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Good evening, everyone. Welcome toe. I are bites. I'm Chris. I left to down into once in Somerset on Do your speaker this evening. Thanks again. Too shy on. And he is ST six, Interventional radiology and richest raw down in Southampton. He's gonna be talking this evening on biliary interventions and also covering biopsies and drains on, Say, 100 over to shy. And now he's got a fantastic presentation lined up. So I have you guys really enjoy it, And don't be in the shop. Um, So if you have any questions throughout, please drop them in the shop or every two. You show him. All right. Thanks so much. One apologize for the mess behind you. Is my boss's office. Uh, nothing to do with me. Yeah. So just gonna a sham My screen here. Okay, so we're gonna be talking about Bob. Sees drainage on biliary interventions. Quite broad topic to go through, but we're trying covers much we can in the time, and I try and keep it. Sort of case based something. It's a bit more interesting for people that your sort of stage of training So first up biopsies there are two types of biopsies. We generally do an interventional radiology, the safer ones of the background prank, more biopsy. So if you're looking for solid organ dysfunctions, that liver lung re know anything really on, just want to know if there's something underlying that's going on. You take a background sample of that off that structure of that, walking the sight. More riskier ones are the targeted biopsies. Now that's when you got suspicious lesion within an organ, say, the liver or the kidney. That looks like malignancy, but you need to prove it before you start anything. Um, that's that's the other type of biopsy we would do. We also need his solid, and sometimes the tumor was so obvious on imaging that you know it's a malignant religion. But you need to get a sample to see if it's got a hormone receptor sensitivity or anything like that that can target management. So it's We take these hard to biopsy is to either get a diagnosis or tailor the management of the patient going forward. Um, so ah, the checklist, Really, it's kind of you kind of wanna make sure they don't bleed, so you need to check the coagulation. If they've been on blood thinners for blood count just to see if they're not anemic or the platelets. They've got enough platelets, we usually say to fast for about six hours before the procedure, and that's mainly if they need sedation or and and if they were, also asked him to have intravenous access. And that's because if they do have a bleed, a lot of the the um of the biopsy, then we can resuscitate them quickly also helps us give sedation through the vein as well. Complications. It's I mean, I don't want go through every single complication for everybody because it's really a win specific and target specific. The main ones generally a bleeding the risk of introducing infection into a steroid area, potentially getting a non diagnostic sample. That could be because you may be missed the lesion or because apart the lesion that you biopsied is necrotic for whatever reason, and, you know it doesn't really contain any cells that give you any answer, so you might have to tell the patient you might have to come back for another procedure. The other thing that you need to worry about is damage to adjacent structures So if you're taking a liver biopsy were taking kidney biopsy, you might damage the bow or the lung, the pleura. And if you're doing a lung biopsy, you know, one of the specific, uh, complications that could be getting a, uh uh, Palm knew before act sorry and see it's all depending on weight. What? Yes, that was sampling. That's pretty obvious what the complications could be. Now he's a tall kid who got I've got a sort of a couple of overarching needles that are used. There are lots out there, but these are the simple basic principles of the needles. So over here, if you see my pointer, no biopsy needle, there's other brands. Of course, on what this one allows you to do is you take this needle right up towards the lesion and then you advances. Tracy, press down on this trigger mechanism and you advances tray and you can watch this trade coming out under ultrasound. And then when you click it again, ah, shelf sort of thing fires over the top of it, and it traps the sample within this ship within this tray, and then you take it away and the other type of of of biopsy needle. Is this the bio pence? But there are lots of other ones like it as well. So you take the needle right up to the lesion and then, um okay, so that the's three prongs fire forward over the needle and in trap some, but a sample set fires forward and traps that sample and then you can take this back out with you. The benefits of this is the largest Amporn histopathologist love having lots of tissue. So you always get more bang for your buck. The problem is, with this is that if you don't really know what's behind, you need with you this throat could be three centimeters. Two centimeter, one centimeter. But if you don't really have a good idea if you have a vessel here or an important structure behind that, you could fire right the way into it. So you need to know what is behind what you're trying to biopsy with this. This, of course, gives you a lot more control but gives you less sample. I'll just put this in here so specifically a bone biopsy. You know, I'm not gonna be talking about this too much, but this allows you to sort of grind through bone as a co actual system, which I will be talking about later. And you can barbecue through the inside of the needle. Um, good, just to say that you're making a hole in the patient by taking a biopsy, and the sort size of sample that we normally take is a 16 gauge or an 18 gauge. Most people, I think, take 18 gauge samples for some reason were really scared of taking 16 gauge samples, and I'm not sure there's a lot of evidence is just they get more complications from having a slightly bigger sample taken from them. So the modalities This's a great image