EPISODE 42

ERCP Up Close: A Fellow’s Guide to Advanced Endoscopy | Dr. Benji Smith

Episode Transcript

Dr. Randy Lehman [00:00:05]: Welcome back, listener, to another episode of The Rural American Surgeon podcast. I'm your host, Dr. Randy Lehman, and I have with us today Dr. Benji Smith. He is doing a fellowship in ERCP in Louisville, Kentucky, and I'm so glad and excited to have a chance to talk to you today. Welcome to The Rural American Surgeon. Hi, I'm your host, Dr. Randy Lehman, a general surgeon from Indiana.

This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Dr. Smith, thank you.

Dr. Benji Smith [00:01:03]: Oh, thank you so much for having me. I'm excited to chat with you, too.

Dr. Randy Lehman [00:01:07]: Yep. So tell me a little bit about, first, an introduction of yourself, your background, and what led you to where you're at now, and then what you're planning to do with it in the future.

Dr. Benji Smith [00:01:17]: Yeah. So, yeah, I was born and raised in the upstate of South Carolina. My dad's a surgeon, and his dad's a surgeon, so I always loved doing stuff that my dad did. I kind of figured I'd follow in his footsteps. And sure enough, I enjoyed all the biology stuff in college, went to med school, enjoyed that, and enjoyed my surgery rotation. Luckily, I matched close to home in Greenville, South Carolina, in a general surgery program there, and I'm very happy to be there and be close to family.

As far as the endoscopy stuff, as you know, you don't always get a lot of positive feedback as a resident. After doing about 10 or 12 colonoscopies with one of my attendings, he sat me down and said, "You have a natural talent for endoscopy. You really shouldn't let that go to waste." You don't get a lot of positive feedback, so that kind of stuck with me. One of my mentors and attendings trained with this guru in Louisville, who's the ERCP guy and a hepatobiliary surgeon. I always really loved doing stuff that this attending did. I just asked him one day, "Hey, I really enjoy endoscopy, and I think I somewhat have a talent for it. I like doing the stuff that you do." He said, "Yeah, I'll make a phone call." And next thing I know, I'm moving my wife and brand new baby up to Louisville for a year.

Dr. Randy Lehman [00:03:08]: Yeah. And so where do you think that's going to take you? And it's a one-year fellowship, correct?

Dr. Benji Smith [00:03:14]: Yeah, it's a one-year fellowship. Right now, it's very heavily focused on endoscopy. Dr. Vitale is doing less surgery as he gets older. There is still some surgery there, but it's a lot of ERCP, EGD, and colonoscopy for a variety of reasons. So I think for me, it'll lead to a diverse general surgery practice. I do enjoy taking care of, and you might chuckle when you hear me say it, but these pancreatitis patients. As you know, pancreatitis can cause a lot of very difficult issues to take care of. Dealing with these pseudocysts and pancreatic duct strictures, occasionally you have to operate on those people, but a lot of times these days you can manage them with endoscopy.

So I think pancreatitis will probably be a part of my practice. I'd like to start out doing general surgery and as broad of a breadth of general surgery as I can and kind of see where that takes me. It's interesting to see because I'm his 41st fellow, so I can look back and see what all the other fellows are doing. They all have different practices, but they're all doing really cool stuff, and they're all learning new things, and it's cool to see where it leads.

Dr. Randy Lehman [00:04:49]: How many of the fellows are doing ERCP?

Dr. Benji Smith [00:04:53]: Pretty much all of them. Almost all of them, I'd say, and in varying quantities, obviously.

Dr. Randy Lehman [00:05:02]: Yeah. Did you otherwise go straight through your training?

Dr. Benji Smith [00:05:05]: Yes, I did. I went straight from college to medical school and then now in residency. I do have a year left of residency when I go home. The way his availability worked out and he was also threatening retirement, so basically, if I had waited a year, I might not have been able to come up and do the fellowship. So that's kind of a long story. But long story short, the program back in Greenville was excited to send me to come do this because it's such a need. A surgeon that can do these things has been shown to be so helpful. They were happy to send me up here for a year and then take me back as a five.

Dr. Randy Lehman [00:05:55]: Yeah, that's great. You think you'll find yourself back in Greenville when you're done with residency, then?

Dr. Benji Smith [00:05:59]: I'd love to. It's a great healthcare system. I love the people.

Dr. Randy Lehman [00:06:06]: Which program are you at?

Dr. Benji Smith [00:06:07]: It's a PRISMA Health program in the Upstate.

Dr. Randy Lehman [00:06:11]: What do you like about the healthcare system?

Dr. Benji Smith [00:06:15]: It seems to be, you know, it is getting to be a pretty large healthcare system, like a lot of them are, but they do seem to take care of their surgeons fairly well. I think patients are given a very high quality of care, have a lot of resources, and I get taken care of well, so it's nice to see. Of course, I don't know a lot about other places, but that's the gist I get.

Dr. Randy Lehman [00:06:48]: Sure. Okay, wonderful. Well, you had actually been a listener of my podcast, and you said that we have a lot of things in common. But yet you're not really talking about rural surgery. So could you elaborate a little further on what it is that you and I have in common?

Dr. Benji Smith [00:07:10]: Yeah, yeah, sure. Well, firstly, when I was thinking about being on the podcast, I was like, well, I'm not really doing anything rural, and I'm also not really doing surgery. I am American, so I guess we have that going for us. But I started listening to you when I heard you on Behind the Knife, and I was like, oh, this guy sounds really cool. As I was listening, you kind of hit on a few things that are close to home for me, like medical missions.

I heard the word helicopter, which I love. I'm a private pilot, don't fly helicopters yet, at least. You professed your faith behind the knife, which was pretty cool. At least you implied it. I can't remember exactly what you said, but as a Christian, I just thought that was really neat that you did that, and I started listening to the podcast. I think we, I'm fairly certain we go to the same place in Guaymaca, Honduras.

Dr. Randy Lehman [00:08:10]: Whoa.

Dr. Benji Smith [00:08:11]: From your description of it, it has to be the same facility. I went there. Growing up, my dad did a lot of medical missions, and so I'd go there with him. I actually spent a summer there in college when I was kind of trying to decide if I wanted to do medical school or not. I stayed down there for several months with them and loved it. I've gone back one time since then in med school but haven't gone since. When you were describing that, I said that has to be Guaymaca. It's such a unique place. They do so much great stuff. They're very, very close to my heart because that's kind of where I decided I definitely wanted to go into medicine.

Dr. Randy Lehman [00:09:05]: You know what they need in Guaymaca? A scope tower.

Dr. Benji Smith [00:09:09]: Yeah, yeah.

Dr. Randy Lehman [00:09:11]: For Dr. Smith to come down.

Dr. Benji Smith [00:09:12]: Yeah, I don't think they have any endoscopy.

Dr. Randy Lehman [00:09:15]: Nope.

Dr. Benji Smith [00:09:16]: Capability down there.

Dr. Randy Lehman [00:09:17]: Yeah, that's correct.

Dr. Benji Smith [00:09:18]: Yeah.

Dr. Randy Lehman [00:09:19]: I don't know. You got to get the prep, too. That's another problem. Figure it out.

