be our next speaker. Dr. Miranda is the Associate Clinical Professor of Medicine at the Vallaudolid University Medical School and serves as an editorial board in many journals. He's the past president of Sociedad Española de Endoscopia Digestiva. Manolo, you can talk about my pronunciations later at the end of your talk if you'd like. Manolo is very well known for doing everything complicated that is involved with EUS and ERCP, making connections to the smallest of ducks, placing 12 luminoposing stents if he needs to to get somewhere, he'll get there. So with that, Manolo, the stage is all yours. Please enlighten us. So it's a real pleasure to be here and sharing this excellent session and course. And I'm going to address biliary and pancreatic duct drainage. These are my disclosures. And I'm going to comment a couple of points about the procedure, operator requirements, indications, procedural steps, devices, and some tips. As you know, we can image with EUS the left liver from the proximal stomach. And this gives us access to the intrahepatic bile duct. And from the bulb, we can image the common bile duct that gives us extrahepatic access. Wherever the access site, we can place a stent across our puncture tract for transmural drainage or manipulate a guide where anti-grade through the papilla for transpapillary drainage. And exactly the same thing applies to the pancreatic duct. We can image under EUS from the stomach, the PD, place a stent after the steps I'm going to describe for pancreatic gastrostomy, or make it go anti-grade for pancreatic rendezvous. And after identification of the target duct, we inject contrast, we obtain a cholangiogram or a pancreatogram, and we place a guide where. In other words, the role of EUS is just the same role as duodenoscopy and needle puncture is cannulation. But this is a unique procedure compared to other pancreatic fluid collection drainage or other EUS guided intervention in that fluoroscopy is a key element. And we don't call this papilloscopy guided biliary drainage. We call this cholangiopancreatography to stress the fluoroscopy element, the component of the procedure. And EUS guided biliary drainage is a bit of a misnomer. This is a learning curve study. We have 100 patients with 20 endoscopies in Spain during the learning curve with a 70% success rate. Interestingly, needle puncture, cholangiography, and guide where placement, the success rate was 90%. But guide where manipulation, tract dilation, and stent placement had only a 66% success rate. So this is to highlight that EUS component of this procedure is minimal. It's just the beginning. And that may kind of misfit among the EUS work for several years. So how often do we need this? This is the other confounding concept that EUS guided procedures are related to failed cannulation. Failed cannulation is just a minority of situations where we would consider EUS guided duct access and drainage. There are a lot of other patients, even if they don't have a native papilla, or even if they have benign disease and they are typically considered for PTC after failed cannulation, or even when ERCP is not considered possible. Some patients go right away to PTC. And then we have the fact that cannulation and ERCP success are not synonymous. For instance, we can have incomplete drainage, and some of these patients undergo PTBD after incomplete ERCP. So how about the operator? This is Dr. Tok Peron's learning curve. You can see his fixed 60 EUS guided hepaticoenterostomy. The success rate went up from 75% during the initial 30 procedures up to 100% afterwards. Interestingly, the use of EUS guided biliary drainage increased during his learning experience. Does that mean that he was becoming less skilled at ERCP while he was learning EUSBD? No. What it means is that a lot more patients were able to be managed endoscopically because EUS guided access and drainage complements EUSBD. So this is one important thing. Not all EUS guided duct access procedures are equally challenging. Look at these two images. This is the common bile duct seen above a mass and closer than the portal. This is a much easier access under EUS than this intrahepatic bile duct. So if you are before, you've reached these 40 to 60 initial procedures, you probably should stick to larger closer targets. That is the common bile duct compared to the intrahepatic bile duct. The other misleading concept is the EUS guided rendezvous is a friendly anatomical easy procedure. Of course, identifying the common bile duct from the above is easy. Puncturing with a 19-gauge needle, again, it's easy. But look at all the manipulation risk of contrast leakage during antigrade passage of the guidework across the papilla and