SynIRgy in Innovation: Celebrating 50 Years of Advancing Patient Care

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR Podcast Series.

I’m Jennifer Phelps. In the summer of 2018, in July, I was diagnosed with a pancreatic tumor. It’s a neuroendocrine tumor. Six weeks later, I was scheduled for a Whipple, which is where they remove part of the pancreas and the gallbladder and part of the small intestine, and I recovered well from that, but they realized that they didn’t get the whole tumor, so in November of 2020, I had surgery number two, but then they found that they still hadn’t gotten it all, and so they decided to go in for surgery number three. And this time, we got the whole tumor, so that was fantastic, but a couple days after the surgery, there was leakage around the bile duct, so they brought in the interventional radiology team.

After that surgery, the bile duct at the point where it was sewn back into her intestine was leaking, so the tube was put in initially to divert the bile away from her abdominal space back into her intestine where it belongs, and as a result of having the tube for a long period of time, her body formed a scar around it and developed what’s called a stricture. The way the tube works is you put a large tube about the size of a Sharpie pen through the skin into the liver, traverses the bile duct and crosses into the intestine, and we leave that there for a year, allowing the body to remodel the bile duct, and this is successful in over 90% of patients at treating this narrowing. The problem is, at one year when we took pictures of her bile duct, there was zero flow from her bile ducts into her intestine. Conventionally, patients that that happens to end up going either to a repeat surgery, which was off the table for her, because she had basically no surgical options left, or a tube for life.

It interfered with my daily life, it was painful and uncomfortable, and during so much of that previous year, I was just holding onto this, okay, this is coming out, like, this is awful, but someday this will be gone, and the idea that it may not ever come out was pretty awful.

When you have a young patient that’s active, it’s hard to condemn them to a somewhat morbid thing like having a tube in your liver for the rest of your life, but I knew another physician who specializes in advanced ways to treat refractory biliary strictures, so I offered to connect her to Dr. Chadalavada, and then the rest is sort of their story to tell.

I think before I welcome Dr. Chadalavada and Jennifer to the stage, I just want to make a point, and first of all, thank you, Jennifer, for being here and being willing to come up here and talk about this. It’s not an easy thing to share difficult times with a crowd of strangers, but it’s incredibly important, because one of the things you find very quickly in interventional radiology is you’re not dealing with a picture on a screen. You’re dealing with another human being, somebody who has the same aspirations, concerns, the same family issues, work issues that you have, and you’re doing things to these individuals that may change them for the rest of their lives. It’s a very different burden to you as a physician, and a huge privilege that anyone would let you do that to them, so it’s a wonderful thing to have you here, so I’d like to welcome to the stage Dr. Ram Chadalavada, who is a graduate of the SynIRgy program from 15 years ago, so all of you, when you see him, that could be you, and Jennifer Phelps. Ram, I’m gonna ask you how you fixed it, because we’re all, we love procedures as interventionalists, and that’s what we want to talk about, but first, Jennifer, if you could tell us how having a tube in you for, 17 months, is it?

17 months.

How that impacted you, and the reason why I think it’d be important for everyone in this audience to hear that is, an interventional radiologist putting tubes in is just kind of what you do maybe 5, 6, 7 times a day, and people are coming through, and you’re placing the tube, and we move on to our next patients, and yet there’s somebody who now has to deal with this day in and day out, and I’ll let you tell the rest.

So my first thought about the tube was that it saved my life, but that didn’t mean I liked it, right? I was grateful for it that, you know, I was very aware that without this internal-external biliary drain, I would not be here. I needed it, it was lifesaving care, but it hurt every day. Every breath I took, as Matt was talking about, it went up through my ribs, and so every single breath hurt. I was aware of it all the time, it was something that had to be maintained, I was flushing it, it leaked, it would hurt. Like, it was just, pretty much every moment of every day, I was aware that I had it, and then that affected my daily life. I have 16-year-old twins, and so I’m trying to be a mother. I’m a single mom, so I needed to stay working, and that’s always been a big part of my identity, and, you know, so I didn’t wanna just show up at work, I wanted to excel. When I was diagnosed with my tumor, I was 45, so this is, these were those prime years of my career, and I was in pain all the time, so it was a lot.

And can you talk a little bit about your interactions with the healthcare system? You have this tube; you get to know it pretty well.

Yeah.

She’s really good at tube care.

I’m really good.

Yep. And maybe, if you had a problem with the tube, you know, how would you have that interaction, and what would it mean to you if, let’s say, you thought the tube was clogged, for example?

Right. One, there was a learning curve that, I had this for 17 months, but at the beginning I wasn’t that good with it, and the patient education of how do you work with this, how do you maintain it, how do you know when there’s a problem, those sort of things took time to get to know. The other thing is that when I would show up in interventional radiology, I felt like I was going in for an oil change, right? Like, it was whoever was up and next would take me, and honestly, sometimes, like, there was kind of this focus of, oh, they just want to do the procedure, they don’t want to hear that much about how it’s going. There was kind of a procedure mentality. Over time, I built relationships. Dr. Krosin got very involved in my case because I was having more and more complications, and that made a world of difference that once Dr. Krosin was part of my care team, then I felt like my questions were being answered, we started getting really creative and proactive about pain and comfort, and I felt like he was more invested in the fact that I still had a life that needed to be led, and so that made a huge, huge difference.

