Cholangioscopy: What Interventional Oncologists Need to Know

Part 2 – Further Applications of Cholangioscopy

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 the second part of the discussion, our experts discuss the further applications of cholangioscopy, such as treating stones, managing biliary strictures, and ablation for cholangiocarcinoma.

Listen to Part 1 - Cholangioscopy 101 and Practice-Building here

Transcript:

Dr Elena Violari, MD, RPVI: There are several applications of percutaneous cholangioscopy, as mentioned already, ranging from diagnosis and biopsy: cholecystoscopy and lithotripsy in non-surgical patients with acute cholecystitis, management of benign biliary strictures, treatment of intraductal cholangiocarcinoma with ablation. Can you please talk to us a little bit about these procedures and your experience with them? Do you do all of these procedures, or do you do more one or the other? I'll start with you, Junaid.

Dr Junaid Raja, MD, MSPH: For us, it's been a process and evolution. Some of my partners are doing more of the stonework. I've shifted my practice a little bit more toward the actual biliary portion: assessment of stricture, biopsy, ablation, et cetera.

In terms of endobiliary malignancies that we ablate, those are very few and far between. I'm curious to hear what the other panelists feel as well. Usually, the diseases progress to a much higher grade at that point. And if it's very early grade, then they typically know, because they did an endoscopy and were able to get up that way. So that's not really as much of a point that we have.

What we have been working towards is treatment of benign biliary strictures with radiofrequency ablation. Aaron Rohr, MD, who's at the University of Kansas, and I have been talking about this and then doing this for a couple of years, as I've heard other places have as well. In terms of, again, getting to that tube-out mentality, these patients with benign biliary strictures, historically not much has worked for them. The best protocol has been prolonged intubation, and that whole process, from initial access to potential extubation, is typically 7 to 8 months, and that’s a really long time — where there's an interval where the tubes fall out, they get infected, they get obstructed, they have just every sort of miserable issue and pain.  We've been able to have good success, in terms of ablating biliary strictures to then accommodate a large caliber drain quicker, leave it in for a short period of time, and then being able to extubate in the order of some weeks rather than 7 to 8 months.

Dr Violari: How about you, John? Do you perform all the range of procedures with cholangioscopy or there's some areas that you do more than others?

John Smirniotopoulos, MD: Yeah, I still do a little bit of everything. The endoluminal malignancy, not so much, just because, I think you’re right, Junaid. By the time we get to that, it's usually widespread at that point. I'm trying to think of one where it hasn't really been, but we don't see a lot of it because again, the disease process at that point is pretty widespread.

The benign strictures and also anastomotic strictures and transplants are really an interesting and fruitful endeavor. I certainly treat stones quite a bit, and that's very satisfying, and I like that, and I like pushing what I can do with the stones to get those patients tube-free. But at least with the stones, I know, because I can see if the stones are gone, I can get them tube-free, I think I have an algorithm for it.

The strictures, though, can be tedious to deal with, and like you were saying, really it is that prolonged debate, where a lot of that data had come from for success. And even those have recalcitrant restenosis, no matter how many times you call in cholangioplasty. There’s some data suggesting cutting balloons as well, but I've seen a lot of these patients where it still comes back.

I think when you start talking about ablation and you start talking about maybe stricturotomy with a laser, that's where I think it gets interesting. And we have room to have an impact for patients there. A lot of that data is going to be evolving and forthcoming as more and more people are doing it, but from an anecdotal point, we've seen good success from it, and we try to follow our patients who have it, because again, these are patients ideally who can follow up. But I think that's a really nice patient population where we can have such a profound impact. Not only do we get them without the tube, but we're not putting the tube back in 3 months later.

Dr Violari: What are your thoughts, Premal?