stricture into the duodenum. And then you have to remove the echo endoscope in exchange for a side-viewing endoscope. There's friction at the upper esophageal sphincter, at the cardiac, at the pylorus, and at the apex of the bulb. And throughout this process, it's very easy to dislodge this wire from the duct. And guideworks have a tricky feature. The easier a guidework is to manipulate across the papilla and the stricture, again, the easier it is that the guidework dislodges from the duct during endoscope exchange. So rendezvous should not be equal with a user-friendly safe procedure. And within your institution, everyone is agreed that endoscopic drainage is preferable to percutaneous drainage. The percent of duct access and drainage procedure in which EUS guidance is required may go up to 7.7%. And this is not, again, competing with ERCP. It's complementing and probably competing with PDC. So if you read about this, you will come across these algorithms that recommend these. Always try transpapillary, either rendezvous or antigrade drainage first. And reserve colitocortisone anastomy and hepatic gastrostomy for failed rendezvous. This is based on opinion only. And the problem with this approach is you waste time trying to achieve transpapillary rendezvous or antigrade guidework passage. The leakage and the manipulation increases, and hence, the risk of complications, as opposed to going right away for a transmural approach. So for simplification and having a clear plan of action, I would say that rendezvous is only preferable in benign biliary obstructions, such as failed cannulation and a common bile duct stone in an intradiverticular papilla, or for pancreatic duct indication. Whereas transmural drainage, colitocortisone anastomy and hepatic gastrostomy for palliation of malignant biliary obstruction, or in the case of the pancreas, for a disconnected pancreatic duct. So for instance, look at this patient. He had a unilateral stent placement at index ERCP, came back with cholangitis. So we could only access the right side at ERCP, and we puncture with EUS, put a guide wire, dilated the tract, placed this stent for drainage of the left side. This is hepatic gastrostomy in a bilateral clasking tumor that we could only drain unilaterally with ERCP. This is a 10 millimetre partially covered sense, and there is a risk of migration. That's the reason why immediately after placement, we dilated to its nominal diameter. And you see after dilation, the metal stent comes closer to the gastric wall. So for secondary anchoring, we use a double pigtail stent through it, and we can also anchor it to the gastric wall with a hemoclip through the interstices of the metal stent. So this is in case there is delayed migration. With balloon dilation, we control for immediate stent foreshortening. So look at this other case. This is a larger, closer common balda. Is there any sense in trying rendezvous here or integrability drainage? No. It is just puncture, guide wire, keep the ultrasound plane of view. This is very important throughout the device exchange. The echo endoscope does not move. We place a cotri device for the common balda. That's a must. Transhepatic access, we can skip cotri, but not to go through the common balda wall. And then balloon dilate before metal stent placement. So this is the dominant approach for malignant biliary obstruction. And the one that is most commonly reported in practice in real life, colitical duodenostomy and hepatic gastrostomy. This is another question. Who do you love better, mom or dad? Which is better, colitical duodenostomy or hepatic gastrostomy? This is not really important. There's no difference in outcomes. However, there might be that this question only applies to distal biliary obstruction. This is where you might consider which is better. And that's probably dictated by your level of expertise. Look at colitical duodenostomy, your scope position is very stable because you are in a long route. You're very close to the duct, which is dilated and is easier. The guide wire manipulation is very easy because the guide wire can only go up or down as opposed to the hepatic gastrostomy, where it can go in many directions. The only difficult part is dilation and that we can overcome with cotri. So when two drainage, transmural drainage choices are available, probably colitical duodenostomy is best if you are in your first four procedures. However, in patients with surgically altered anatomy with gastrectomy or WIPO and hilar blocks, you need to access through the left intrahepatic duct and the decision whether you should go will be based on your level of expertise and the confidence that you've built with colitical adrenostomy before