Dr. Benji Smith [00:09:24]: Yeah.

Dr. Randy Lehman [00:09:24]: Okay, great. Well, I'm going to skip the wise rural surgery special to you, but we substitute it for that. So let's move to the segment of our show called How I Do It. Today we're going to be talking about ERCP, as you're in this special fellowship with Dr. Vitale down in Louisville. Man, I think I might have seen one ERCP in residency on a patient I went over, you know, just wanted to check on or whatever. Very limited exposure. So you're going to be opening my eyes. I know there's a side-viewing endoscope. Introducing it theoretically is a little more challenging, probably easy in experienced hands. Then you're getting down into the second portion of the duodenum, and then you're going to identify the papilla, pass a wire, and then instrument the bile duct. But aside from that, what big technical components am I missing?

Dr. Benji Smith [00:10:18]: Well, no, I mean, that's it. It's just a matter of doing each step. When you start out, it's hard to get the scope in the mouth, and then it's hard to get the scope in the esophagus. This is a technique that I think is useful for any endoscopy. For upper endoscopy, putting your finger in the patient's mouth and kind of pulling the tongue towards yourself allows you to slide the scope posterior to the epiglottis and slide it down the esophagus because you're doing it all blind. You do it by feel a little bit.

Dr. Randy Lehman [00:10:58]: Do you still use a bite block?

Dr. Benji Smith [00:11:00]: Yep. You use a bite block. Almost all of our patients are intubated, and they're prone with their head turned to the right. You can really look at the ET tube, and that means that you're lined up because it's a side-viewing scope. If you're looking at the ET tube, you're sliding along that. When you get to the epiglottis, you just kind of deflect downwards, and you pop into the esophagus. 95% of the time, it's that smooth; you don't even think about it. In some patients, especially elderly little old lady kind of patients, that can be a bit more challenging or if they have an esophageal stricture or something like that.

Dr. Randy Lehman [00:11:44]: Do most of these people have an EGD beforehand to rule out any sort of structure? Like, I'm imagining what if you had a large hiatal hernia or some other structural abnormality you didn't know about and you were trying to pass a blind scope?

Dr. Benji Smith [00:11:54]: Yeah, no, interestingly, it's probably a good idea to do one. In fact, on all of our US cases, we do an EGD first, just to really look at the stomach very well because the US scope is also obliquely viewing. That can give you a landmark for, hey, this stomach is this shape, and this is how I'll kind of go. A lot of times for ERCP, we look at all these people have a scan. So, if there's a big hiatal hernia, I keep that in mind, but we can usually get through it without too much issue.

Dr. Randy Lehman [00:12:34]: If a person has prior Roux-en-Y anatomy or some other altered anatomy, can you still do an ERCP? I mean, Roux-en-Y, I guess, is different, right? But say they had, like, something else. Maybe they still have a pylorus and they have a GJ or something.

Dr. Benji Smith [00:12:51]: Yeah, if they have. The most common you'll encounter is probably a gastric sleeve, which almost makes it easier because it's just like a train track straight to the pylorus. The people who have a GJ, the concern there would be that they have a gastric outlet obstruction, so you might not be able to get through the pylorus, but there's nothing stopping you from doing that. If they do have a pylorus, the Roux-en-Y patients, you know, you can theoretically get around there with push endoscopy and stuff like that, but we don't do a ton of that. We do PTCs for a lot of those patients.

Dr. Randy Lehman [00:13:36]: Okay. Ever do any rendezvous procedures?

Dr. Benji Smith [00:13:38]: Yep. Yeah, we do a decent amount with interventional radiology. We're actually doing one tomorrow. And we do that for altered surgical anatomy, but also for just failed cannulations, which, with Dr. Vitale being so good, it's pretty dang rare that we fail a cannulation. He's really, really good.

Dr. Randy Lehman [00:14:03]: Yeah. Oh, I can imagine. He's the expert. When you are talking rendezvous procedure with IR, describe that.

Dr. Benji Smith [00:14:12]: Yeah. So, let's just say they have a tight stricture and we weren't able to cannulate otherwise. With normal anatomy, we go into the IR suite, and they perform a cholangiogram through the liver with a needle, and then usually just introduce a wire. It almost always goes very quickly and smoothly going antegrade. You'll see that wire pop out the ampulla. Then we snare the wire, pull the tip of it through the ERCP scope, and load a sphincterotome onto that wire. Then we push that down to the ampulla, perform our sphincterotomy, and put a stent in or do what we need to do. And then we just pull the wire out, and that hole just kind of heals up.

Dr. Randy Lehman [00:15:10]: Yeah. There's another type of rendezvous procedure, I think. I'm talking about somebody that had a Roux. Yeah. And then you do, like, laparoscopy, and you bring an ERCP in through. I don't know how. I didn't ever do it. Have you done that?

Dr. Benji Smith [00:15:27]: Yeah. So you can do a laparoscopic-assisted ERCP, I guess, where you find the, uh, find the excluded stomach or the remnant stomach, bring it up to the abdominal wall, and a lot of people put a very large trocar through the abdominal wall into the stomach. Then you can put the ERCP scope through that, or you can just bring up the stomach and cut a hole in it and put the ERCP scope through that and do your ERCP that way. You can do that open or laparoscopic. We don't do a ton of those here. A lot of that's because we manage those patients with PTC. We kind of rely on IR a little bit more. That's just Dr. Vitale's kind of trend, as he's done a lot of these and realized that it's less complicated, easier for them to manage, maybe fewer complications just to do it with IR primarily.

Dr. Randy Lehman [00:16:33]: So, what are your most common indications for ERCP?

Dr. Benji Smith [00:16:36]: Classic is stones. I'd love to say that was our most common one that we do. Unfortunately, there are a lot of strictures, malignant strictures, a lot of pancreatic cancer, and cholangiocarcinoma, and things like that. That's been a fun part about learning EUS also, because a patient comes in severely jaundiced from out in the community somewhere. There's maybe a mass in the pancreas. Nobody really knows. We do an ERCP and stent them, then put the EUS scope down. You can see the mass there, biopsy that. We have pathology there in the room reading our specimens as we are taking them. We can diagnose that patient's cancer on the spot and treat their problem, and then after they get some chemotherapy, operate on them and take the mass out.

So it's pretty cool to do all that stuff, at least in training. It's fun, and I enjoy it. To be in kind of that whole picture for the patient.

Dr. Randy Lehman [00:17:44]: Sure. So talk me through. So you're doing an ERCP with stent and an EUS at the same time? I would say most of the patients are coming in with painless jaundice. It'd be very. That'd be like your board, you know?

Dr. Benji Smith [00:17:58]: Yeah, yeah.

Dr. Randy Lehman [00:18:00]: So say they came in painless jaundice, maybe got weight loss and wasting and things. And you're really worried. Pancreatic cancer, probably. Most of those patients are going to get labs and a CT scan. They're going to show your bilirubin's elevated. And I wanted to ask you specifically how you think about direct and indirect bilirubin?

