He is the head of the endoscopy division of the Ecuadorian Institute of Digestive Diseases, EASAD, in Guayaquil, Ecuador. He's also the director of the Pentax Training Center in Ecuador, where local, national, and foreign doctors get trained in different advanced endoscopic procedures. He's conducted several studies throughout his career, which have been recognized and awarded internationally. And he's passionate about digestive endoscopy with a special interest in endoscopic ultrasound, confocal, laser endomicroscopy, colitocoscopy, POEM, ERCP, and many other advanced procedures. Carlos, thank you for joining us. Thank you so much, Anrita. It's an honor and a pleasure to be with you. So this is my disclosure. Okay, so today for the agenda that I will present, it's about EOS vascular therapy, goal-bidder drainage, bidder drainage, and radiofrequency ablation treatment. What is the impact of EOS guided therapy? So nowadays we have a lot of different techniques that we can do it, as already Dr. Holt mentioned it. So we can do drainage, we can do injection therapy or neurolysis or injection therapy for treatment of cysts or tumors, ablation. And we have also vascular therapy nowadays. So I will start with EOS guided vascular therapy in gastrointestinal varices. So it is very important before to start to do any kind of treatment guided by EOS to remember the anatomy and where the varices is coming. So we need to remember that the portal hypertension develop the pressure, a higher pressure in the left gastric vein. And it is important because we need to detect this during our procedures. So it is very important also to remember the classification of the varices as gastroesophageal and isolated gastric varices that we can find in our patients. So what is the rationale for EOS guided vascular therapy? First, we can perform a B-mode visualization and double mode so we can differentiate between arterioles and venues. The security of vascular axils, we need to remember that all vessels have an histology and these wall vessels have a muscular layer. And also the vessel pressure is part of the security of the vascular axils. So we can have a possibility to perform an angiography, possibility of injection or deployment treatment through the needles, no scars, less morbidity, mortality. We can do an ambulatory management in some cases and it's a cost-effectiveness treatment. So this is very important to evaluate that we have an anatomy that we can observe during EOS, but also we need to remember as already mentioned that all the vessels have a muscular layer and this is a protective situation as well as the pressure of these vessels. So we can do a diagnosis with the US and we can have the access. So regarding hemostasis by EOS guided, we have several works and cases reporting about hemostasis in no variceal bleeding as well in variceal bleeding. So the techniques that until now are performed are the injection therapy using thrombin cyanoacrylate, deployment therapy using coils and microcoils as well as the combined therapy. So this is, we need to use needles to have the access and therapeutic scopes. So we can use 22 gauge needles in some cases when we want just to inject the cyanoacrylate or if we want to deploy, we need to use 19 gauge needle. We will use also cyanoacrylate or 2-octyl cyanoacrylate. In my practice, I use 2-octyl cyanoacrylate injection. And I will talk now about the US guided injection therapy. So this is a very interesting case that we had in our center. So this is a patient that coming because of bleeding but this was an isolated gastric varices after thrombosis, splenic thrombosis and segmentary portal hypertension. So it's very important to detect where is the side of the bleeding. So you can see here with Doppler, this is the feeder vessel and this is the side of the bleeding that sometimes with a normal gastroscope is very difficult to detect. So in this case, because of the diameter of the vessel, I use just 22 gauge needle just in the area of the feeder vessel. So you can see, we perform an angiography just to see, to be sure that we don't have any shunt and we can see exactly the distribution of the vessels and the security that we can have to select what kind of treatment we can perform in this patient. So in this case, I decide to use just cyanoacrylate first because the diameter of the vessel, second because of the diameter of the other vessels as you can see here. And then the injection therapy with cyanoacrylate injection was enough for the treatment. You will see here exactly when we start to deploy the cyanoacrylate, you see. So we can occlude the feeder vessel and after this, all this rises and this side of the bleeding is immediately stopped. So I will talk about now US Guided Deployment Therapy. So this is a case where we identify a shunt and in this case, we decide just to use, just to use a coil treatment because the risk of embolia using cyanoacrylate even with coil was more risky. So I use in this case, seven coils and we arrive to stop the feeder vessels. And as you can see here, after the deployment, immediately you can see disappear of the variation. And this is something that we can have with this kind of treatments. So regarding the literature, the first words were focus on the shunt to evaluate if coils or cyanoacrylate what was the best technique or more effective and the first result from Europe show it that the coils have less adverse events. I will talk about Combined Therapy. So I think this is one of the most important studies published until now regarding the Combination Therapy. So we have 152 patients in this study published by the group of Dr. B. Mueller with a six years of experience in United States. And as you can see here, they have a treatment successful for more than 99% with a mean coil per patient of 1.4 coils and with a mean of cyanoacrylate injection of 2ml. And the complications were around 3% including abdominal pain, post-procedure, pulmonary embolization and bleeding