embarking on hepatic gastrostomy. So again, for the pancreatic duct, we have pancreatic gastrostomy and rendezvous, but then there's one newly or later development, which is pancreatic bulbostomy. And sometimes rendezvous works very nice. There's a hugely dilated PD from the stomach, scope-looking antegrade. We puncture with a 19-gauge needle and an O25 guide where it goes very easily. And then we retrieve the guide where with a side viewer, we can apply traction from both ends of the wire and a stand is placed. However, when we have a mass forming pancreatitis, we need to create a permanent diversion from the bulb. We have a much more stable position and a straight shot to the PD and pancreatic bulbostomy is easier than pancreatic gastrostomy. Again, patient anatomy dictates what needs to be done. This is external fistula after necrotizing pancreatitis, disconnected PD. We can highlight the PD by injecting contrast to the percutaneous catheter. We can only drain these with pancreatic gastrostomy. This is much more challenging than pancreatic bulbostomy or than hepatic gastrostomy, which in turn is more demanding than choleric or duodenostomy. So going to the procedure itself, this is the room setup. We have US fluoroscopy. We have an assistant at the head of the patient to hold the scope and to monitor the ultrasound because the endoscopist is looking at the fluoro and the assistant is looking at the ultrasound. There's a time to confirm which bile duct is dilated. Do I have a proper target? There are no vessels. We confirm with fluoro the scope orientation that we are in a stable position. To do this before puncture is best to have the needle inside because the needle changes the rigidity of the echo endoscope. We will be using a 19 gauge needle. This is the rhythm, first rhythm of the procedure, but then after you go for the puncture, everything has to move very fast, slick, without any glitches. So before we puncture, we zoom up fluoro, we adjust the table, we have everything ready, guide wires, dilator, stents, and we puncture with a stylet remove. The needle pre-flushed with contrast and then we get a feel when we enter the bile duct. We aspirate through the needle. If the bile duct is small, if it is a huge common bile duct, bile aspiration can be skipped. If we enter, if we get some blood, we need to remove the needle and flush, but this is a critical step because we may lose the window, the dilated duct. So after that, we place the guide wire, an O25 guide wire through a 19 gauge needle. If the guide wire does not go, it goes peripherally into a secondary branch or contralaterally. We try to remove the needle a little bit backwards into the parenchyma, but the degree of manipulation with the guide wire and the needle is minimal. So we just need to have a position of the guide wire that is enough to place a dilator. So for dilation, we can use a tapered cannula that holds a O21 wire and a three-layer stent introducer system, a boogie, or more often, we have to use cuttering as we'll discuss later. And it is with these dilators that we redirect the wire into the desired position. And we will be usually dilate the track with a four millimeter balloon after cuttering. And this is very important. How do the scope does not move throughout dilation. We have to see the ultrasound plane. This is our dilating balloon. We don't we don't pull back to look at endoscopically at our puncture site. We keep the guide wire on the dilating device inside throughout the whole procedure. So okay, I'm not sure I can move this video forward. This is a hyaluronic stricture and for a benign condition. And we perform ERCP before hepaticoenterostomy. And at ERCP, we cannot access the proximal duct. We have cross leakage of the disruptive duct. And we have to make a choice between percutaneous drainage, emergency surgery, or EUS guided drainage. This is a non-standard indication because it's a benign condition. We puncture segment two. We see a 4.8 millimeter duct within 25 millimeter reach. This is the systatome. And this is a four millimeter balloon that we keep across the punctured tract under ultrasound vision. And there is nothing wrong with dilating the tract. As long as you keep the wire, it will facilitate your stent insertion. It is more dangerous to fail stent insertion than to dilate. And then to control for deployment, we try to avoid a very short distance as in this case. This is too close to the gastric wall. We at least need two centimeters. This is slightly above one centimeter with an unexpanded sense. And what we're doing is to avoid for shortening and migration beyond the gastric wall, we have to control with a second overlapping sense. So we miscalculated in this