Dr. Benji Smith [00:18:18]: That's a good question. Dr. Vitale says it can fool you, so he doesn't really care about fractionated bilirubin. Dr. Phillips, who is another surgical oncologist here that trained under Dr. Vitale to learn ERCP, does care about it, or at least he wants to know it. I'm not sure where I'm at on it. I'm kind of a, I'm kind of a less is more kind of person. And if their clinical picture lines up with obstruction, then they need the scope and not be fooled by the lab values. But, yeah, I don't know. I'm sure there's much smarter people out there that will have a much better answer. But that's kind of what I've been doing this year.

Dr. Benji Smith [00:20:12]: Yeah.

Dr. Randy Lehman [00:20:13]: So where my listener, being a rural surgeon and my being essentially me, we most commonly are checking bilirubins when we're worried about a patient after cholecystectomy. I would say, yeah, or we're working up a patient before we go for a cholecystectomy. And then you got these bile ducts that are like 7, 8 millimeters, you know, they're like borderline, and you don't know. Yeah, they're not clinically jaundiced a lot of times. So I get it a lot. And I, I guess if I saw a post-op patient and they had an indirect. They had a total bilirubin of like two and a half, but it was an indirect of 2.1 and a direct of 0.4. I would be quite reassured.

Dr. Benji Smith [00:21:05]: Yeah. Yeah.

Dr. Randy Lehman [00:21:05]: But what do you think? Like, would you. Not Dr. Vitale or anybody, but would. If that was your patient and in, you know, basically like 15 months from now you do a gallbladder, it was a hard one. And the next day you get LFTs, I guess. First question, are you going to get the direct bilirubin? And if you did and it was the numbers I said, would you be reassured?

Dr. Benji Smith [00:21:28]: So yeah, in that theoretical, I would be reassured. Exactly. Because of the things that you said. I would be 100% reassured, but I don't know if it would change my management. I'd still be nervous. If I was nervous enough to check their labs and get their fractionated bilirubin and stuff like that, I'd still probably be keeping an eye on them for an extra day or two.

Dr. Randy Lehman [00:21:59]: It might change if you fed them that day.

Dr. Benji Smith [00:22:01]: Yeah, that's a good point. Yeah, I might do that.

Dr. Randy Lehman [00:22:03]: You know, clear liquids versus feeding them. It might change. You know, you see it come down a little bit the next day and you might be more. I mean, it will. It does change my management in that regard. So it's not major stuff, but. And it doesn't change how. Well, it does change how I sleep at night too, because I'm stressed out less. Yeah, yeah, yeah, fair enough. Okay, so thank you for going down that rabbit trail with me. I now would like to ask you about EUS and technically, how do you get the biopsy? What are the gauges of the biopsy? How many biopsies do you do?

Dr. Benji Smith [00:22:33]: Yeah, and I apologize to some of your other listeners who might not be interested at all, but I will tell you some cool things about EUS after I answer your question.

Dr. Randy Lehman [00:22:42]: But.

Dr. Benji Smith [00:22:43]: So we use two scopes. We use a radial viewing scope, which just gives you a 360-degree. There's no biopsy channel through the radial scope. And we use a linear scope, which gives you. It's obliquely viewing, and it just gives you 180 degrees of vision, but you have a working channel. So EUS is, I want to say, a little easier to learn than ERCP because you basically just park the scope in different spots, and then you essentially memorize what to look for and what moves to do to find the anatomy that you're looking for. And so after you get the hang of it, you say, well, this patient has a pancreatic mass. You go into the bulb of the duodenum, you deflect up, and you're looking right there at the pancreas, and you can see the bile duct come down. If there's a mass causing a stricture of the bile duct, you can see that as a hypodense area. And it's usually not very discrete. You can usually see it right away. And so you introduce a needle down. We use a 25-gauge needle a lot, which most GI people now are using 22-gauge or 19-gauge. Dr. Vitale thinks he gets really good samples and less bleeding with the 25. And we diagnose people's cancer all the time with it, so I can't really say one way or the other, but we use a combination of 22 and 25 for that. And you just, you watch the. I wish I had a video or something. You watch the needle, you know, exit the working channel, and then you, you set a gauge on the needle to determine how deep you want to penetrate. You know, I want to make sure you're not going through the lesion into the portal vein or something. And then you just take multiple passes, and then that just basically gets a core of tissue that you're jamming into the needle.

Dr. Randy Lehman [00:24:40]: Are you applying suction on the needle at this time?

Dr. Benji Smith [00:24:42]: We. Some people do. We don't usually. You can. You can. And we consider this FNB, fine needle biopsy, not fine needle aspiration. So we just. We just do it without the. Without suction, and we almost always not an issue. And we. And then they. They introduce a stylet down the needle, and it just shoots out all the stuff that's in the needle. And you can look and see if there's any core tissue there. Core tissue. And they basically smear that around on a little slide. And then the pathology tech sets it, and then the pathologist looks at it, and you just look at it with them, and you can see there's cancer cells right there.

Dr. Randy Lehman [00:25:24]: And that's your diagnosis. They look at it without fixing it in any way or how do they.

Dr. Benji Smith [00:25:29]: Yeah, they fixate it. That's a good question. I need to. I think it's. They fix it with alcohol, and I think they stain it with. I want to say use. And I'm not 100% sure. I need. I need to ask them about that. I had this thought the other day. I was like, I should really know what stuff they use. But anyway.

Dr. Randy Lehman [00:25:46]: But it's not frozen.

Dr. Benji Smith [00:25:47]: It's not frozen, no.

Dr. Randy Lehman [00:25:48]: Yeah, so.

Because that wouldn't make any sense because you're trying to do margins for frozen, not a fine needle. Right, right. Yeah, that makes sense. So it is probably H and E then, I would imagine, but, yeah, very good. So then you've got a diagnosis. Now, do most people that are doing this fine needle technique have pathology with them, or is that just a Louisville thing?

Dr. Benji Smith [00:26:12]: It's kind of up in the air right now. There's a lot of research on it, and it's kind of a debated topic in the gastroenterology literature. And so it just depends. I think at some of the really big institutions, they just put everything in formalin, and then at some of them, they have pathology there. There hasn't really been a great study in recent times with modern technology as good as it is. And now that we're doing more FMBs than FNA, it could show that it's definitely better, but it is nice to know that you're in the lesion. It's good for the patient to tell them, you know, yes, this does look like cancer, or no, they're seeing only inflammatory cells, and they don't think it's cancer. But we'll have to wait till the final pathology. So I think it gives something to the patient, you know, and it's probably the worst day of their life most of the time. And so to be able to give them a little bit of something and their family who are, you know, these people are coming from, like, three or four hours away in the middle of nowhere in Kentucky. They've never been to Louisville. They have a cancer. Maybe they don't know. They're scared. So I think it's helpful.

Dr. Randy Lehman [00:27:32]: Oh, yeah.

Dr. Benji Smith [00:27:33]: The pathologists hate it, but I'm sure it's their job, so they can do it.

Dr. Randy Lehman [00:27:39]: Very good. What about the stent? Let's go back to a step and say you got obstruction for whatever reason. Well, who gets a stent first off? And then technically, how do you do it?