Premal Trivedi, MD: I would echo the sentiment so far. We have a publication in American Journal of Transplantation detailing our experience with laser stricturotomy. This is a second line in a patient population that has failed all conservative measures, so you figure this is a harder-to-treat type of disease to begin with. And I'll share a couple of thoughts on what we've learned over the last few years doing it. Most centers will see just a handful of these a year, which is a challenge, right? If you really want to get good at stricture treatment, you want to do a whole bunch, but we're going to be limited to recruitment, even in high volume centers, to reasonably, depending on your center, between 10 and 30 patients a year, if you're really high volume. And so I think we do need to work together to figure out fundamentally what the best option is. I started doing laser treatment for strictures in collaboration with a urologist. I really learned it from him. It makes a lot of intuitive sense, what you're doing is cutting out the structure and then you leave a tube in. Our protocol was we let it heal for a month and then we check again. And it seemed to work pretty well in this population that had failed long-term large bore biliary intubation. Then we started treating first line and had some reasonable success.

I will say there's a point of caution which is in some of these patients who I was successful with, what I saw was that on the follow-up check, there was a longer stricture, and when I put the scope down, there wasn't new scar tissue. It couldn't have formed within weeks. What it was is just a mound of tissue. And this is what I was referring to earlier about this mucosal inflammation. I think there's maybe technique-related, what I was seeing was a reactive inflammation of the mucosa, that in itself resulted in some narrowing. And, of course, I had everybody look at it, I had our GI colleagues look at it. It resolved in all these patients, but it raises the question, what is the appropriate end point for treatment? Is there fundamentally thermal injury related to treatment? Can you do it in a way that there's not thermal injury? These are all questions that I think we can answer if we work together and do prospective trials.

And the first thing we need to do is just, in a prospective fashion and a first line setting, compared to standard large bore long-term intubation and see if laser or other ablative strategies are superior. We think they should be, but we just need a trial to figure that out. And we did submit a proposal to the NIH to do that.

Dr Violari: That's awesome.

Dr Smirniotopoulos: Can I ask one question, Premal? I don't know if you remember, I asked you about a case like maybe over a year ago, but I mentioned also because my urology colleague is the one who got me a little bit on their techniques for their laser stricturotomy. They like using holmium, not holmium laser, because of mucosal damage and doing single as opposed to multiple areas of stricture. But one of the things that they brought up, which I found interesting, was they don't plasty after they do the stricturotomy. They just do the stricturotomy and put the tube in, which I found interesting, because my gut was to plasty. And they said they could actually spread the injury and cause a granulation effect that would be more superficial to where we're going, or it'd be deeper in the tissue lining, and cause more scarring. And I'm wondering, have you noticed anything like that in your practice, just when you mentioned that?

Dr Trivedi: Yeah, we actually started plasty-ing after working on the first few cases. So we wouldn't plasty normally. What we found was that there was, again, anecdotally, because we have ultimately a handful of cases that we're comparing different techniques against, but we found that we started doing fogarty sweeps to remove all the debris and then we would do a definitive plasty after the laser. We found that it looked a bit more open even after doing the scar tissue ablation if you did do the plasty. And we sort of built it into a protocol after not initially doing it. And our urology group was not so worried about doing the plasty.

I suspect that, to me, I'd have a little bit of a hard time understanding the pathophysiology there. I think if there's injury or inflammation, it's really going to be thermal injury. We're used to doing plasty as part of our standard protocol, so I felt pretty comfortable with it. We don't want to do it every time, but you raise a good point. Do I know the definitive answer to it? No, but our inclination after doing a handful of these cases was to actually do one plasty at the end after the lasering and then let it heal over about a month.

Dr Violari: Do you still use the protocol for management of biliary structures including small and large-bore catheters? Given your guys' experience and expertise with the scope, at what point do you use this advanced technology, including laser stricturotomy for the treatment of this refractory biliary structures?

Dr Trivedi: I don't know if there's a right answer to it. If you feel good about what you're doing, it makes sense to offer it, but I'm very careful about offering it in the first-line setting, where we have a proven technology, and I say this is investigational. You know, certainly patients have a tendency to want it when you say “We could probably get your drain out within 3 months versus 6 to 9 months.” But I think being very honest about the fact that this is still investigational, and we really need a trial against standard of care, and that standard of care has existed for a while, and no one's gonna argue against it. That’s how I frame the conversation.