No, I think, Dr. Kaufman, I think you said it great. You can get into a routine, but I think what Matt did, and to pause and take a glimpse into what her experiences was and almost take a retrospective view, like, how often was she coming into the ER, how often is she calling in about drain care? It seems something that’s so mundane and routine, but that gave the impetus to kind of invest in Jennifer and see how you can actually impact, because I think even on every drain, you know, I want to know what the plan of care is for the next time or the unexpected event, so those are the responsibilities that we have as physicians and physicians-in-training to just think beyond and, you know, make it personal in that sense.

It’s part of that dealing with a whole person, and one of the great things about this specialty is it’s a one-to-one relationship. You are, when you’re doing a procedure, you’re with one person for whatever period of time it takes, and if you’re in a clinical practice, you develop a long-term relationship with that patient that just makes everything so much easier. So did you know about IR before you started down this journey?

No, I had never heard of this specialty.

Oh, that’s so unusual.

And I have a lot of doctor friends, so.

Just the other day, my mother-in-law, and I’ve known her for 50 years, said, “So what is it that you actually do?”

You should invite her to SynIRgy.

Yeah, exactly, so. Yeah, so, but you now know us.

I do.

Yeah, and you have a sea of sort of potential future interventional radiologists. Before we tell them what was actually done, they’re all dying to know, so what do we do? Come on, just get through the chitchat. Do you have anything you want to, like, convey to them, or like, any message you’d like them to…

Well, I think this part of this story is coming up, but one of the things I will say is that, by the end of this journey, the ability of my care team with Dr. Krosin, and then him reaching out to Dr. Ram, like, at the end of it, I think we all benefited by the stepping back and the collaborative spirit, that by egos getting out of the way, that, you know. I had been through oncology and other specialties as well, and there’s kind of a competitive part of it of you’re my patient and you should have care here, and instead, what I found with interventional radiology, or at least with these practitioners, was that they were willing to collaborate and help me to get the care I needed, and then as a result, the procedure that I ended up having with Dr. Ram is now offered back at my home institution, and so that institution now has a new procedure and way to help patients, Dr. Ram looks like a hero, like, I mean, he’s just, he’s the hero of this whole story, and I’m fixed. Like, I am tumor and tube free and living my best life again, and that, that to me is the moral of this story is, collaboration can be victorious for all of us, which is really awesome.

Yeah, I think you said it so well, there’s nothing more to say about that, but, Ram, I’m dying to know, everyone else is dying to know, so what did you do?

Well, you know, Nick, can we get some of our slides up? I want to give some anatomical and historical context. So basically, Jennifer had multiple surgical revisions, right? She had the Whipple, and she had to have cancer cut out of, essentially, her liver and her pancreatic area and all the other anatomical structures, but you know, whenever you have this surgery, you have to put all the parts together, back together and reconnect, right, you have re-anastomoses. So one of the main drainage systems that needs to be hooked back up is the biliary system, and so this is what the native biliary system looks like. You got our common bile duct, you got our pancreas, and we have to essentially reroute that. So she had what’s called a hepaticojejunostomy, and so essentially, once you cut out a certain area in that intrahepatic region, you have to figure out a way for all the bile and all these other components to drain, and keep in mind, she had over three interventions. She’s had oncologic treatments and so many other things that affect her, so when she was reconnected back as a hepaticojejunostomy for the last time, she continued to have a leak at that particular area, and then you kind of get high and high up in the liver to the point where your surgical access and window is no longer available, and so nobody wants to operate back in there, right, Jen?

Nope. I only have a little nub of a bile duct left, just a little nub.

Pretty much a nub. And then, you know, when you make all this surgical interventions in this area, it tends to create scar tissue, and so that’s a natural healing process. And so this particular problem has been there for decades, right, and so we’ve established protocols from Indiana, Hopkins, MGH, known as a benign stricture protocol, and that’s what Jen was going through. It’s, 90 plus percent of the patients, it works tremendous, but then what happens to those patients that fail? And Jen was a failed patient. And so let’s kind of advance, so I’ll just show you a couple of-

Can I interrupt?

Yeah.

I don’t think I failed. I think the procedure failed me.