Dr. Benji Smith [00:27:51]: Yeah. So stenting is also kind of a little debated topic. If somebody has a stricture and they're jaundiced, they get a stent, but if somebody has, you know, got their gallbladder out, a Cholangiogram showed a stone, you're pretty certain it's one stone. You do your ERCP, no issues, get the one stone out, and you do a sphincterotomy. There's some evidence that shows you probably don't need to put a stent in that person. We put them in pretty much everybody. And that means you have to go back and take it out, but it kind of gives you a chance to go back and make sure you didn't leave any stones, which is nice. Which is definitely what I'm going to do when I start out. So, for us, almost everybody gets a stent unless they've had prior ERCPs and their ampulla is wide open and draining freely.

Dr. Randy Lehman [00:28:47]: So, let me, for the listener here. So you go down. We'll say it's that scenario you just described. You feed a wire. You can see it coming out. You feed it into the ampulla. Then you pass a sphincterotome. And exactly how does a sphincterotome work?

Dr. Benji Smith [00:29:02]: Yeah.

Dr. Randy Lehman [00:29:03]: And then next, tell me through the stent.

Dr. Benji Smith [00:29:06]: Yeah. So you really engage the sphincterotome. It's kind of a tapered tip, and you engage that in the ampulla. When you're engaged in the ampulla, you can either inject a little contrast and kind of see the anatomy. That will help you determine which angle you need to push the wire. Sometimes the wire goes straight up, no issue. But a lot of times, there's this sharp angulation, or you need to adjust your angle to really get that wire to go. So you engage the sphincterotome, get your wire up; hopefully, that goes smoothly. Sometimes that's kind of the rate-limiting step of the whole thing. Then you push your sphincterotome in a little bit, and there's a cutting wire that's hooked up to the basically bovie. It creates kind of a bowstring effect. You aim to cut the sphincter, the ampulla, between that 10 and 12 position on a clock. You can make a pretty generous sphincterotomy without causing much issue if you do it that way. We use a mixed cutting and coag current on the, it's a Herbie device.

Dr. Randy Lehman [00:30:28]: So that means it's going away from the pancreatic duct? Is that why you're putting it 10 to 12?

Dr. Benji Smith [00:30:32]: Yeah, exactly. And there's apparently less blood vessels up there. That's what I'm told. We don't get into much bleeding doing that. But I have seen it. But yeah, away from the whole kicker with the ERCP is hurting the pancreas. You can do everything perfect and not touch it at all, and the patient still gets bad pancreatitis. It's very frustrating.

Dr. Randy Lehman [00:30:59]: So what's the rate of pancreatitis with ERCP, and what's the rate of dying from pancreatitis with ERCP?

Dr. Benji Smith [00:31:06]: Oh, yeah, I quote 2 to 3% for post-ERCP pancreatitis. For us, dying from that, that's tough. I'm not sure.

Dr. Randy Lehman [00:31:18]: Pretty rare, though. Way less than 1%, right?

Dr. Benji Smith [00:31:21]: Yeah, it's rare, but it happens. We get patients transferred in from all over who had an ERCP attempt, and patients do die from it. It can be an extremely serious complication and oftentimes devastating. You want to make sure that sometimes the indication for the ERCP wasn't always great too. We do see some pretty horrific complications from what seemed straightforward, so it seemed.

Dr. Randy Lehman [00:31:57]: Yeah, well, the lesser the indication, the greater the complication, right?

Dr. Benji Smith [00:32:01]: Yeah.

Dr. Randy Lehman [00:32:02]: So you just want to make sure you're there for the right reasons and you've had a discussion of risks and benefits with the patient. Basically, that's truly informed consent because what we do is not ever without complication risks. Yeah, so there, there's always that risk. Okay, wonderful. So then I cut you off, though, about putting the stent up. So go ahead and hop back to that.

Dr. Benji Smith [00:32:24]: Yeah, so we do a lot of, if we're putting a stent in the bile duct, which is kind of the scenario we were talking about, you kind of size it up on the patient and what their bile duct looks like. We do almost all of them as 10 French, just straight, flanged stents. These are plastic, and some people do seven French or even five French. They put smaller ones in. But we get pretty good drainage with our 10 French stents, and almost everybody's anatomy will accommodate that. You know, that's like 3 millimeters. So you put a, with the wire up in the bile duct, you put a guiding catheter over the wire, and that's just a small catheter that's less than the inner diameter of your 10 French stent. So you deploy that kind of in the position that you want the stent to be in. That has markers on it. So you can say the markers are 8 cm apart. So you can say a 10 cm stent will fit well here. Then you put the stent onto that guiding catheter outside of the scope. Then you put, there's a pusher, which is just a plastic tube that pushes that. You push down and push.

Dr. Randy Lehman [00:33:51]: Is the wire still inside the guider at this time?

Dr. Benji Smith [00:33:54]: Okay, yeah, yeah, the wire's still up. So it's wire, guider, stent, and then pusher. You just, and you just shove that stent down. You're kind of using the elevator on the ERCP scope to kind of help you maneuver it up. It also requires your assistant to give some back pressure on the guider, or else you'll just be pushing the guider up and perforate the liver. So you may kind of have to be pulling it out as you're pushing the stent in, kind of coordinate it. There are some stent deployment devices and stuff.

Speaker A: They basically do the same thing. They're just a little bit, I don't know, quicker. And for short wire.

Dr. Randy Lehman [00:34:36]: So what holds the stent in place?

Dr. Benji Smith [00:34:38]: Those flange. There's an inner flange, so that kind of holds it. And also just the—We put a pretty big stent in, so it's just kind of pressure of the wall and the ampulla.

Dr. Randy Lehman [00:34:52]: Gotcha. Anything else I need to know about stents? So then you take those pieces out and you're going to come back and exchange or remove the stent in what time period?

Dr. Benji Smith [00:35:02]: Yeah, that's great. So the plastic stents we leave in for about three months. They could stay in a little longer, but we go in and do another ERCP in three months and repeat everything. We do put metal stents in, which is probably good for surgeons to be aware of that there can be plastic and metal stents. But we put some metal stents in, those are getting more common. There's covered and uncovered ones, so there's complexities within the complexity, but the covered ones slide out pretty easily. We leave those in up to a year, six months to a year. An uncovered stent is something a surgeon might hear about because once you leave it in a little too long, you can't get it out.

Dr. Randy Lehman [00:35:47]: Right.

Dr. Benji Smith [00:35:47]: Gets grown in.

Dr. Randy Lehman [00:35:49]: So are you doing—I mean, I'm thinking like colon cancer. You know, when we're talking metal stents, then usually that's a palliative care type of an operation. Is that all true for this as well? Like you're planning on that stent to come out with a Whipple or not ever, or what's the—

Dr. Benji Smith [00:36:07]: We don't use a lot of uncovered stents, but that would be the case to use one is if you're not planning it, if you're not going to take it out. But we use these covered metal stents that work really well in really dilating a stricture over time. So if they have a tight, benign stricture from pancreatitis or something, or just chronic inflammation from stones, we'll put that in there. And probably after their initial ERCP session, and that helps to dilate that area because it's a—whereas the plastic senses 10 French, these stents expand up to 10 millimeters.

Dr. Randy Lehman [00:36:49]: Oh, wow.

Dr. Benji Smith [00:36:50]: Yeah, so they expand. They have pretty high kind of radial force that they put on the—

Dr. Randy Lehman [00:36:57]: And they're self-expanding, not balloon-expanding?