here of a lady about to have an ultrasound guided neck biopsy. She seems really happy about it. She also seems quite happy that the paper the clinician is using the one probe. Ah, then the other workhorses really CT guided procedures and there are benefits to using either one. And I'm just going to describe that for you now. So what you want to consider when you're planning a biopsy is you want things to you want to go for the most superficial target. You can get two, and the reason being is, it's gonna be easier for you to get a sample on. It's safer, so you want to be away from structures that we're going to potentially get damaged and make the patient really, really unwell. So you want to pick a superficial, safe area to biopsy, but you also want to get a good sample, so you want to pick his tissue. That's gonna give you a good result with the result that you want. So you don't want to be going for something really small that might be malignant. It's not really going to give you the real so really answer that you need now. The drawbacks of CT are that you can get Give radiation to the patient, obviously, but interestingly, more more now with using a sort of modality, which is CT Fluoroscopy that's were in the room on were guiding the needle and taking quick pictures with CT just three slices at a time and advancing any low. And that gives radiation does to the operator as well. So you got to consider that you have to give a lot of times contrast that the patient to delineate the different structures. Otherwise, it's the same tone of gray on. Then, once you've done that, you really have to move quite quickly. Because and I know where you're going because once contrast is washed out your back to the gray again. So you lose constituting a of the lesion. So you really have to be know what you're doing with the CT. The limitations of old sound. That's great, because you know you can hold the image there. It's not going to go anywhere. And you've got control over what you're doing. So that's great. But there is a real depth limit. The ultrasound can't penetrate very too far into the into the tissues or all of the time. And it was he can't see through things like a round bone on your should see one of the i. R. Juniors physics lectures to explain why. So I'm gonna move to some cases now. So we're gonna do is quite bit unfortunately So, um, what I'll do, it's just gonna gate and I Spain and flip around here. Okay, See, should now be seeing the CT scan. So I put this on here because this is just about the principles that we discussed now. So we want to be something superficial. Something safe, but something that's gonna give us an answer. So this a patient's got queery lymphoma. Now, the quite clearly do have lymphoma, except lots of abnormal lymph nodes. And you don't have to know what those are your stage, but I just point some out for you. There's, um, abnormal lymph nodes here, right by the jugular vein. Oh, you got some random abnormal lymph nodes here and tear really in the neck. But these, you know, you might be able to get get to that. Um, I don't think you'd want to get to that one. If I go down to this screen here, you can see that we've got lots of big ones in the axilla here. So these could be something you might want to go for, um, on our keep coming down to the abdomen on. Then you've got lots of these abnormal lymph nodes here in the knees and tree of the bowel can see a lot of those are abnormal. Now, what's your shot selection here? These are abnormal. They're quite big, but they're going through bounce. So you don't really want to be going for those neck ones. They're very small. You might not get a diagnosis example, and they're pretty close to some important clockwork. So the answer, obviously, is to go for the easy axillary lymph nodes. So that's how you start off work your way through what you want. A biopsy. Basically, Um, right on and good. Um, so the next case, actually is a different one, actually. Have to go back on a scale bank. Teo. I carry Onda. I'm gonna get the next patient, right. So the same sort of principle here gonna work through our next case. So this is a patient who has got a macroscopic fat containing mass in the retroperitoneum is a year. And I know this is the liposarcomas proven otherwise, but we need to tissue. So this is actually so what we're gonna do You do any CT of your results? Sound? Well, actually, looking at it, it's quite superficial. There's a lot of mass here to biopsy is not really near any important structures. The kidneys well, out of the way. Um, the bowel is really out of the way. It's anterior. There's no vessels. Okay? Spain's pretty high up, actually. Through this window here, we'll get some pretty good samples. So this is gonna be an ultrasound guided biopsy. Um, good on. I just show you what that biopsy looks like. Okay, so that's the liposarcomas that I showed you. And this is the needle needle going through it. So that's basically quite easy, That's know, very superficial. Nothing in the way on the needle going through Safelite Upsie. Great. Okay, so at this case, I'm going to be introducing the concept of the the stroke of the co axial system. So let's go back. Um, the three apologizing actually is quite a bit, but I like scrolling through the CT's Makes it easier for me. Um right. It's get this one up. Right. Say, this is a patient who gave the answer way. Um, has a mass here, which we don't know what it is. Ah, on it's isolated. But if you lift it here now you've got Can we always gonna be able to see this without sound? No. I mean, we could probably see it. Maybe through the liver, but not really and anti. Really. Well, there's a stomach in the way of the pancreas in the way you got the hepatic flexure of the colon in the way you can't see through there on going through the back here. It's such a narrow window. You're not really gonna be able to see this without sound too Well, So what we did is we got that This patient in the CT scanner on down shave initial run. So Po in the prone position because our