post-procedure. So one of the limitation of do this, the technique, the original technique that is putting the coil and the cyanoacrylate inside the gastric varices is that we can have a migration of the glue and the coil 2.6% of the patient three months after treatment. So we decide to perform modified technique based on the radiologist technique. The radiologist technique, they don't go inside the varices, they go to the feeder vessel and perform embolia inside this vessel. So one of the advantages that we can flourish in performing angiography, we can determine the feeder vessel and the number of the diameter of coils. It means we can use less coils, we can confirm that we are inside the gastric varice, we can avoid splenic vessels, confirm the obliteration and determine the correct site of the bleeding vessel. So this is a video of the original technique. So you can see here, so we are over the gastric varice, this is the feeder vessel. So in this case, we went inside the gastric varice and we put more coils and cyanoacrylate. The difference from the modified technique is that we try to see the feeder vessels. For this, you need to follow the vessel and to see where all the vessels goes inside one of these vessels. So in this case was this vessel, this is the feeder vessel, all the vessels come here. So it's like all the ways go to Roma. I don't know if I say very well in English. And then we perform a flush, you can see with saline and this is distributed in all the vessels. So this can confirm us that we are in the correct vessels. Second, we can do an angiography and we can see that there is not any shunt and this will guide us to take the best treatment for our patient. So we apply the coil and then we apply the cyanoacrylate injection. And after to perform the embolization, there is an immediately disappearance of the varice. So this is our first experience of using combined therapy. So we arrived to see that in terms of time regarding free intervention was increased in our patients. So one of the other advantage is that in cases of important bleeding like this one where we can, didn't see anything. So this is a big clot is here. The patient was in hypovolemic show, as you can see, we cannot see even the Doppler. But after we put the infusion, therapy and the venous infusion therapy, we arrived to see exactly the vessel and applying the angiography, we can confirm that we are in the correct vessel. We see here the bleeding area and this is the feeder vessel. So we apply our therapy here and this patient was very well after the treatment. So this is a result of our study. This was a randomized study in 60 patients comparing coils alone versus coils and cyanoacrylate injection. So we demonstrate with this study that we have improved the re-bleeding and the various re-appearance and the re-dervation free time of these patients when you compare with coils alone. So the conclusion of our studies that the combined therapy is better than coils alone. So this is another example. This is a very big vessel. So if we need to put coils inside the vessel, it's a lot, a lot of coil that we need to use. So in this case, we went to the feeder vessel and we apply the coil and also the cyanoacrylate injection. So after this, you can see here an immediately disappearance of the varice and immediately recovery of the patient. So this is another examples. In some cases, it's very important to determine if there are two feeder vessels. If you can see here in the first injection, I just see one feeder vessel by the U.S. Zopper show with me that probably there was another one. And it was exactly, I put the first coil here as you can see here and the first immunization here, but I saw a second feeder vessel that is this one. And we do a second treatment to have a very good result. I would talk about also one of the advantage of this technique is that we can use as a rescue therapy in gastric baricell building. And this was a case that was treated three times in another center by glue, by the original technique using under endoscopy visualization. The situation was that this patient with the amount of Siena chelate, we saw that this patient have an embolia, pulmonary embolia was in a very critical situation. And we arrived to see just the vessel where it was bleeding and we applied the coil and Siena chelate and this patient was rescued. And this is a control one month after. So regarding the cost effectiveness of the technique in our center, we performed a study comparing the endoscopy technique versus coils and Siena chelate injection by US. And we saw a lot of very interesting results regarding the number of procedure per patients is less with the US technique, the length of hospitalization, including intensive care and intermediate care unit. The cost per procedure was better, was less when you apply the endoscopy technique. However, when you perform an evaluation of the total procedure cost and hospitalization cost with the complication and total treatment costs, the US guided therapy is superior to the standard endoscopy therapy. I would talk a little bit about gallbladder drainage. Already Dr. Ho showed the indications. I will not talk about that, but it is a very good way to evaluate we have very good technical success with functional success of 91% overall when we have tumors and we have adverse events in around 60% and extend dysfunction in 8.3%. So this is an example of a patient with a tumor and no condition foregoing to resection. So in this case, we perform a LAMs as you can see here. And this patient have a recovery, a faster recovery after 48 hours and was sent to home to have his recovery. So as you can see here, so this is a complete drainage. And really these have very good results regarding how this patient evolution. So there are some examples of gallbladder drainage also. And nowadays we have the results of primary US guided gallbladder drainage to prevent acute cholecystitis in patients with biliary tract tumors who