Dr. Benji Smith [00:37:01]: Yeah, they're self-expanding.

Dr. Randy Lehman [00:37:02]: Is there such a thing as a balloon for the sphincter?

Dr. Benji Smith [00:37:07]: Yeah, we do like a balloon dilator or something like that. Yeah, we dilate, and it's just like what you see on vascular or something like that. It's very similar. But yeah, we do that for strictures, pancreatic duct strictures, or ampullary strictures, or just a smaller ampulla and a big stone. We might dilate. But anytime you do that, you're at risk for causing some pancreatitis.

Dr. Randy Lehman [00:37:35]: Do you do that under fluoro? And do you inject contrast in the balloon?

Dr. Benji Smith [00:37:38]: Yeah, we have contrast in the balloon, and we use a lot of fluoro, so—yeah.

Dr. Randy Lehman [00:37:43]: Okay, sure. All right. Anything else that I'm missing technically or something maybe a surgeon should know?

Dr. Benji Smith [00:37:51]: Yeah, that's a—there's, I guess, one thing a surgeon should know, or there's—sure, lots of things. But one thing is these stents can cause perforations of the duodenum, and we do see that. So if the stent's left out a little long, you know, the part of the stent that's in the duodenum can perforate the back wall. A lot of times they're retroperitoneal, and you just need to go remove the stent and give them antibiotics and maybe a drain or something like that. They might not need surgery, but it can be a surgical issue for sure. And that's something that your rural general surgeon listener might see one day. Hopefully not, but maybe.

Dr. Randy Lehman [00:38:38]: Yeah, that's great to know. Very good. Well, this has been wonderful to get a chance to talk through that. I think we should move on to the next segment of our show, which is actually our financial corner. I didn't know if you had a money tip for our listener.

Dr. Benji Smith [00:38:54]: When I saw the question, the devil's advocate in me just had to say something. So we bought a house right when I started residency, and maybe it wasn't the best financial decision at the time because we found a house that we absolutely loved. It's in a great neighborhood. Everything was perfect, but it was just—it was way too expensive. And, you know, I maxed out my doctor, you know, mortgage, basically, which wasn't the best idea. But I do not regret it one bit because, for multiple reasons, we love our house. We love our neighbors. We have great neighbors. It's very safe. It's very walkable, with lots of good, you know, restaurants nearby, all that stuff. And also, it's gained a ton of value, and we have a low mortgage rate. People told me not to do it, and then I kept asking people until somebody said, "Yeah, sure, do it," and then I took their advice. But obviously not saying that's the right answer for everybody, but, you know, sometimes you—sometimes it does pay off. I don't know. That's probably not the advice you wanted me to give.

Dr. Randy Lehman [00:40:20]: No, I appreciate it. That's why I'm asking you that question. Of course, I always have my own little twist on it, but a lot of times I tell people, you know, the house that you buy determines so many other expenses. And I think the house should be considered a luxury spending item. Anything that doesn't make you money while you sleep should be considered a luxury spending item, in my opinion. And that just is supporting your quote-unquote lifestyle. So the thing is, a lot of people will say the house is the best investment they've ever made because, for many people, the house is the only investment they ever made. And the reality is the holding cost of that house is so high to pay the taxes and insurance and maintenance over the years. It's a forced savings thing, and it will appreciate with inflation. I'm not saying it can't be an investment for some people. And that's why a lot of the financial pundits don't say that you have to go debt-free necessarily on your house.

Dr. Benji Smith [00:41:15]: Yeah.

Dr. Randy Lehman [00:41:16]: But the thing is most people—if I took your current financial situation, it depends because life is short and life is not about maximizing your net worth at the end of however many unknown years that you have to live. That's not the point, and so you make your own decisions. But that being said, take it into just purely finance. If I took the money that was invested into the house—if you could—because you might be a vet and you might not have the opportunity, you might not actually have the money, but you might find some way to leverage this asset when you couldn’t leverage anything else. Right. But if you leveraged and you invested the same money into something else, like, you know, real estate for investment purposes, for example, and you lived in your parents' basement, you know, you would be financially ahead, like there's no question.

Dr. Benji Smith [00:42:18]: Yeah, yeah.

Dr. Randy Lehman [00:42:19]: But it also depends on how things are managed. Obviously, if you bought a commercial real estate investment and then you lost your tenant and it sat vacant for three years, you could go bankrupt by doing that.

And if you leverage against stocks, which most people tell you not to do, you might get a higher return, but you might go bankrupt doing that too, right? So, I am definitely not telling you in this podcast to do any of that stuff. I'm just asking if there's something, like generally, as far as a principle. And so you have provided us much to think about, sir. And that's my two cents on the topic.

Dr. Benji Smith [00:43:04]: So.

Dr. Randy Lehman [00:43:04]: Very good. Let's move on to the next segment of the show, which is typically classic rural surgery. And I usually ask my guests to tell us a story that your urban counterparts just wouldn't believe. But in lieu of that, any classic surgery story would be great.

Dr. Benji Smith [00:43:21]: Yeah, yeah. So, you know, training in Greenville, you know, where I've lived for so long and where my parents live and all this stuff, you know, you will encounter somebody that you know occasionally. It probably doesn't happen in a much bigger place that's somewhat rural. But I went through a phase where I kept seeing all these people.

Dr. Benji Smith [00:43:51]: That I knew or that knew me through something just because of me living there for my whole life. An example of that is, I think, I was an intern or second year and I was just looking at the trauma list and I see a girl who I went to high school with. Not only did I go to high school with her, but I also went to college with her.

Dr. Benji Smith [00:44:22]: And I was good friends with her brother, and her brother married my wife's sister. So when I saw her on the trauma list, I was obviously very alarmed. Luckily, she was okay. But yes, there have been several other times where I think I know this person and you go in and sure enough, it's somebody you went.

Dr. Benji Smith [00:44:52]: To high school with or who babysat you. One of the nurses there babysat me for multiple years. So, I think that's a really cool part. You probably experience that kind of thing way more than I do. But I think that's a really cool part of practicing where you live and grew up because it means so much to those patients when they see somebody that they know and hopefully in my case they trust me.

Dr. Benji Smith [00:45:22]: They seem to enjoy it, and it kind of takes away from the terribleness of being in the emergency department or being admitted to the hospital with some issue. You can kind of help your friends out. My wife's best friend was pregnant and she called me with a medical concern and she perfectly described acute appendicitis. It was at night, but I just called the in-house resident and said, "Hey, get an MRI for this girl. She's going to be in the waiting room in a few minutes and just get her appendix out because it sounds like that's what she's got. Sure enough, that's what she had. She walked right into the waiting room and got her MRI. I called the MRI lady and kind of sweet-talked her a little bit, and she got her right in. I don't think you can do that in a bigger place.

Dr. Benji Smith [00:46:23]: Like I told you, I think I'm a rural surgeon at heart. I don't know if I'll be able to practice in a rural setting with the things that my life is kind of leading me towards, but I do really enjoy those aspects.

Dr. Randy Lehman [00:46:40]: Yeah. And so, that brings up a good question. How close is too close to be involved in a patient's medical care?