window that we want to go for is very narrow, but it's just through here. This is our plan trajectory. Um, and if we're to north, we're gonna hit the liver for to south Gonna hit the kidney for two lateral. We're going to get the adrenal. Glad you actually have to be quite precise. Here s o put a little trace it down just to see where we want to go. Sort slightly off for their This is where we want to go. So do it again. This is where we want to go. Um, and this is my first needle just coming in here, But actually it's going to medial. Shall I Just it I adjusted it even worse. It's going away to medial now and readjusted. And actually, now that looks like it's about to hit the kidney, so readjust. And actually they're. It's nicely sitting just above the kidney. There's the bowel. There's the adrenal, nothing in the way of sitting over the mass. That's perfect. And I'll just change the window on here so you can see I'm using this Copaxone needle. Know what that means is, and there's a sharp needle, but it's two part needle and unscrew that. Take the in the style it out, and then you pass your biopsy done through here and you fire down onto this lesion on. The reason that's good is because this was quite difficult to get to on. I don't want to be, and you need more than one so important to manage. Maybe you need to sometimes three. You don't wanna be constantly doing this over and over again. So you get in there once and then from this position, you can just anchor the anchor the needle of correcting needle in different directions and take samples for this whole mass. So that's a good CT guided biopsy example using a co axial needle. Um, cool, right? So There you go. Come, actually, needle on. Do we got that in? I'm gonna have to flip straight back and introduce the next one. So in a difficult clockwork now, difficult clockwork is something to really consider because ultrasound doesn't really give you always give you the best visualization of these of these areas. So let me just go back to chance. Going goes this one trying to get to the next case. Right? So this is Ah, biopsy that one of my colleagues, uh, hit, uh, he's actually going to presenting later on. I think in June, uh, did and so he's really good at CT. So you know, this is great. So this is interesting mass here. It's this inflammatory kind of looking central, central mass wrapping itself around the aorta and just here for Zoom up that for you you can see the renal artery coming in right embedded in that mass. And actually, it's such a inflammatory mass. It's taken a bit of the colon that was nearby or the bowel. So that's nearby, and it's eroded it. And it's artificial ating into this mass. So this is really difficult, obviously, you know, be able to see this with CT. They need a diagnosis and they need a sample. So we got a patient in Tom. Use this technique where he puts four needles down just to see what takes an initial CT to get his bearings on what plan? Where he's gonna make his initial ah, approach on and and this is Ah, this is the CT fluoroscopy. Okay, so it comes on, and once I'm afraid so what? What he's doing here is he's got this needle in a little bit and then that he's in the room and then the presses a pedal on about 32 millimeter slices are taken just where he wants to be. Just where he's focusing on. And he will continue to advance the needle slowly on skipping of it. Slowly advance the needle bit further each time making small adjustments as he goes. He's getting down to this mass now very slowly. He's almost there, and he's right there. Now you can see this is you know you can't see what's going on. This was saying about when contrast is not there. It's also off gray, and we know there are some important structures and that we know this renal artery, you know, could see that the eight. There's the A water ureters. There s o this point. Um did a clever thing on Decided to enjoy give the patient contrast to really highlight where these structures weren't. Here you go. Heart's in his mouth because there's the water. There's a renal artery in his needles basically saying above it, Um so he knows that And what could do? There's actually either side above or below. He's gonna be hitting mass. As long as he doesn't go to immediately and into the aorta. He'll be able to use his co axial needle to take some biopsies. Samples of this on hey managed to get a good sample. So he's taking that, taking the boxes from that position. And just to make sure there's no bleeding is down another CT scan after there's no big hematoma. So job well done. Okay, so that's the benefits of CT when he'd be in some really dangerous Russia. But also some of the limitations of CT when you don't have contrast in the system. Ah, good. That case got you. Okay, good. So they get there's his cool biopsy. Right? So This is another type of biopsy. I'm not gone through a lot the different types of boxes you can do a lung and everything like that and because of time. But transjugular biopsy is kind of an important one is well, because we do. This is a sort of background parenchymal biopsy of people have got liver dysfunction, and normally we go through the skin without sound and just take a pretty safe biopsy. But if you've got something like ascites, what's happening in a normal person with liver dysfunction is that they've got soft tissue overlying the overlying the capsule of the liver, which actually just access a vacuum and stops blood from coming back out of it if they do have a small bleed, so it acts as a protective barrier. But actually, if you got ascites, you've got a potential space here, and you can carry on bleeding out into that ascites. So the benefit of doing a trans jugular liver boxes, you go inside through the vein, and we all know that goes in a straight line down the heart and then you into the hepatic veins, and you can go through the right hepatic vein and take a biopsy. And we also do it for patients who have got increased bleeding risks on lots of people have liver dysfunction. Do have an increased bleeding