The other piece I'll mention is, and we haven't gotten into this, is benign biliary strictures, we think of it as one thing, but it's actually multiple things. There are some patients who have actually no scar tissue at the anastomosis, but will look like there's a narrowing. There are some people who, it's just a little bit of a tight anastomosis and there's on top of that some dyskinesia, some functional issues in the roux-en-y. And then there's a subset of patients who have a thick rind of scar tissue and that's the subset that we that we are focusing the laser attempts on. The rest of the people, we do what we know best which is leave a drain in let it remodel big over time and hopefully it helps.

How about you, Junaid?

Dr Raja: For us, it's also been just kind of patient to patient. Again, the easiest thing is patients who fail prior interventions or prior therapy with large bore intubation. With transplant patients, we've obviously been a little bit more cautious as well.

I think it's a challenging disease. I love the stratification that Premal just gave right now. I think it's a challenging disease. It's not a homogeneous disease. I do really feel strongly that there is something more that we can offer them in the future, it's just exactly to this question, what's better in what situation? And some of our advanced endoscopists here actually will even put in metallic stents for 3 months for some of these patients and then remove them. Where does that fit into the treatment algorithm? I think it's just again a question of getting more data and more information of what is going to give durable patency and I think that's really the key. We can pat ourselves on the back and say I delivered heat or ablation to territory, but did I meaningfully impact the patient's care? And I think that's really what we need better data for. And I think that's going to hopefully shift the needle somewhere.

Dr Violari: And what do you think, John?

Dr Smirniotopoulos: Yeah, I think like they're both saying we need more data. We need to, you know, look at this. But I think that's what we're all kind of invested in right now, is making sure we do add that data, collecting it, following our patients. We’re all trying to do things at a somewhat measured approach.

And I'm excited by the idea of using stricturotomy as kind of like a first line. I still go through, almost like a dialysis circuit. I’ll try plasty, and if you come back and it's still down then we'll talk about a stent. That's the way I approach it, which may not be the right way to do it, but I know from a conservative standpoint it's like, I know this because I do it a lot. This is still evolving it's not yet standard of care, it's investigational. I think it has a benefit, but I think we're still very much in that data collection phase.

What I'm encouraged about, and not just the 3 of us but also on a national level and again, really by leaders who are not on this call right now, is there's such a robust collaboration nationally to get this type of data and to really put it together and to hopefully in the very short future, publishing the results of some of this data so we can look forward and see what really is the best treatment for patients and a variety of diseases using the cholangioscope.

Dr Violari: Now, when you do this procedure of laser stricturotomy for a refractory biliary stricture, what do you consider a technical success?

Dr Smirniotopoulos: The way I look at it is, I can identify the stricture under the cholangioscope and in our practice, where we have a laser and what I'm looking for is almost, I don't know how to describe it. It's almost like a seam that I open up on the on the diseased tissue and if you get a little bit of blood return from that as well, then I know I've hit on new tissue as well. I'm looking for almost a release of that tissue. And I look at this in terms of short and long segments, and I demarcate about a 2-centimeter limit there for them. But I don't think of it as a long pullback procedure, it's actually pretty quick. And you really do see that it's almost like the tissue flays a little bit, it flays to the side.

And then you can of course confirm that under cholangiography and we all probably inject there as well. But really from the scope, what I've been looking for is that release or spread of the tissue.

Dr Violari: Premal, what about you?

Dr Trivedi: You ask an intriguing question because amongst the people who are doing this, we all probably have a different end point, and we have trouble using words to describe it, right? I'd like to watch John do it.

I don't think we know. I learned from my colleague who knows a lot more than me, treating ureteral strictures. The end point that we decided internally here was treat as much as you can while doing it safely. A lot of our patients were done in the setting of a prior-[-en-y]. You have to be watching out for where the portal vein is and where the hepatic artery is. And occasionally if you're looking for it, you'll see kind of a pulsation on one side of the duct. Obviously, you don't go near that piece. That's out. Then you start on the opposite end and you chip away. And if it's the kind of stricture that you go once or twice and it sort of releases and you have a near normalization of the caliber, let it be, that's sort of our approach. But often given that we worked in a high complexity population that had failed other measures, we dealt with a lot of really thick scar tissue and the stopping point was not clear. In fact, a couple of the patients required more than one session to fully heal. So I'm not sure where the true end point is, it’s an active point of discussion.