Agreed, thank you, Jen. Yeah. Agreed. And so this is a picture of a patient. I’m going to show you Jen’s pictures later, but this is actually one of the earlier patients that I took care of who started with this severe stenosis. They had a tube in the whole time, and then by the time we got our work done, we were able to get to this end result of having a wide mouth anastomosis, where all the biliary contents were able to empty out through the bile system. So that’s the end goal of what we’re trying to do, and I think again, it’s the collaboration, the innovation, the technology and collaboration with our industry partners that allowed us to, you know, garner this type of outcome for Jennifer. So this is actually what we call cholangioscopy, and, you know, this is something that my mentor, Scott Trerotola, and I know Dan Picus and others, they’ve been doing this for decades using cholangioscopes, and so what has happened in generations since then is, our technology has advanced significantly. It’s like partners such as Cook and others who’ve innovated to where we are today in being able to actually directly visualize what’s happening. So in this particular case, what we’re doing is we’re in the biliary system, we’re visualizing, we have a camera, and we’re flushing it with fluids and irrigation. You see all that coral reef? That’s the actual strictured material that’s causing some of the issues with being able to discharge the biliary contents. And so what we did was we actually took a laser fiber and went in and made like an incision. Think of it as a thick broccoli rubber band that you buy at the grocery store, and that’s super thick, and the only way to release that tension of the stricture is to cut it with the laser, and by cutting with the laser, you’re actually releasing that tension and the rubber band aspect. And then as you release the rubber band, we were able to expand that with plasty, cholangioplasty, with lots of the balloons that we have every day, and we’re able to stretch that ring open. And this is us assessing back at that particular location. So we tend to get percutaneous access, but when Jen came to me, she already had her percutaneous access. She had a right-sided access, which is the most common, but is also painful, because her access was through an intercostal approach, so in between the ribs, and that’s what’s creating her discomfort whenever she’s breathing, when she’s laying on that side, and so left-sided tubes, if you can possibly do it, are less painful. Right-sided tubes are way more painful. So this is what the actual sheath looks like, so the stenosis that we get access. This is a picture of us actually making an incision of the actual stricture site, okay, so laser technology has also advanced in our specialty. That’s something that we are more routinely using and incorporating, whether it’s in biliary care, GU care, gallstone management as well, so. Additionally, once we make the incision within the laser of that stricture, we’re actually able to cholangioplasty, so take a large balloon, stretch that wide open, and then we put a tube back in, because we don’t want that to fail, or sometimes you overstretch something and it can recoil on you, and so we want to make sure that’s kept wide open as well. And we put a drain back, and we bring back Jen. So this is actually me, cholangioplastying her anastomosis after it’s been lasered and stretching that really wide open. And so this is actually the end result of her anastomosis, so that wide mouth open drainage of the biliary contents from the biliary system into her bowel. And so, Jen, I believe that’s our last picture that we left you with, right? The other things I think that also spoke to me about Jen. I think oftentimes, John, you’ve probably had this come to you, and I think this is unique to IR, people ask you to weigh in when there’s no other options that are known, and anticipate or expect us to think of outside-of-the-box or unknown. I know your, you know, career, you’ve done so much for so many patients as well, and probably being in that situation is what’s unique.

Well, I think it’s a common situation for us, actually, in IR. Jen, it’s probably not as common for you to be in that situation. One of the things that’s most captivating about this specialty is the ability to step in and help and maybe have a solution when others have just not been able to do that, not because you want to have the bragging rights, but because you really want to help, and you can bring together all these different kinds of techniques and tools, and combine them in a way that’s different and can create a solution. One of the things I just wanted to point out is, what you’re seeing is not standard, “Yeah, you just go” “to the books and you read about how to do this and it’s-” This is really typical of the creativity and innovation that interventional radiology is all about, and that’s how this specialty has just grown over time is this creativity leading to something that seems to work. Data is very important, it’s not just, “Oh yeah, “look at this great picture, it worked,” but the data and then leading to great devices.

John, I think that speaks really well, because, you know, this is not something that I just came up with and decide to do. It’s actually a collaboration across the country of people that I reached out to, Ravi Srinivasa at UCLA, Premal at Colorado. We have a really great working relationship across the country, and I think generationally. We communicate across the country regularly, as, you know, no matter what institutions we are, whether you end up at, you know, east coast or west coast, and I think that’s what I love about what we do in IR. We get real-time input from the smartest colleagues and really invest in brain power to help our patients. And the other plug I wanted to also just make is, it’s Jennifer that also motivates me to collaborate with our industry partners, particularly with, like, Cook and and others in that to be able to advance the technologies that we have so that we can solve the problems. Like, sure, it’s fun to sit and say, “Oh, do this,” “or I would love it to be slippery” “or have more traction or durability,” but really the reason is to help patients like Jennifer with the actual outcomes of the products that take place with industry, and so I just wanted to tell you that you inspired me in that way as well, so.

I’m biased, but this is the best specialty there is in the hospital, and we get to do all the best things there is, and help people, and you get to develop long-term relationships with your patients. I have patients who I’ve seen for 25 years, and it’s just an incredible relationship to have that. It’s a huge privilege to take care of patients. The future of this specialty is very bright. We’re just gonna continue to evolve and go into new areas and find new treatments and reach out and collaborate with other specialties. Most important, I want to thank you for being here. Our patients are our greatest teachers, and it’s humbling to have anyone allow us the privilege of working with them. We learn so much, and we hope that we can help, so thank you so much for being here and teaching everyone in this audience.

Thank you.