasing stuff, but I'm sure Premal’s all over that now in his current role of being aware of that—  but that actually made a difference to us, and there's some room for negotiation. So those talks were already kind of underway between 2 different departments that we collaborate with a lot. It just organically came that way.

But one other thing to think about though, right? That's just the scope, it's just the generator. The SpyGlass is disposable, which is fine for our purposes. I've used the reusable ureteroscopes with our urology colleagues too. They're also great. They have them available. But remember, those are often coming in a kit, it's usually the surgeon's kit. You have to time it on a day that they're not using it, or make sure it's okay with them. So, the disposables are somewhat easy to set up, because the company will be happy to let you buy a disposable scope and use it and get you up and running.

Having a basket, as you said, is important. And if you're going to treat stones, knowing what you want to treat the stones. I think one of the things to be cautious about is if you start treating stones and you get in over your head. Maybe knowing what you can and can't do with the equipment that's available to you. Because each of these things will have some barrier to getting into your angio-suite, whether it's EHL, that may take another ROI or some discussion. Laser, you may need to collaborate with other colleagues, like in neurology, to see if they can help you with laser credentialing or bring that down. I have a good relationship with neurology, so we do shock pulse quite a bit, and that's a whole other discussion.

One other thing to mention though is also an irrigation system for your scope. And it can be as simple as what I do: I just use a single extra pump syringe. We essentially stole a lot of stuff from the urology side. It's just a spring-loaded syringe that hooks up to a saline bag, the other end hooks up to a scope or whatever, and it just springs back, and you can adjust your flow, you can have a flip pedal, too. Again, that's now going with a company to get that in place. You can piecemeal it, you can do it all in bulk, you can do a combination. We've kind of done a combination of the two.

I think sheath size is actually a great point, Junaid. And I think that's something that we don't really focus on too much. Having a nice sheath that you're going to work with, that’s a really, really nice point.

Dr Violari: Unfortunately, this is not what I'm currently using in my practice. And my next question would be, what training does it take to build a cholangioscopy practice, for someone who didn't have this training during fellowship? How do you get privileges and get credentialed at the hospital and so forth?

Dr Smirniotopoulos: Yeah, so your last point is very interesting. And I know Premal and I talked about this, was it 2 years ago? When we were planning the hands-on workshop and our GU was talking about it, too, the credentialing thing. I don't think we saw it when we were starting to do this, we've had it for 4 years now, or more. But it's interesting because the credentialing does pop up at some hospitals. You know, are you credentialed to scope? I don't know if you guys have a good answer to that because I feel like it's going to be very hospital-based, if the credentialing committee says, oh are you credentialed to do cholangioscopy?

I don't know if you guys had to deal with that, but for us, we didn’t. It came, we did a number of cases, and it's just part of our repertoire now. It's similar to fluoro[scopy] privileges. It's there. But I know it is coming up at other hospitals throughout the country. Do you guys have any thoughts on that?

Dr Violari: For example, for credentialing recently, we're applying for the Y90 privileges at our hospitals, and one of the questions that we had to answer regarding getting credentialed is have you recently gone to a conference dedicated to Y90? Every year in Chicago, we have the Y90 Masterclass, so that was one of the things that you could add in your application to get that credential. Is there something similar or something that could happen in the future for cholangioscopy?

Dr Trivedi: I think there's certainly a national appetite and a push for a course that's dedicated to cholangioscopy. There's been good efforts made. SIR now every year for the past number of years, again, thanks to great leadership from a number of people who are not here to take credit for it, there's solid programming. There's a hands-on workshop, there's good categorical courses. You could attend SIR and get a good foundation.

But on top of that, to your original question, what do you need to get going? You're going to need a partner who can help you navigate how to manage things as you run through them. That goes back to my initial recommendation of, it would be really great to have someone in IR and someone locally who was outside of IR with a lot of experience that you can turn to, and if you can start with a patient situation where you can add value, right? Let’s say this is a transplant patient who has a recalcitrant stricture, and you need to figure out what it is. That's a great place to bring people together in collaboration. GI can't get their retrograde and you offer your skills antegrade. That's a natural collaboration.