What Ravi Srinivasa [MD, University of California, Los Angeles] will tell you is that less is more. There's a higher chance of thermal injury if you're doing more, and the point is well taken. I've described a couple of cases of that, so this is the challenge. Maybe if you're starting prospectively now, what I'd recommend is you do enough to release to a normal or close to a normal caliber. Maybe less is more. And then let's pool our data and learn what the best practice is, keeping an open mind. It may not be laser, maybe [radiofrequency] RF is the smart way to go, maybe it's cryoblation. We got to figure this out.

Dr Violari: What are your thoughts, Junaid? What's your technical endpoint?

Dr Raja: Well, for me, it's a little bit more straightforward because with RF, we have a set protocol of what an ablation consists of, and we just try to get to that end point from a technical standpoint.

But the scope has been great, in that regard. I usually will use a larger sheath, I'll be at an 18 French sheath, I'll have my scope in there, and the device. The ablative device is about 6 to 7 French, and I'm able to park my scope a little behind and watch in real time. Not really because you're not seeing much happen when the ablation is occurring, but really when you do that pullback and you irrigate forward, sometimes you're able to see what they're describing with laser, where you have treatment-related changes and that caliber has already actually opened up. From a technical standpoint, that's been our goal.

From a clinical standpoint, our goal is then to bring the patient back. We do about a month with large-bore intubation at that point. And then when they come back after that month, both by scope and by cholangiography, having light patency, and then externalizing the drain, capping and going from there. That’s more of our clinical trick.

Dr Violari: Is that what everyone else does too? In terms of your full op, capping trials. What's the ultimate goal? Obviously making patients tube-free.

Dr Trivedi: Yeah, I think having a common end point that we can all agree to that we would use for standard of care is reasonable. It should look pretty normal on cholangiography, and we still do a 2-week capping trial to make sure, to do that additional screen. We're not doing the Whitaker test anymore. You can't convince me to. We try to  make the end point as close to standard of care so we can all agree that it's a successful treatment.

Dr Violari: What are the risks of this procedure? Premal, you touched a little bit on it. Can you guys talk more about the risks of doing laser stricturotomy or ablation?

Dr Raja: I think the biggest fear is bleeding, life-threatening bleeding, and Premal talked about portal vein and the hepatic artery. The question is how much heat are you transducing across, whether by laser or by RF, and what impact does that have? In terms of the duct itself, the worst-case scenario is you've caused additional thermal injury and additional stricture. That's a longer term and complex issue to resolve. But I think the most feared complication is always going to be bleeding and perforation.

Dr Violari: What about you, John?

Dr Smirniotopoulos: Yeah, I agree that if you have done at least a few of these, and especially as you're scanning the duct, you will occasionally, depending on the disease, see the nice pulsation next to it, I know that there's a vessel right there. We’re all very careful with this and I think we're all taking a very measured approach to this, but that is one of the risks that we discuss with the patient, and just letting them know that bleeding is not a zero-risk with it. We’re obviously careful, we're using a couple different imaging modalities. And then I do actually talk about worsening strictures as a potential risk as well for that reason. Just to make sure it's all there.

And one thing that I also tell them is maybe we will have an incomplete stricturotomy with this, and we have to bring them back. Not so much a risk, but that is just something to prep them mentally for as well. Because again, my thought is I can always go back and do a little more, I can't take back what I've already done.

Dr Raja: That’s a good point.

Dr Smirniotopoulos: These are just some of the many things that I tell the patients when we're talking about these procedures, especially because they're newer and we're still developing them.

Dr Violari: Talking a little bit more about gallstone treatment, data say that from 1994 to 2009, there was a 567% increased rate of percutaneous choley tubes placement, but only 3% increase of lap choley. These are important numbers that basically tell us that per[cutaneous] choleys are significantly increasing and lap choley is not so much. And as we know, percutaneous gallstone removal is not a new concept, as these techniques have been described in the literature since the 1980s, in GI and surgical, as well as IR literature. However, as Premal mentioned earlier as well, I think within the last 5 to 10 years, there has been a huge advancement and push forward in the IR literature, which is great to see.

What are some of the indications and patient selection for gallstone removal in the biliary tree or the gallbladder? If y ou guys want to touch a little on the appropriate workout, pre-op preparation, and the set up in the room. Go ahead John.