Dr. Benji Smith [00:46:48]: That's a great question. I've thought about that several times with all these cases. Honestly, I think you can be there as somebody. I think you should be there whatever you are outside of the hospital to them. I really don't think you should be making medical decisions on somebody that you know, who’s admitted with an issue. There's just no way to get around your bias and you'll be blinded towards things. I think you can still see the patient, obviously if they're comfortable with that, see them in the hospital, talk with them, help them, discuss things they might not fully understand. All that's fine. You can talk with the doctors, of course, taking care of them. But you should really try to separate yourself as much as possible from the clinical decision-making. I've seen a couple of scenarios where things were missed on somebody who was supposed to be getting VIP treatment, you know, so I don't know. That's my, I don't know if I'll always follow that, but I hope to because I think they should get the best care.

Dr. Randy Lehman [00:48:10]: So, let me summarize what you said. If you know the person outside your doctor-patient relationship, you should not be involved in clinical decision-making.

Dr. Benji Smith [00:48:20]: I think if you have a relationship with them and it's more than just a slight acquaintance, really. If I knew somebody and they said, "Hey, will you take my gallbladder out?" I still might send them to my partner who can do just as good a job. I don't know. I'm still thinking through that but I'm kind of holding firm on that.

Dr. Randy Lehman [00:48:47]: Yeah, that's fair. It's completely unreasonable for my practice. But you have to have a line. The main thing is, did you hear the story that I told about the case that changed me?

Dr. Benji Smith [00:49:04]: I don't think I've listened to that one yet.

Dr. Randy Lehman [00:49:07]: There's an episode I put out called "The Case That Changed Me." At the time of this recording, it may not actually be out yet, but it's basically about when my grandpa had severe acute cholecystitis. Had my partner do was very obvious there that I would be no way that I would be objective in that case. The big question is, can you be objective? What are you doing? Because if my kid has a big splinter stuck in their foot, I'm not taking them to the nurse practitioner at the urgent care, I'm sorry. Am I willing to inject local anesthetic into my child? Also, even a biopsy of a skin lesion, I would do that on somebody, you know. No question. But if it comes back melanoma and it's my first-degree family member, would I want to excise that because of the downstream risks? No, I don't. Did I do the right operation? But what if it's a basal cell on your grandma? Like, that's fine. What's your, what are your complications? It's going to be bleeding and infection. You could have a recurrence, but it's not going to be metastatic. The question is, can you be objective? That's my answer. You have to know your relationship with that person and if you can't be objective with the complication, then they need to go somewhere else. I've got all types, from good friends, family members, to my buddy's sister's husband's dad, but if I know them and if you can't be objective, they need a different doctor.

Dr. Benji Smith [00:51:16]: I didn't.

Dr. Randy Lehman [00:51:18]: But then I ended up buying a bread spot sow off of his son later and stuff, and it's just. Where do you draw the line now? That guy had rectal cancer. And.

Dr. Randy Lehman [00:51:42]: And your risks, like, even if I had a colonoscopy, even if I had a perforation, like, if I had the worst complication with a colonoscopy, I could say, "Look, I do a thousand of these, and I did it the same, and I was objective." I think I could live with that if I did the rectal cancer resection because I don't do rectal cancer in my practice.

Dr. Benji Smith [00:52:00]: Right, right.

Dr. Randy Lehman [00:52:01]: Friends, sister's husband's dad wants me to do it.

Dr. Benji Smith [00:52:06]: Then.

Dr. Randy Lehman [00:52:07]: Then they have a complication. First off, I know in my heart of hearts that I didn’t really do the right thing for that guy, and no, I wouldn't be able to live with that. So, expounded a little bit on it, but I don't. I'm not saying what I said is exactly right, but it is how I think about it in my regular practice.

Dr. Benji Smith [00:52:27]: And that's, that's totally a, you know, a personal. Everybody's probably different on that. I know. I know surgeons who've done operations on their significant other. You know, me too. I would, I would, you know, but so, you know, and they're comfortable with that. So I don't know. It's just that. I don't know. It's an interesting question. I don't know if there's a right or wrong on that, but I. I've definitely, definitely seen complications from things that you thought would not cause a complication. Now you're in a little bit of an awkward situation. Yeah.

Dr. Randy Lehman [00:53:04]: Major case under general anesthesia on a spouse. Do not.

Dr. Benji Smith [00:53:10]: That's rough.

Dr. Randy Lehman [00:53:10]: Do not do that. All right, let's move on to the last segment of the show. Resources for the busy rural surgeon. Anything regarding ERCP or any other resource that you'd like to share with us?

Dr. Benji Smith [00:53:21]: Yeah, I think, you know, for the surgeons out there, I think they just need to know who the doctors are that are doing their ERCPs for them. Talk with them, have conversations with them, meet them. You know, if you're transferring, maybe try to meet that person in person. Have a. I think it's important to have a relationship with your advanced endoscopist and be able to call them on the cell phone, be able to send them pictures from the surgery and really discuss things with them. Because a lot of things can get lost in translation, I think, when somebody's just sent without a conversation.

And Dr. Vitale does a great job with this. He gets phone calls from people all over, everywhere, and just to his personal cell phone all hours of the day and night. And he, you know, they'll call him from inside the operating room, say, "I think I just have a really bad bile duct injury. You know, I'm showing—" they'll show you the videos in real time. "What do you think? What do you think we're looking at here? What do you think we should do?" So having a relationship with the person who's going to do the ERCPs on your patients is important, especially knowing the complications that can happen. You know, maybe do a little research, make sure this guy has good outcomes before you send all your patients to him because it matters, and the patient—and especially if the patient's going to have to go back to them. They're going to have to travel to get their stent out or whatever. And so I think that's what I'd say for that.

As far as when the question was asked initially, I'd say my resource that I've used the most in training is the tech. So either the respiratory tech when you're in the ICU by yourself—that the RT saves you. When you're learning how to operate, the scrub tech, if you're nice to them and you do the right thing with them, they'll help you out and take care of you.

This year has been great. The endotechs there, some of them have been doing ERCPs for like 40 years. They will help you and teach you, and you can learn so much from them. And they're just a blast to work with. If you get along with those people, it just makes life so much better. And they take care of you. And yeah, I've definitely relied on the techs in my life, maybe sometimes more than the attending. So yeah.

Dr. Randy Lehman [00:56:19]: Let me ask you three bonus questions.

Dr. Benji Smith [00:56:21]: If you don't mind. Yeah.

Dr. Randy Lehman [00:56:24]: First question. Who gets an MRCP?

Dr. Benji Smith [00:56:28]: Yeah, that's great. Part of it kind of depends on who it is. Sometimes we will get an MRCP when the case isn't clear. You think there could be a stone, but the numbers are kind of equivocal. Connecticut imaging. Ultrasound shows kind of borderline dilation. You can't really see, and you don't want to jump and just do an ERCP on. So you'll get an MRCP. It's also helpful for determining mass versus stone. One thing that MRCP is really good at is showing defects in the bile duct. So you get a lot of good kind of contrast there. So if there's a stone there, it'll show it, and if it's just. If it's a mass there, it's really good at showing that too.

Dr. Randy Lehman [00:57:24]: MRCPs are non-contrast, right?