risk. Is there an hours off on the theory of that being is if you take a needle out here if you pat, it may take a needle out here. If they do believe they're going to bleed back into this, uh, back into the system. So that's it. So I should show you that the kit for this and because it's bit odd, But so this is the main thing is that this is a big hockey stick, kind of dilated. It's got metal inside it, and then a catheter and the biopsy needle on. And this is what you use this off? Get yourself into the hepatic vein when you're down there cause you need to need an angle and I'll show you why in a minute. Ah, take any I said, Okay. So if I show you this, Okay, so this is what you want to do it through. The chest is well, actually, just a bit of anatomy. Um, so you're coming in through the jugular vein here and I seen safe. You know, if it bleeds, you just press on it and you take a route down here. That's the innominate vein coming in. And then you're into the SV. See out the back door, right, Atrium ivc. And you could just see the ghosts of these hepatic veins. But I put it into the portal venous phase, and you can see that. So you want to get into this right hepatic vein and then with that hockey stick, see, been bending in there and then you get a angle, the angle, the biopsy, um, she anteriorly and take a sample. So here you are, lots of spaces, lots of space. Take a sample in this big, big, meaty area here, so I just show you some selective images. So that's that's getting in. That's the life floor of you getting into the patent vein with the catheter. This's a hockey stick and just you can see here the needles being it's sliding in, get to the end on This is one of those shelf type of ones that was telling you about earlier. There it goes on. If I run you in, you got some point. Take it out and s. So that's how it transjugular liver barks. He works, I think. Fairly interesting way of taking a biopsy. Ah, right. Okay. So drainage. This is next topic. So the mainstay of drainage in IRA's to and drain and infected collection have put a little asterisk there because, you know, it's starting to become, uh, well, once a burden, but it's sort of taking over a lot of our work. And there is really cool to be able to put a drain in something that's not really accessible and patients avoiding surgery, but it means people aren't, You know, being blocked drains in people now, Um, so, yeah, it's got great benefits because of minimally invasive, but you and you don't have fluid, but lots of the times if they got really messy abdomen's and they're asking us to put a drain in it, sort of like no, really going to do the job. You know, sometimes I just need surgery on a wash out the way sort temporizing things by. And then these smaller trains, um so theatre thing is well for drains is to relieve the mechanical symptoms of fluid accumulation. So obviously talking about side. He's a typical liver failure or ah ah, very in cancer, whether, um or if they've got me to thelium appear effusions lung cancer, your pleural effusions, and they could be drained. Well, I'm not gonna be talking about those too much, because actually, that's something that we do if they have, if people in the water having difficulty doing But it's not something we should be doing too often. The respiratory team and the gastro team more than capable of put in the put in in these trains. Um, right, So the checklist, it's pretty much the same as for biopsies, Really? So you need to know if they're gonna bleed fast them, because we want to give might want to give them sedation or resuscitate them on the complications again depends on what you're doing. Where you're going there is like the add a caveat of infection. I mean, your putting you're going into an infected collection. So if they do get infected, how do you know it was because they're just not infected? And what's what you've done? Actually, one of things you can see sometimes is when you get into a big A big collection that's encapsulated big employment. Then they do sometimes have this inflammatory capillary bed on DA. If you aspirate a lot of the pass out to you, get to this or bloody kind of puss. There is a theory that you can sort of trans like eight, some of the bacteria through that capillary beds, inflammatory capillary bed and give them something called a septic shower. So they do have to have close observations. After the you put a drain in just to watch out for a bleeding and be sepsis from a from a septic shower, they can get quite unwell again. Damage through Jason's rushes depends on where you're going, right? So some of the tools Ah, every everyone has it. That sort of different press preference. He use a single partner needle. We speak enough to get a wire through. To get in. You put the wire through straight away. You can use a two part needle with a soft out a catheter, so it's a sharp thing that you put into the into the collection. And then you advance the soft bit over the top, just like a cannula, really, And through that soft plastic you can introduce a wire. This is a three part need or like a You might have heard of a calendar needle, so it's got a metal bit inside it, which you advance in what you think you're in. You can. There are two plastic bits here. One's thinner and one's one's the inner ones. The outer you advance the plastic bits, and then you just have an see out of plastic bit extra step, and but it's a bit more sturdy, so you don't lose. Actually, this is not quite floppy when you get and and so you need a stiff wire. So this is like an amplatz wire. It's got jaded, and so what they do typically is have to have a soft end. So when you get into the collection, it can be soft. But then it gets quite rigid so you can track these big drains in through. This isn't a big drain. This is an 8.5 French drain, but you can go up to a lot. These these very large range is up to 2024 French, Um, Gordon drains, and that's what you want to do on doing a labor. The points of probably probably heard it a million times. It's a slow