Dr Smirniotopoulos: I could probably talk about this for an hour. I mentioned, we started seeing an increase of these patients come during COVID. We're placing more tubes, but it's obviously the percutaneous cholecystostomy has been done for a while without scope use, under fluoro[scopy] imaging. Now, all of us have used a scope, we'd probably say that's okay, they probably were missing a lot of stones. Using a basket and flouro, the stones can hide.

I think if I again divide it and look at the gallbladder and then I look at the biliary system, we initially started doing a lot of the biliary tree cholelithiasis on patients that were post-roux-en-y and they had a cholecystectomy and they had a lithiasis that would develop. We saw a string of these about 5 years ago, and that was an easy patient population. GI couldn't get to them with the scope. The surgeons obviously didn't want to go back and re-operate, and so we said, of course, we can put a biliary drain in and we can scope and get these out. To me, that's very straightforward in terms of your patient selection because we're running out of options. They can try ursodial for some time, but the data behind ursodial working to quote-unquote “dissolve” a stone is incredibly heterogeneous and some people would say not even worth the effort. Preventing new stones is a different subject, in the gastric bypass population.

For patients with gallstones, a lot of what started off was, we put the tube in to eventually have surgery, and then they may get discharged from the hospital or seen in the hospital by the surgeons, and for whatever reason, as I mentioned earlier, they were determined not to be great for surgery. Meaning that there were other comorbidities, or maybe they had prior abdominal surgery that would essentially push our surgeons to say, okay, I might not be able to do lap fully. I might have to convert to open. And if there are risks with the open surgery, then I don't want to attempt lap at all. If they don't feel that they can do a safe open choley, it's cystectomy. We started seeing those patients. Every patient I saw with a tube with stones that I thought, okay, maybe I could pluck their stones out. I would run it by the surgeon at the time, this is again, 4 years ago, and discuss it with them and say, "Okay, are you sure you're not going to take this patient? I know you wrote it down, but just double-check and triple-check.” And so that's how we started building it. And it got to a point where the surgeon then start referring patients to us right off the bat. They call us up and say, "Hey, there's no way I'm ever going to take this patient. Do you think you can approach it with a scope?"

In terms of, you mentioned the equipment and stuff in the room. I try to categorize the stones based on what I think of size and number from pre-op imaging, or if they had a choley tube placed with cholangiography, I can measure it there. It helps me determine the tools all in need and I'm fortunate that we've been doing this long enough where I have a number of tools at my disposal. Very simply, when we started doing this, we started using a disposable cystoscope and ureteroscope and using a Zero Tip nitinol basket and just basketting up stones. And it was pretty tedious, and it would take a while, but that is a place to start.

Now, the way I approach it is, I upsize my sheath access if there's a lot of small stones and I actually do an irrigation system, where I flush out the gallbladder and I have a fogarty that's partially inflated in the sheath and tandem do a sweep with a single action pump syringe. And as I'm flushing, I'm sweeping the fogarty through the sheath and creating negative suction and that actually pulls out small stones pretty easily. And then I'll go and basket the other ones. Those are stones that are under 5 millimeters. You see some patients that they're their gallbladder is like a cobblestone street, just full of stones.

Stones that are larger than that, we have EHL you can use, we have laser you can use. And then when I start seeing stones, and this is again my own personal practice, that are above 2 centimeters or more, and we’ve treated stones that are 4 centimeters, that's when I'll call my buddy who's a urologist say, "Hey, can you come down and bring ShockPulse down?"

ShockPulse, it's a urology tool. It’s Olympus, it uses shockwave lithotripsy, high pressure saline and then it sucks out at the same time. Whatever you're destroying gets sucked out instantaneously, as opposed to breaking apart and basketing it. It does require 18 or larger French access, so I got used to using 30 French access. And as it requires large access, you have to be comfortable with that, but typically 24 is what we use. We can get rid of a stone that's like 4 centimeters in maybe about 15 minutes. And it sucks out the fragments and we can also visually clear it.

Now, that is no way the majority of the patients that we're treating. But our practice has fortunately just evolved in that way where we've been doing it for a number of years, and we have those tools at our disposal to pick and choose.