Dr. Benji Smith [00:57:28]: We always. Technically, yeah. But we do them with and without contrast.

Dr. Randy Lehman [00:57:33]: Okay.

Dr. Benji Smith [00:57:34]: You get a little bit better soft tissue, you know, information on the pancreas.

Dr. Randy Lehman [00:57:38]: But I always get asked every time I order imaging studies, "Is it with contrast?" But then it's by somebody that doesn't know what they're talking about. And quite honestly, I don't know what I'm talking about always because, I mean, with CT I do kind of, but it's not a—there's not a right or wrong answer. And when you say contrast, are you talking about IV contrast? You know? Yeah. Is it Omnipaque or gadolinium contrast or PO contrast or rectal contrast or drain contrast? You know, there's like so many different questions. Yeah, but I have MRCP available near me, and it has been a non-contrast. So.

Dr. Benji Smith [00:58:20]: Yeah, that'll show you, that'll show you what you need to know if you're worried about a stone or not. Okay. The one thing when you do need the—it depends on the patient. But if you're ordering contrast for an MRI, they do a non-contrast run and then they do one with contrast. And so if the—depending on the scan, like a.

Dr. Randy Lehman [00:58:41]: Takes twice as long.

Dr. Benji Smith [00:58:42]: Yeah, it takes twice as long. So an MRI, you know, with contrast, they have to lay there for like 45 minutes to an hour. So somebody that's kind of spazzing out, they're not going to be able to handle that, and you're going to get terrible images.

Dr. Randy Lehman [00:58:56]: Second question. When you go out into your practice, are you going to do routine cholangiogram?

Dr. Benji Smith [00:59:02]: Do you mean on every coli?

Dr. Randy Lehman [00:59:04]: Yep.

Dr. Benji Smith [00:59:05]: Everyone. No, just if they're just if I'm concerned from labs or imaging.

Dr. Randy Lehman [00:59:10]: So what would be your cutoffs for who you would do?

Dr. Benji Smith [00:59:13]: I think when I start out, if they have any transaminitis or a history of pancreatitis or a dilated bile duct, then I would. Then I would just do it.

Dr. Randy Lehman [00:59:24]: Or bilirubin elevation or not?

Dr. Benji Smith [00:59:26]: Yeah, yeah, sure. But even if their bilirubin's normal, but their LFTs are up in any way.

Dr. Randy Lehman [00:59:32]: Like what about an alk phos elevation isolated?

Dr. Benji Smith [00:59:34]: Yeah. Alk phosphatase is actually pretty sensitive. So that's one I do look at a lot.

Dr. Randy Lehman [00:59:41]: Okay, what if they come in an acute cholecystitis type picture and they have AST and ALT 1.5 times normal, ALK FOS is normal, and bilirubin is one.

Dr. Benji Smith [00:59:56]: Yeah. So I would, I would, starting out, I would do one if, if I could safely. If not, I'd just train some labs knowing that it's probably just elevated because of the inflammation proximity. Yeah. But I would, I, I hope that I hold by that and, and actually do it in practice. But I really, I, I really do plan to be pretty sensitive.

I'm not playing with all the things I've seen. My gallbladders are going to take a little bit of time. I'm not too worried about cranking out a 15-minute cholecystectomy with all the terrible injuries I've seen.

Dr. Randy Lehman [01:00:34]: I understand. And who, Last question. Who gets an ERCP first? In the ivory tower of Norton's, we'll say versus a lap chole if you have LFT elevations or would they always get an MRCP first?

Dr. Benji Smith [01:00:58]: Yeah, we try not to get MRCPs on everybody. We try not to do many at all. In fact, it takes forever to get one, so it's kind of a pain. But we really hold for the MRCP unless we really don't want to do an ERCP and we want to rule out a stone to really say, put our stamp in it and say we don't need to do an ERCP on this person.

But for those patients that come in, if their bilirubin's over four or five, we're going to probably do an ERCP first and then put a stent in. General surgery likes that. Then they'll take the gallbladder out the next day, or we'll take the gallbladder out. But if it's mildly elevated, a little, and maybe imaging shows maybe a little something in the distal bile duct or something like that, we'll ask them to do the lap chole and flush things through or try to. Which seems to, seems to never work. I don't know if you have better success.

Dr. Randy Lehman [01:02:03]: I never get it to work flushing it, but I do laparoscopic common bile duct exploration.

Dr. Benji Smith [01:02:08]: Yeah.

Dr. Randy Lehman [01:02:08]: And, and I will actually, I want to ask a fourth question about. Yeah, the. But let's get there. So at Mayo, we had GI doctors. I don't know how your relationship. Probably your relationship with general surgery is better because you guys are general surgery.

Dr. Benji Smith [01:02:22]: Yeah.

Dr. Randy Lehman [01:02:23]: But we had GI doctors, and we had general surgeons, and there was always this pushback. Like, general surgery would say, you know, the bilirubin is like 2.5, and they need it. The bile duct's 8 millimeters, they need an ERCP. And then GI would say, no, they don't.

Dr. Benji Smith [01:02:40]: Yeah, yeah.

Dr. Randy Lehman [01:02:42]: And then it would be this thing. So they developed an interdisciplinary algorithm so that we could take the guesswork out of it until it was close. And it's always the same thing, like, know the world, know the rules, follow the rules, break the rules, just like everything else in life. So our guidelines were bilirubin, less than 4. Now, I don't think there was anything about direct versus indirect bilirubin on that.

Dr. Benji Smith [01:03:05]: Now we have to bring that up again. Yeah.

Dr. Randy Lehman [01:03:07]: And then bile duct size. I can't remember what it was. I'm not sure, actually. Or even if it was a thing.

Dr. Benji Smith [01:03:19]: Yeah.

Dr. Randy Lehman [01:03:19]: Stone in the bile duct on imaging, that means ERCP. It was not a try and flush it type of scenario.

Dr. Benji Smith [01:03:28]: Yeah.

Dr. Randy Lehman [01:03:30]: And.

Dr. Benji Smith [01:03:32]: Or.

Dr. Randy Lehman [01:03:32]: And there was some elevation, like, if it changed from one to another.

Dr. Benji Smith [01:03:36]: Increasing. Yeah.

Dr. Randy Lehman [01:03:37]: Yeah, increasing. It was something like that. I don't really remember. But it. The point is the rules. When you really understand the physiology, the question is, who are you really concerned about? And I think you came up with a lot of the same answers.

Dr. Benji Smith [01:03:53]: Yeah, a lot of it, too. Not to cut you off.

Dr. Randy Lehman [01:03:55]: Yeah.

Dr. Benji Smith [01:03:56]: A lot of it for. For us is. Well, today we're doing. We're doing scopes. You know, we can knock this ERCP out. We might be here a little bit later, but tomorrow we have a full day, and we. Yeah, like, we have dinner planned, so we know the patient's probably going to need ERCP anyway, and Dr. Vitale feels like he can do it very safely with a low complication rate, so there's absolutely nothing wrong with the indication. So. And it works out so that we can do it, and it works out with us. So, you know, we'll just. We'll just. A lot of times. That is. A lot of times that is what determines when we do.