holding, a technique that by this guy here it's just basically putting a needle into something. A wire. And then over the wire, you introduce the tube that you want to go in there. Um, right. Okay, let's go to the case. Onda we are on. It's, um yeah, just late this first. Okay, so Okay, so this is a quick one here. So you've got this patient with lots of collections. They've already put a drain in this side. It's not draining a lot. You think that if you look at all this fluid, you think Oh, it's also off the same. It's encapsulated. Probably all communicates, but they put drain in here, and it's not really doing much. It's a little this stuff, and this is one of the limitations of CT can make things that really simple that just looks like Ascites doesn't If it's got this off capsule here, there are subtle signs on they're infected and they've got all this a team. Here is the subtle signs that you think Oh, actually, it's an infected collection. So, you know, you think if you put one a cytic drain in here. You're doing a drain. Everything. But I'm going to show you. I have to flip back for this. Um, I have to show you what you would actually see when you get in there with an ultrasound probe. Okay, on. But this is what it looks like. Okay? So you can see all these septations these some of it's thick and, you know, some of it's quite an a Kotex or when it's things that and a coke means a simple fluid and that got these little septine and there. So, actually, you can see that if you put a drain in there, you might just drain a small pocket of it, but they don't drain everything. So what we try to do is find an area that clearly communicates to collections of communicate. We get the wire. It just sort of Schmidt around in here a bit trying break up the septations. Not too aggressively, obviously on. And then we'll put a drain in over that. Yeah. Okay. So remember what was saying earlier. Ultrasounds, limitations? Uh, can't see through AARP. Can't see three bone on the other. Things could be in the way as well, so I should get back. We're getting slicker at these little transitions now, I think, Um Okay, kid. Right. Okay, so this is a complex CT scan, Okay? So don't give him out about it. But I'll tell you, they've had something called a pelvic exam terazosin. Which means they've had all of their pelvic organs removed, probably for some malignancy. They've got lots of things going on here, so they've got a stone murmur. End colostomy. Ah, on these are ureter extents going into something called an ileal conduit. So it's when the urologist fashion a spout sort of a channel using the terminal ileum, which will come out into a bag here. I guess that's an ileal. Conduit. Got a drain in already a big surge called drain. Here in the in the bed of the surgical bed, they've taken away all those organs. Actually, there's this, like collection here, which isn't really going anywhere on. It's draped that the condo Azor draped over the top of it. So there you go. So that collection isn't really going anywhere. And they want to have done all these things operate this massive operation on this patient. They've still got the staples in. Um, you know, you want to optimize their recovery. So if they do have a collection, if it's infected that you should try our best to really get rid of it because they've gone to a lot of effort just to get to this stage. So how are we gonna get in there? We'll have Let's have a look now. Oh, Tre. Sound. Well, they got a big bag there. They got bowel there. Can we go from sideways or behind? Not really. Liver's in the way there. And you got bone. You know, I lack crest there, so you can't really go in that way. There's no real way. So we will obviously. Now we're gonna have to try and do this with CT. So up Steps, er, Tom ct, CT drainage king and he but so great. So basically one of things you are very my post operative patients is very difficult to move them and position them. But it's really important to try. And so you can imagine if you just had a a laparotomy it so wedged up on your laparotomy scar on the stoma, it's not very comfortable so you have to work quickly. We have to work within the limitations of the patient stays. Put the put the his standard technique of the four needles there to get an initial position, and this is where he uses his tap tap tap thing. But he's going down the patient this time, so each slice is incrementally stepping down the patient cause you can see here is trajectories never in your collection. If you watch, he's just going down over that crest. Here comes sorry. It just very jumps the stacks. He's just gone over the crest there, notching it forward and down, forward and down each way slowly does it now the collections coming into view here. There you go. And bingo, he's hit the collection aspirate. He's gonna hit Puss on. Then he but sort of a drain in there. That's it. So that's good. That's brilliant and say, and good example of when it sound isn't good. CT is really good if you already get a CT. Uh, okay, good. Right. Okay, So this is basically why done here is dislike manipulated the image to show you what's actually happened. The trajectory of this train so you just got over the pelvic in that chair or at the ah iliac crest. Here. Sorry on. He's just I ankle downwards into this collection. Uh, next. Okay, so is there a useful fluoroscopy? Well, yes, there is. And we don't do salt initial drains with fluoroscopy. Um, but we do dio sort of manipulations of drains, and I just quickly go through this this for you. Um so Okay, great course. And so this is CT scan. Ignore the bowel obstruction. Well, don't you know, just for the past purpose of this talk on what's happened here is the patients got a pre sacral collection. Onda. This is a drain that was put in, and it's sort of come back sort of just out collection just in. It's not really draining this sort of thick rim around the collection tells you that it's inflect infected, and it's probably been there for a while, but we're not really going to get anything out of that. So