case. And now we have the tract salvaged. We make it the intragastric length longer. And as I've explained, we balloon dilate with an eight millimeter balloon dilator to control for shortening and further anchor with a double pigtail seven French stent. We have available the six French systatome. When you need to resort to other types of cochlear that are less desirable, the only precaution is not to advance the tip too much. So just protruding above the catheter. And if you have to, this is only it is more dangerous for trans-hepatic access. The common bile duct wall is very fibrous, is non-vascular. The only thing you need to be careful not to enter the portal vein. So you, in other words, it's best not to use catheter. If you do, it's best to use a six French systatome. If you don't have it, you can use a needle night, especially to the common bile duct, but with careful attention to detail. The only step that needs careful attention to detail is trans-hepatic or transmural SEMS placement. As I've explained, this is too short. Again, when this then expands, it's going to migrate beyond the gastric wall and cause peritonitis. The Japanese and the Koreans, what they do is they leave four, five, six centimeters. They use ultra long SEMS, which is probably a wise thing to do, especially if you are in your first 40 procedures. So before I conclude, some tips. Are lambs the answer to an easy one-step biliary drainage? I'm sorry to say this is not the case. Biliary lambs, dedicated biliary lambs that we have in Europe can only be used when the common bile duct is about 15 millimeters, which is only in malignant distal biliary obstruction. And the delivery catheter is a little bit too stiff. And the distance that it travels is not too long. So it simplifies a lot of cases, but it's not perfect for every case. There are other one-step devices coming up. Some of them are already available in Europe. And an important point is that the delivery catheter is made very thin. It's an incredible difference between just one French less in size. So for one dibu, sometimes the duct is not very dilated. We can use 22 gauge needle, as Uzma said, with coin 018 wire. And as I said, it takes some manipulation and the failure rate of passage across the papula, even if your position is correct and your needle is looking in the right direction, is in the order of 20 to 30%. So if you do nothing else than puncture and try a wire, you don't inject a lot of contrast, you don't use cuttery, the patient will probably avoid complication. It may have pain for one or two days. It needs to be placed on antibiotics. But sometimes when we fail, what we do is we put contrast and methylene blue, and a papula that could not be seen is made visible by the methylene blue and is made protruding. So methylene blue cholangiography is one possible salvage of failed antigrade rendezvous that works very nicely. Another important simplification for rendezvous is the hitch and ride reported by the Japanese. They have dedicated monorail sphincter tomes. We in Spain have discovered a way to do this just with a regular sphincter tome with a scalpel. We cut a slit on the belly of the sphincter tome. We just avoid to retrieve the sphincter tome. We can navigate the sphincter tome over the outgoing wire and place a second wire into the bile duct. And then if you fail in malignability obstruction, the gallbladder is an easy salvage target. When you fail choleric adrenostomy, you have a common bile duct filled with air, you can't see anything. The gallbladder is still there. You can place a LAMS or you can place a SEMS. If you place a LAMS, you can perform cholecystoscopy and antigrade biliary drainage. And I think that I don't have time for just to conclude. EOS guided biliary drainage is a fluoroscopy guided endoscopic procedure. It's not EOS. EOS is just the beginning. It's a steep learning curve, but there are unmet needs in a lot of patients. And once you go over the learning curve, success rate is 100%. We will use rendezvous for benign biliary obstruction and pancreatic duct. Transmural for malignant biliary obstruction and disconnected duct. Once we stick a needle into the duct, everything has to be very well planned and have to move forward expediently. We will use standard 19 gauge needle with O25 wire and we'll use fully covered metal stands for transmural drainage with anchoring and the degree of invasive we tailor to the indication. Thank you very much for your attention.

biliary and pancreatic duct drainage

endoscopic ultrasound (EUS) guidance

endoscopic retrograde cholangiopancreatography (ERCP)

stents for transmural or transpapillary drainage

fluoroscopy in EUS-guided drainage

procedure optimization