It’s obviously not going to be that simple, when you're starting to build a practice. But as Premal and Junaid mentioned, starting with those relationships with other people and other specialties that may have your back on this and that you can collaborate with, might actually translate into the ability to use different tools and their tools and collaborate well together. Laser certainly has been like that, and for me, ShockPulse has been like that too.

Dr Violari: In patients where you're planning to use like a 24 French access, do you prefer a transperitoneal access to the gallbladder?

Dr Smirniotopoulos: I used to think, early on, okay, I don't want to damage the liver, and if you're transperitoneal, especially if you place the choley tube and allow them to decompress, they might not scar up against the abdominal wall. In fact, the gallbladder might calm down, contract and push away. And so if you're dealing with a larger sheath, you might be fighting a free-floating gallbladder. I preferentially always get a transhepatic approach, even if I'm dilating up to those sizes. The sheaths that I use, I use a NephroMax sheath, I used a BD X-Force, or honestly, just a Conquest balloon catheter and an Amplatz renal dilator set. I try to do a balloon dilation for those seaths to kind of stretch, to reduce the pushing as opposed to like a rigid dilating system.

Dr Violari: Premal, would you like to add something or talk to us about?

Dr Trivedi: Nothing smart to add after John's soliloquoy. In my simple brain, this is what I'll tell you. I think small stones and soft stones are easy. If you've got something that's 1 centimeter, regardless of whether it turns out to be soft or hard, it's a pretty good bet that you can handle it with whatever you can pull. We use laser, I think it's a good approach for the vast majority of stones. Where laser gets to be challenging and frustrating is that rock hard, laminated, 3-to-4-centimeter stone where you're chipping away literally for hours. And then you've got to retrieve those fragments or flush them out through a peel away. Whatever gusto you came in with, it dissipates very quickly. I'm eager to learn about what John is describing for big stones. They're the minority of my case mix right now. I think just getting started, if you pick EHL or you pick laser, that should be sufficient for the vast majority of stones.

The other thing I'll mention is just to be mindful of what you're doing. The softer stones tend to be a result of biliary dyskinesia. It's actually easier to achieve success, but I tell my patients there's fundamentally an issue with bile flow. I'm not changing that. Just recognize that this might recur in a few years.

I'm now multiple years in follow-up for these patients and the stones haven't come back. I can say with greater degree of certainty that it's not an immediate problem, but it is a long-term problem. And I think our patients should know that.

The harder stones have to do with more metabolic causes. Maybe you can get away with, they're harder initially, but maybe the recurrence rate will be a little bit lower.

Dr Smirniotopoulos: Really quickly, I love that you said that because that's also what I tell these patients too. I don't know if or when these stones will come back, they probably will. But I've also been following these patients now for 3 years. And I also, luckily, not seeing a stone recurrence yet. And I typically get annual ultrasounds at this point. It'll happen, I just don't know when, but I really like that you mentioned that.

Dr Violari: What are your thoughts, Junaid?

Dr Raja: Back to one of John's original points, we have a multidisciplinary pathway for our new cholecystostomy tube placements. Any patient that we place the cholecystostomy tube on is automatically going to go and see acute care surgery as an outpatient within about a month of our placing the catheter. And then they also have a tentative clinic visit with us, that would be subsequent to the surgical evaluation. And so within that 4-to-6 week span, if they're not deemed a surgical candidate, they'll come to us in clinic and we can discuss the potential of stone retrieval, depending on, again, why they weren't a candidate and if it's something that's within their desired goals of care.

For patients who go on to cholecystectomy, that's great. That's another patient we don't have to worry about a choley tube exchange for. And I think, again, that's just sort of where the genesis of a lot of this work came from.

We do tend to go transperitoneal for our cholecystectomy tube access. I hear what you're saying, John, and I very much believe that you're correct in that. For us, more than concern about over-dilating across the liver tract, is really about maneuverability and the angle of access into that gallbladder. We’ve had cases where the transhepatic approach is unfavorable to stones that have now collected behind you. And again, you can either get secondary access or you can do some advanced techniques or maneuvers, but for the most part, we've just shifted and do transhepatic access. I strongly agree with you in terms of irrigation. I love that Fogarty trick, and I hadn't heard that before, so I'm looking forward to using that.