we need to manipulate that drain and maybe even make the drain biggest called up, sizing the drain. So what you do here is to get them on the floor. Oh, table on their side. Um and, you know, you know, to actually, it's all just, uh that they saw on, uh, see how long that takes you So you can see here. This is the collection on the sagittal view. That's the collection on we've got Where's the drain? There's the drain. Okay, so coming up and down into here and it's calling around in there. So we're planning on the CT. That's what's going to look like now we'll get the fluoride rinse, we get them on the side. And actually, it's probably the bend is out of you in on this. Unfortunately, there is sitting in the outside of that collection we put a wire in on. But, uh, she thin says cheap where we can inject contrast through on D, um, is that and then you inject some contrast and you can see that you're pacifying the cavity of the collection. So now we know the wires in the cavity of the collection. We advanced a slightly larger drain into that collection on we got past back. So that means your your upside the drain repositioned under fluoroscopic guidance. That's sort of main reason we use fluoro in these cases. Um, right. And so I good, they get flu row in these cases. Got another case straightaway. Okay, so this is, uh if you have a guest, most of you are gonna apply to radiology. This, like your typical referring complaint that you're going to get patients go up the pain, haven't examined them. Done a really know what's going on. Can you do a CT, please? On. Do you try to argue? But you just got to do it anyway, because that's what we do. Eso I just get this patient, this patient here don't be to disarm that because it is called just giving them a diagnosis and then doing the management as well. Okay, right. It's getting less across. Yeah, they were getting sick, the transitions. But they've got bad again, haven't they? Okay, cool. Right. Okay. So abd a pain. Whatever. Don't know what it is, so you can see here straight away. These ducts are up. Okay, so you shouldn't really see those These air hepatic duct a raised You see this big common hepatic duct, which is, you know, dilated and enhancing. And here you go ahead. Press day. This is the goal bladder and you've got it. You may have heard of the term fat stranding Where inflammatory? Slandering this is a bit more than that. So you got all this edema around the school bladder here, which is thick walls as well on here. You've got this thing that you know what's so enhancing Its just dense. Um and that's a stone in the global. It's that they've got obstructive colecystitis know how you're gonna get to this. Well, you were seen on the post that it's gonna be a cholecystectomy, isn't it? You could take the gallbladder out hot cholecystectomy. However, this is gonna be really aggressive and hospital for you to get into on this. When you take the gallbladder out, you've got you've got to close the doctor, haven't you? And that tissue is gonna be really flying friable on the suits. Not really gonna take. So what we like to do is to go in there, take away that infected pass out, let everything calm, calm down, leave the drain in there for a bit, and then they can come back. Onda have a cholecystectomy at a later date. Um, so I just show you now what that looks like what we did. Um, okay, cool. So this is the ultrasound image that you'll get on. This is thick wards. A list like echoed echogenic fat around here means that's a Dema on the liver is just there. And you got this This, uh, stone here on we going without sound guidance. I just put a needle in there. And then which interests inject? A little bit of contrast. You can see that this off contrast feeling around stone and this is the gallbladder here and cystic duct. Um, get and that's from right Superior. Drain it on stenting. Now, put this little diagram in here. Ah, just a show. Just give you some relevance about what we're gonna be talking about. So you got the left in the right hepatic duct, which drain the left and right lobes of the liver bile. They form a confluence and form a common hepatic duct. And then when that meets the cystic duct coming from the goal bladder, it forms thie common bile duct, CBD, and that rain's goes across pancreas and drains through the sample of aspirin to duodenum. There's a pancreatic ducts which joints there as well okay, That space, it can ask me. It's more toe Know this anatomy because And you can understand how different pathologies will cause obstruction. Different levels Pancreatic pathology Go about doctor pathology, liver pathology, for example. So ah, Lord, text in this one. But I think it's important because, uh, it's one of most serious procedures we do. And so what? The common causes. What? Why would somebody kneed, drainage or scenting of the but very system? Will they get very strictures? And and, uh, they should have had, ah, on ercp on. And if they found in the ercp will go through this route. This thing called eight p t. See, that's something you might have heard off. It's a percutaneously transplant IQ cholangiography. So we go through the skin through the liver, into the bar ducks. Ercp is endoscopic retrograde cholangiogram Creagh ta graffiti to injecting dye from below fire an endoscope. And if they found that will do the PT see and the main reasons for obstructions or malignant on. For the vast majority people were pancreatic carcinoma, So a low obstruction cholangiocarcinoma cancer, malignancy of the bile ducts themselves, and that can happen anywhere within the body aches and the disc grading system called the bismuth system that you might want to look at some point have to, which shows you where the where the where the tumor is. Metastases in the liver obstructed doctor focal duct dilatation and on Ampyra or duodenal cancer, obviously saying so. Your level is a pancreatic carcinoma on your bladder carcinoma, just invading on HTC as well, so hip at cellular carcinoma. Guess again. Just Mass is within the liver, which