Dr. Randy Lehman [01:04:34]: Yeah, that's real. That is real life. I completely understand. And basically, though, you guys are not worried about doing an ERCP after somebody has taken out the gallbladder, clipped the bile duct, the cystic duct?

Dr. Benji Smith [01:04:48]: Nope, nope.

Dr. Randy Lehman [01:04:49]: Like in terms of providing too much pressure, causing a leak or anything like that.

Dr. Benji Smith [01:04:54]: Yeah, before this year I thought that that would cause an issue because we'll even do like with a balloon, we'll occlude the distal bile duct and really jam contrast in to make sure we're not missing anything. But if you see, if you see a little. First of all, I think the clips don't just come off that easy.

Dr. Randy Lehman [01:05:17]: It's supposed to hold 300 millimeters of mercury of pressure.

Dr. Benji Smith [01:05:19]: That seems like a lot.

Dr. Randy Lehman [01:05:22]: Blood pressure 120, you know, so.

Dr. Benji Smith [01:05:24]: Yeah. And then the other side of it is if they had a cystic duct leak, you'd be putting a stent in anyway. So it treats, it treats, it treats the problems that you might cause. But I haven't seen, I haven't seen myself cause a bile leak by injection yet. I'm sure I will. I have a way of messing up everything in every possible scenario.

Dr. Randy Lehman [01:05:47]: That's good. Surgery is a humbling profession. And you're, you're exhibiting great humility. This is, I'm sure you're doing great. So, last question. I, I talked to the people that did laparoscopic common bile duct exploration transistic who I trained with. They tracked their numbers for success and they said, you know, we're shooting for 80 or better of success rate for clearance of the duct because we're in a place with no ERCP. People have to transport to get this and often delays and things like that.

So we feel like if we're 80% that that would be, we can tell, tell the patient that, you know, most of the time we can clear it. These are our numbers. I guess that's good. But then I went to grand rounds and I had a presentation or chief conference, I mean, and I had to present and it was, it went down the rabbit hole of my biliary algorithm. And I talked to them about, and I was like close to being done. So they all knew what I was going to do talking about for five years.

And I told them how I thought about things. And Dr. Nagorni, who's the biggest HPB surgeon, he challenged me on that, and he said, hey, what, so what's special about 80%? That's a made-up number. I would say if you were successful 20% of the time, you saved that person from traveling. And so, so I actually had one patient while I was on rotation that was unsuccessful with those guys. And I had to call Rochester to tell them, hey, I need an ERCP. And the Receiving GI was not a fellow; it was a doctor that I was talking to as a resident was very upset until I said, he said, why did you do the gallbladder first? And I said, well, we did laparoscopic common bile duct exploration, but it was unsuccessful. Tone completely changed.

And he said, "Oh, okay, I understand. Well, thanks for trying." And then we, you know, moved on with the transport. So, I... That experience and the whole just thinking about it, you know, right and wrong, trying to figure out what's the best thing to do. It seems like if, you know, there's a stone going and taking the gallbladder out just because when you send—it's probably not going to come back to you anyway.

Dr. Benji Smith [01:08:11]: Yeah.

Dr. Randy Lehman [01:08:12]: With their posterior CP pancreatitis without even doing like—no, because the surgeon at their referring hospital is going to take it out before they leave. That's what I'm saying.

Dr. Benji Smith [01:08:20]: I...

Dr. Randy Lehman [01:08:21]: What you're saying.

Dr. Benji Smith [01:08:21]: Yeah, yeah.

Dr. Randy Lehman [01:08:22]: So, it's wrong to just do it and then like not do a cholangiogram and not even try. Yeah, I kind of think that. And maybe they won't come back, but my success rate is—I think it's eight out of nine actually, now that I've been...

Dr. Benji Smith [01:08:41]: Yeah.

Dr. Randy Lehman [01:08:42]: So, I'm feeling good about that. And I also am selective because I look at the anatomy, and if it's a long skinny duct, then I don't do it. And if it's a short fat duct, then I'm like, yeah, I'm pretty sure I can get that. So I guess that's my backstory on how to... And I still don't know what's the right percentage. And I'm wondering after I told you all that, do you have an opinion?

Dr. Benji Smith [01:09:05]: Yeah, I love laparoscopic assisted common bile duct. And I was, you know, the take-back-the-duct thing, I'm all for it really. I'm not an ERCP, you know, purist. I just like the bile ducts. So any way of looking at it, I think is cool. We did them back in Greenville pretty frequently with, we use the Spyglass, the Boston Scientific, and with some success. And you know, there are some cases that it doesn't work for and you know, there's like a valve and you just can't get past it, even though you dilate or something. So I think you're exactly right. I think especially in your setting, as you're... You've got more experience with it. You can look at the anatomy and say, "I should probably be able to be successful here." If there's a bunch of stones in there, you know, it seems chock full, you know, I don't know if it's the best thing.

Still another thing, I know we're way over time, so I apologize. But another thing that I've been seeing is a lot of times there will be a stone, but there's really a stone there because there's a distal ampullary stricture from cancer and they're getting their gallbladder out because it's distended and they have non-specific symptoms. Of course, we see these patients because we're kind of funneled down into it. But it's pretty common that we see somebody that had their procedure done to get their gallbladder out, and they had cancer all along and they had a distal bile structure. They were sent to us to maybe get their stone out or something like that. So you have to, just like you were saying, look at this scan really closely and really make sure there's nothing else there. And with the clinical history and everything too, of course. But you know, always kind of have cancer in the back of your mind when you're looking at that stuff. But that's off the path of our Spyglass. But I do love it, and I think especially in pediatric cases, it could save the kid another procedure. And if the anatomy is favorable, I think that's a good case for it. And in some select cases, I think it's pretty slick when it works. And the patient probably thinks you're the coolest guy ever when they don't have to be transferred somewhere.

Dr. Randy Lehman [01:11:46]: Actually, the patient has no idea. They just know that Dr. Lehman took my gallbladder out, and I draw pictures and I try to describe what I spared them from and how interesting it was. And then all they say is, "Yeah, Dr. Lehman took my gallbladder out." You have to carry that with you internally.

Dr. Benji Smith [01:12:07]: Well, it's, there's something just cool about it, and I think that's an okay reason, you know, if you have a good, strong clinical indication also. Yes, I think that's fine to kind of do those things. So. Yes.

Dr. Randy Lehman [01:12:23]: Well, this has been my pleasure. Thank you so much for agreeing to come onto the show, Dr. Smith. I really appreciate it.

Dr. Benji Smith [01:12:28]: Thank you. Yeah, this has been great. I'll keep listening and keep getting some tips and tricks, even though I'm not necessarily a rural surgeon and maybe not even doing all that much surgery right now, so.

Dr. Randy Lehman [01:12:44]: Right. Well, you know, a lot of this stuff is obviously applicable to general surgery.

Dr. Benji Smith [01:12:48]: Of course. Yeah.

Dr. Randy Lehman [01:12:50]: Well, thank you very much to the listener as well for being with us for this episode. Very interesting. Learning about the ERCP fellowship in Louisville and a little procedure that many of us do not do but often order. And now we know a bit more. So thanks for joining us for this episode. Don't forget to like, subscribe, engage with us on social media. And until the next episode of The Rural American Surgeon, we will see you later.