But being able to aspirate out stones is such an important part of not going insane during these cases, right? Initial experience with these cases, like 3 hours and the gallbladder is still only like 25% stone-free. By using some of these tricks and tips and everything else, it's been important. And I think it was important, something that Todd taught me, one, staging what you're doing and having a time limit or an end point goal for what you're doing. Today we're going to tackle the half of the gallbladder or the entire gallbladder. Next time, we'll deal with anything that's in the cystic dock and then we'll deal with the CBD, or make sure everything is clear. And I think that's important because as we do these procedures and leave a drain behind, whether for capping or for otherwise, there are additional stones that can just flow out in that time too, as we put in large catheters. And so I found just for my own sanity, that's been a useful technique. Just to add to the great points that have already been made.

Dr Smirniotopoulos: Are you guys typically doing transcystic access for your gallbladder cases? Are you doing a case-by-case, or just avoiding it unless you see something during the case? Or are you deciding to cross the cystic duct?

Dr Raja: It's really if it's patent or not patent. We’ll inject and see, if there's an occlusion in the cystic duct then we'll cross it. If it's patent all the way through, then we don't see a benefit. What about you guys?

Dr Trivedi: I try to, as a rule, start with getting a wire across the cystic duct into the CBD. I don't do anything else. I think the wire is enough to maintain patency. I will occasionally fail at getting the wire through and then I go ahead and treat the gallbladder. And in those instances, I've been okay, but it hasn't changed my approach. I'm still getting a wire across just to control. The idea being articulated is that you don't want shards to fly out into the cystic duct and then have to deal with a new occlusion, that it's more problematic than clearing out stone  in the gallbladder.

Dr Violari: I was just going to ask earlier, do you guys use GA [general anesthesia] or sedation for these procedures? Obviously these are patients that are in our table because surgeons don't want to use general anesthesia.

Dr Smirniotopoulos: Yeah, just to just to touch on the general anesthesia part, some of these patients, let's say they have pulmonary hypertension or something like that. The anesthesia, depending on the anesthesiology team, doesn't necessarily come from the induction part, from the surgical part. It's if they convert to open as well. And so when I first started this, I would think that everyone's going to have sedation and then I found that more people do have [monitored anesthesia care] MAC with it, but more people than I would expect actually, anesthesiologists feel comfortable doing GA. I often defer to them, at least for the first procedure. Subsequent procedures, I feel like I just do a sedation, depending on the patient.

But it's interesting, the GA conversation, because I think you have to be careful of how you look at why they can't have general anesthesia from the surgical side. It's not just because they're worried about the induction necessarily, it's about all the other stuff that goes into the surgery as well. And so just because they can't have GA for a gallbladder surgery, it doesn't mean necessarily they won't have intubation for our procedure, but I think it's very patient-specific. I think it's also very anesthesiologist-specific too, and how comfortable your institution is. If you're at a large transplant center, or where they do hearts as well and a big heart center, maybe your anesthesiologist might be comfortable with GA for those procedures.

For our practice, it's a mix. And a lot of the times it depends on the patient, anesthesiologist, all of the above.

Dr Trivedi: I would recommend getting anesthesia on board for all the cases, especially folks who are starting out. As a rule, we'll have a GA as our default approach and then titrate down rather that titrate-up. Certain patients can tolerate MAC. Follow up, if I'm just doing a little bit of extra treatment, I'll do that with sedation. But the first treatment day is with GA for us. I haven't had any issues getting anesthesia to jump on board.

Dr Raja: We go in mostly with MAC. We do have some patients with GA, and again, we leave it to anesthesia as discretion as well, but I agree fully, with that first session, that's where you need the highest degree of anesthesia or sedation. I think that's where you're doing the greatest degree of manipulation and dilation, and if down the line you're able to tolerate or your patient's able to tolerate moderate, that's awesome, and we've definitely had patients like that as well. But upfront, giving as heavy a sedation or anesthesia as your local anesthesiologist is comfortable with.