can obstruct one of the duck the bit on the benign end of things you. The most common thing is stones pancreatitis. If you get pancreatitis, you can get these post inflammatory strictures along along the ampullary area on also strictures of any other kind if they've had your CP or something like that, and the other reason we can do a PT see is if somebody's got barley, can you in a diver the ball somewhere else? If there an operation of damaged about up just combined up, you want to take the well. I've done it about about externally for a little while, just that everything calmed down. That's something you can do if they've got stone you can clear it. They've got a stricture week and balloon it and you can also start taking tissue from from where we are as well. Just explain a bit more about that as a go on. So the contraindications to build a percutaneously biliary drainage is if they've got a caregiver opathy because it's a very high risk of bleeding. Um contrast. Allergy, obviously, um, on ascites. Same reason is what was explaining with the trans drug A liver biopsy. If you try to cross societies that just gonna bleed out or get a biologic out into the acidic fluid if they do have a cytogenetic, strain it first case of the checklist for this thing to be well hydrated that I mean to be given antibiotics because most most people will have a net amount of infection. Well, we'll we'll even have sepsis when they present for a PT See need to do a full blood count and coags before fasting. Because these procedures even done under very heavy sedation or general anesthetic because they're very uncomfortable for the patient. The risk factors to consider PTC biliary drains one. The most dangerous things we do or highest risks things that we do in interventional radiology. It's got very high mortality from 2010 biliary drainage registration. And that's because of the patient's selection. A lot of times these patients are old when you present with biliary obstruction, Um, you basically usually have a knack Vance malignancy, so they don't have usually a long life span anyway. And these are sort of palliative procedures to make sure they don't have jaundice in there, you know, final months. So that's why it's quite high mortality procedure that usually quite frown on def. They got sepsis or renal failure. That's a very, very high risk of dying. Actually, I thought this was quite interesting because we return, she said. So we have a quite low were lower mortality, and I think part of considerations for that is the aftercare. So you have to be in a place where they regularly monitored afterwards, mainly sepsis or bleeding, and catch that early. Um, right, So this is a case. No more switching. I could be bothered to transfer skills for this. Okay, so I just take my word for it. If you don't know, this is a sort of an ill defined mass of the head of the pancreas. Can't scrolls is This is still ago. That's the old trimester, the head of the pancreas on CT. You know what's coming next? They call bile ducts exploded. This this is a low obstruction, so both sides of the liver has got destructive ducks it that's given if they got bilateral doctor doctor, I'll attention. It's gonna be a low stricture. This is the kind of duct we like to access. So using ultrasound and you'll go through this intercourse or space and try to find one of these peripheral dilated ducks. There's no dangerous blood vessels out here. You use a very thin needle to get into it. It's actually quite a hard punch to get right to the patient's breathings. It's a moving target on without sound. You can sometimes get to hold the breath, but you just got get into that part of thin wire into that duct over the wire seldinger technique who, the way just passed the tube and and then through that cheap, you can put a larger wire and then you can advance a train, so we'll go through that now. So the first thing you do you get in? This is our tube in there now, and you'll inject some contrast. And so this is to really give you a map of what's going on now, One of the times when people can get cholangitis or sepsis is a result. This is if you to If they've already got an infection or can enjoy it, us and you aggressively feel the ducks, you can translate at the bacteria through the bar ducks and give them sepsis or cholangitis. And I've seen it happen. It happens quite quickly, so you can't overfill the dots. But you need a map because you're going to negotiate your wire through this through this down to this CBD in the obstruction there, this is pancreas is gonna be here. That's where the obstruction is. You can see that's nice and dilated that CBD we're not nice, and I see. But it is dot Okay, so, you know, go. She ate your wire down to here on. Do you actually can't cross the stricture? You're bouncing around because you can imagine it's really tense in there. That's a lot of volume. This should be really thin. It shouldn't be, you know, any bigger than five millimeters. Six millimeters. But that's that's massive because your wife is just gonna be bouncing around in there, right? We'll come back another day. So you leave what's called an external drain like that. Thought that Dawson Miller drain are showing you earlier. It's a picked. Our looking drain on will drain all this bile away, you know, over a couple of days, and then we'll come back when everything's calmed down, so you bring them back on. Do you manage to get through this time because everything's calmed down. So here's your catheter through. I'll play that again for you. Inject contrast. This is the duodenum. See, you managed across this stricture on through that you place a stent. There you go. Oh, so you're a wire there yet wire through this castor stiff wire, and then you place a stent, um, through there. And this is what's called an internal external belligerency. Those you know on the ward's already and you're looking, you know, biliary drains you put. It's quite confusing. An external drain basically means it's above the stricture. An internal external