Start there, have a partner who can help you with maybe the first, I would say 3 to 5 cases, just to get oriented. Am I setting this up correctly, what's north, what's south, what is too much irrigation, what's too little irrigation. There's a lot of little tips that go into it. And then beyond that 3-to-5-case initial run, which will get you able to put in a scope and see what things are, you need about maybe another dedicated 5 to 10 cases for the treatment part of it. If you're going to start treating stones, you need a handful of stone treatment examples that are supervised by other people. The infrastructure for that is not quite there yet. I don't know if you have subscribers from industry: hey guys, we need this and we need your support.

Dr Violari: What do you think, Junaid?

Dr Raja: Yeah, I completely agree with both of them. Again, collaboration is just so key. This is not a patient base that's just going to show up at our doorstep. And I think it's a question of troubleshooting. It's a patient population that comes to us initially for urgent or emergent, in certain patients' cases, decompression, if it's cholangitis, or whatever. Or urgent diagnostic purposes if it's a central biliary mass that's causing obstruction, but not quite cholangitis at this point. They get sent to us initially for that and it's just, to the points that have been made before, a question of the value that we're able to add.

We also don't have any credentialing issues, thankfully. I agree having mentored cases, if not with someone in IR or through the SIR or SIO, then, someone locally at your institution. Again, it's just being effective communicators locally. Hey, we see this problem. We know you have this problem too. How can we help in concert? That’s really important.

Dr Violari: How often do you guys combine cases with GI? You mentioned earlier, Junaid, doing rendezvous procedures and so forth.

Dr Raja: Our rendezvous procedures have ironically gone down, and I think part of that is just because we have gotten better with what we're able to offer with the scope itself, by ourselves. But that said, there are cases. Whether they come through them or come through us, but maybe 1 or 2 a year at this point. We still have discussions and collaborations, and it's important not to be adversarial, because just like we bail them out of jams, they bail us out of jams too sometimes. Being able to be humble and say, what would you do in this situation? This is the patient that's been referred to us, by you or by a surgeon, and what's the best thing to do?

Dr Violari: How about you, John?

Dr Smirniotopoulos: Yeah, it's interesting with the rendezvous, because I have the exact same experience. I think our rendezvous numbers have gone down. It does pop up, and we do it every once in a while, but it's not where it was before. And I think that is partially because our scopes goes are going up. When we had the rendezvous discussions now, it's not as simple as it was maybe 5 or 10 years ago: Can you get access and then leave a wire in or come upstairs and take this internal external ability to drain, put a wire and then we'll put a stent. It's more, okay, we're going to treat a stricture. We're having a drain across it, but the patient really doesn't want to drain. Can we do something collaboratively after you treat the stricture? We're going to go ahead and leave access so then we can put up some 3 or 4 plastic scents from below, maybe that's a way to get the bulk we need for the stricture, but also treating it.

So the rendezvous procedures haven't become the simple, put a tube and so I can get a wire and I can put my retrograde stent in. It's more of, okay, how do we help this complex patient in a way that's good for them, but also improves their quality of life? It’s become more of that. But definitely, it's overall decreased, since we've adopted the scope and just gotten better at it.

Dr Violari: Is it the same for you, Premal?

Dr Trivedi: Yeah, I think we, I used to run down to the GI lab, absolutely the same. We'd run down for more basic conversations, wire access, that kind of thing. Occasionally, I still count on them to help me out with, what I think is mucosal inflammation, can you put your eyes on it? I'm not totally sure. And it's still really helpful to have them.

There have been certain situations where having their input on our approach, I can think about an impacted stone that was in the distal CBD, right near the pancreatic head. How would they handle it versus us? Are there any advantages, disadvantages, right? We got into a more nuanced conversation around, you can do a sphincterotomy retrograde approach, open things up, and then you could treat from below. Are there any advantages to protecting the pancreatic duct, doing that versus coming from above?

It's more kind of a collaboration on more complicated patients that require 2 disciplines to come together, rather than a simple, hey, can you leave a wire in there and I'll do my part. That does speak to the success of a program, and I think given that we've had identical experiences, also, you can count on this being a generally good and happy thing between multiple services a couple of years down the line.