Dr Violari: Regarding the national SIR-funded percutaneous cholangioscopy registry, are any of you part of the registry? Does anyone know where we stand right now, regarding how many patients, how many sites involved? Can you briefly just discuss a little bit about that?

Dr Raja: We are a member, I have no idea about the other 2 questions. Maybe John or Premal know. I think it's a fantastic initiative. I think it's that principle, again, we should be carrying across most of IR of being multi-institutional, being collaborative, and being standardized and what we're doing, what our outcomes are, and the data that we're collecting. So we are happy to be a part of it, and to contribute as many cases as possible.

Dr Violari: Awesome. How about you, John and Premal?

Dr Smirniotopoulous: Yeah, we're a part of it as well. I want to say on the last registry meeting, there were over 400 cases that have been added, I think. I'm not sure the number of institutions at this point, just because it's kept growing. Dr Singh has really just done an incredible job getting all these institutions together and collecting the data. He's not only working tirelessly, he just is so enthusiastic about this procedure in our field. And I think to me, it seems to keep spreading so the fire keeps burning and the fuel is still there.

Dr Violari: Premal, do you have anything to add on that?

Dr Trivedi: This has just been a big ruse to shame me into catching up with my submissions, right? I need to catch up.  But yes, I think the registry is doing well, several hundred submissions from different sites, that's really what we need as an initial platform. I’m eager to see all the good publications that come out of it.

Dr Violari: And just a final question, what are your thoughts for future directions, regarding cholangioscopy and also, where else can we use the scope? Do you have any ideas or thoughts about the future?

Dr Trivedi: I'll just say very simply that everyone should adopt it. We may have made things sound complicated as we talk about the nuances, but the reality is, learning this is similar to other new service lines in IR. It is, I would say, going to become the standard of care for biliary disease management. Find a local champion and get on it. We need this adopted widely.

I think the frontiers will become obvious when more sites adopted. I think there's a lot of application outside the liver. Really, it's responsive to local need. This really has to be in response to what your patients are not getting. For some practices, there's plenty of urology need. We don't have any, I think our urologists are on it and offer great therapy in the GU system, so we have not looked into it. I've heard that, in certain facilities, that's a real need, and we can help there. But just like other parts of IR, the fundamentals are going to be the same once you get comfortable with scope use and lasering, you can do a lot.

Dr Violari: How about you, Junaid?

Dr Raja: Yeah, I agree across the board. It's been great. Ten or 15 years ago, we talked mostly about stones, now we're talking more about the biliary tree itself, and not just diagnosing it, but treating. I think that is going to continue to progress from a hepatic standpoint, and we're going to continue to grow and build whatever the needs are.

We have great urologists as well. We've toyed with the idea of using it in specific patients, ones who may have an ileal conduit and then the ureteral diversion that's become stenotic and occluded, kind of the same vein principle we're talking about biliary stenosis on and I think that would be a very interesting future direction, for surgeons who don't want to take the patient back in and revise surgically. It’s true, it's an endo-cavitary direct visualization tool, and I think anywhere where you think of a need, I'm sure there's going to be some new places that we explore into.

Dr Violari: John, what are your thoughts?

Dr Smirniopoulos: Yeah, I agree with what these two are saying as well. And honestly, picking up the scope and getting used to it, that's a really fun part of this. And then building your practice is really rewarding. Finding these populations that were otherwise not really being able to be treated. We’ve found and we are continuing to develop these avenues to treat these patients. I think that, to me, is a rewarding part and maybe that will apply further once we start using the scope outside the biliary system more frequently. Just an example would be a retained appendicolith post appendectomy, same thing as a dropstone, right, where maybe there is a value in having the scope there to visualize a stone and the pelvis via percutaneous approach where you can take it out.

I think as more of us are adopting a scope, becoming familiar with it, getting used to it, you're going to find more uses for it as we continue to grow.

Dr Violari: Many thanks to John, Junaid, and Premal for joining us today and sharing their knowledge and expertise and experience. This is a really, really exciting topic and I'm sure we could spend another few hours discussing all of the interesting applications and potential for adding endoscopy to our IR armamentarium. I hope everyone has learned something new today. I certainly learned a lot.

And I hope you all join us again to the next SIO podcast. Thank you so much, guys.