drain means it's inside the jury, Denham and in the in the in the hilum that holds her in the hilum of the bar ducks, and it's draining away there. So that's an internal external biliary drain. Okay, got holes here on here. Um, good as it will let that calm down for a little bit again, unless we're really happy. Contrast is washing through. If it's no, we leave the strain in on day. Well, let things calm down for another day or two, and then we'll remove the drain would do a We'll inject some contrast and see it witching through the stent. So we're happy with that. That's going to stay open. And I put our here. This is something you embolized the tractor. You can do this many ways. This is Avitene, Pacey. You mix this flowery thing up with some contrast, and you sort of injecting into the path you came to prevent bio leak down your whole eso. What you need to do After that, I'm saying there's a risk of sepsis and bleeding so close observations can give analgesia be quite painful, especially when you're stretching these strictures open and they might need antibiotics. You leave it on external drainage for a couple of days on. Then you trial capping the external drain to make sure the the stent is working on. And you should see a drop in the bilirubin within about by 50% within 10 to 15 days. And if they have come in within it, cut and dry it It's an infected destruction. They should. That should start to improve to three days after your procedure. Okay. And some extra things to think about when we when we've got got through is you can actually start biopsying. So if you've got a A lesion here in the bar, doctor or cholangiocarcinoma or pancreatic head tumor or something, you can get your wire across. And then across this wire, you can use this brush and just brush along here, and this will pick up some cells and you contest theirselves cytology to see what the malignancy is because not always clear from imaging. This is another thing. So this is a very small four separate Gramps tissue. You could put that through your sheath. So this is a schematic of what's specially over the wire, and then you take this out and you can grab a bit of tissue, and this is in practice going through a stent, and it's grabbing a bit tissue there. That's good. I want to watch. This is sort of quite novel and only medicine sense in the UK doing this at the moment, but it's quite big in Asia. Um, and it's called, uh, um endoluminal radio frequency ablation so that you can pass a radiofrequency pole probe along your wire through, say, a malignant obstruction or a stricture, and you can actually burn that a way that's not going to cure the lesion. But what we will do is give you a Channel two part place a stent or to reopen a stent during a channel in there and keep that opens. It's a parrot of a procedure that basically keeps keeps, keeps your internal drainage of bile, and so that's it. So it was a long, but it's lots of cover. I hope you enjoyed it. I'll take any questions. Thank you. Show him That was actually excellent talk. And if anyone's got any questions, please drop them in the chat. Now we'll answer, but it looks you've explained everything so well as we're going along with that. Millions dropped any questions at this year. I just want with regards to biopsies and drains I saw. That's fantastic. Um, difficult to explain. What is that known? The name of it. But this product sense, she weigh you and you have a kind of marker What you're doing the CT. And based on the position of the marker which is taped to the patients back, you can Yeah. Predict the needle direction. Yeah, I think I don't think it's that grid's for ct Your ultrasound for CT guided stuff. Yeah, they're people using these sort of things that you can stick down. They got radio opaque markers and it makes a grid so it can help you plan your trajectory. Kind of like what Tom was doing with the needles placed in a row. He's just got a four pack of drawing up to use the placement, and he can tell they're between which one on which one you're going to start your your, uh uh, needle trajectory. So that's basically what it is. It's just fancier, more expensive way of doing that. Interesting. Um, have you actually seen any of these really? Endo radiofrequency ablation sort of in the UK or is up no. Yeah, they were. They inform if they do them. So shout. Claire Bent, she's She's done a few of them in for me. If I don't, I don't feel you know. There are other sense, and you can have. I started using it, and there's not a lot of evidence for it just yet, because it's still quite new, so but they do use it in in in Asia a bit. That's where most of the evidence comes from. For it, that school is going to see innovation happening, I think. Well, I don't know that. And you got it. Then what? I don't know. Ah, nice. It's got. It's got its limitations. So when you're doing it with in stents, it's got this kind of kind of shorts out sometimes because of the because of the metal. But it's it's initially proposed to sort reline so when? Because the stents can get included after time because off bottles grabbing and you got duodenum there and they do tend to sort of block off. Quite often, we get tumor in growth. Main thing is she marine grade on. Do so. You just basically want to burn that Schumer away if it's in growing into the stent again, the stent Short, short circuit out sometimes. So I think what will be useful? What might happen with this on this? I didn't have the histology diagrams to show you, but it's sort of if you burn if you burn it before you stand, it turns this into it with a flat squamous epithelium rather than this aggressive kind of still. Yeah, and that might don't have evidence for yet. That might mean that the stent stays open longer, but wait and see. Yeah, really interested in, I think, uh, loose. So we haven't got any more questions in the charts. Say, unless you got nothing else to add, will come a wrap it up. No, I don't think again. That was Yeah. Really, really good session. So Well, uh, who and the recording now