have tumor involvement of the orifice of the cystic duct. So we can reduce in around 25% of cholecystitis in these patients. This is just to show you- And a lot of fibrosis area, fibrotic areas. So this is a patient with cholangiocarcinoma as you can see here. So I will advance a little bit more my video. So as you can see in the x-ray, so we don't have the gallbladder. There is any involvement of the orifice of the cystic duct orifice. So we can do a combined therapy in those cases. So in this case, we start with a radiofrequency because there was not any condition to go to surgery. And after this treatment, we perform a US gallbladder drainage. And you can see here the quantity of tubes inside the gallbladder. And this is why it's important to determine in some kind of these patients a primary gallbladder drainage to avoid complications during the follow-up. So I will- Regarding the- This study was, I think, was already shown by Dr. Holtz, but this is from Dr. Tao in Hong Kong showing a comparative evaluation between US gallbladder drainage versus laparoscopic drainage where there's no difference regarding both group. Regarding US gallbladder drainage, so the most important anatomical aspect and technique is that we need to remember that it's very important to have a very good access. So the access will be given to you because of the window that we have to have the access. If we have a better access from the abdomen, you need to go by this way, or if you have a better access by the stomach, you need to go by this way. So this is an example of gallbladder drainage. From the, from, excuse me, from the drainage of a patient with cholangiocarcinoma. So as you can see here, so we go inside the left intrapartic biliary duct and we perform a fistula and then we develop, we deploy a stand and we perform the drainage. So in some difficult cases, this is very important. And I like to, I would like to remark in this presentation that it's very important to see, to have a good access. In this case, we need to put the adrenal stand because it was important to, that the biliary drain. But in this case, it was very difficult to have a very good window. So I had to pass very near from the portal vein. You can see here, this is my common bile duct. And in this case, I didn't use electrical theory because the risk of performing damage of the portal vein was very high. So this case is very interesting because in some case we need to adapt what kind of material we will use to perform the fistula. And in this case, I use the balloon to do my fistula because the risk of, with electrical theory to have a damage of the portal vein that was very near, it was high risk. So this is the control using CT scan. You can see here very well, the drainage. This is the adrenal stand. And you can see the portal vein was not touched. So this is the stand. So this is a portal vein and we have a very success technique in this case. So we can do any window, as you can see here, this is a colitical anthrostomy. And nowadays we have lamps. So it is easier to have access using lamps, even in the intrapartic area. So this is the ducts of the biliary tract. So here are an example. There's another example using a combined therapy. We do a drainage by ERCP, but this area of the biliary tract was not the well drainage. So we decided to put an access here and a lamps here and a complete drainage was performed. So we can also manage the adverse events using endoscopy. As you can see here, we have a stand migration and we pass through the tumor and then we perform a reposition of the stand and put in another stand to avoid a biliary leakage. I will talk my last topic regarding US guided radiofrequency. We have several reports now, not a lot, but we have very good results. Moreover in neuroendocrine tumors and now a lot of prospective studies are developing for solid pancreatic adenocarcinoma. And this is very interesting also because the results moreover in patients with neuroendocrine tumors are very, very good. So now this is a work from the Orlando team with Cheyenne showing that radiofrequency can be used also for cellular plexus neurolysis for palatial pain in patients with pancreatic cancer. So this is one case very interesting that I think is very well applied this kind of situation. This is a 60 years old male with history of abdominal pain, progressive jaundice and weight of loss over the last four weeks and ascites, former smoker. So the CT scan show with pancreatic cancer and the idea was to do all these treatments all performed by US. So you can see here the patient have ascites. And so to perform neurolysis in the original technique could be difficult because we can perform some damage. So in this case, we decide to perform radiofrequency modulation of the, to do a neurolysis. So I will show you. So we can perform a combined therapy. So this is a tumor. This is a very track. And in this case was treated all by US in this case. In this case, so first we started by doing radiofrequency of, this is another biopsy for us, for our center. So first we start with the neurolysis of this electron. You see here, this patient have a lot of pain. So, but the neurolysis was done by radiofrequency as you can see here. So with very good resolving this patient, solving the problem of pain. Then in the same step, we perform a radiofrequency of the pancreas or the pancreatic mass. Okay, and then for finishing, we do a drainage of the very track and the gallbladder in this patient. So, so all these procedure in one procedure are all performed by US as you can see here. So in this case, we use alarms to perform a drainage. So if this patient have a site, this is not a big, a site is not a big problem. So you can, you can perform a technique and a complete drainage was obtained. So we do a treatment in this patient with pancreatic cancer. Thank you so much for your attention.

endoscopy-guided vascular therapy

varices

hemostasis

coils

cyanoacrylate injection

gallbladder drainage