So, Ganesh let's start with you for chronology let's keep it that way. Do you worry about and we'll try to do this quickly guys and so do you what do you worry about creating a PD leak. If you do a main duct IPM and FNA, that is under a high pressure obstructed system. Do you worry about PD leak I know I do. Yeah, no, that's a great point. So the answer is yes but you know it's what information are you going to derive from that FNA the size all those things I mean if it's if it's just a small cyst that's obstructing or involved that I may not sample so I look at all the features but it's always in the back of my mind anytime I go into the pancreas but it doesn't mean I won't do it. So I think the main duct IPM is a morphologic diagnosis certainly you should look at the ampulla for mucin. Nuzat, Nanthali, any comments on that important question? I agree. The juice has to be worth the squeeze for me to do that. I love that. I think that's very, very great, you know, pun intended pun on the other topic. Nanthali, any comment? Yeah, usually for IPM and I'm gonna, the reason I'm gonna do an FNA is to try to aim for nodule if there is any nodule but just to get the fluid, probably not because it's. It's a morphological diagnosis with mucin at the ampulla you're done. At that point you have to decide whether we're going for total pancreatectomy or monitoring. How long do you leave the stent in a pseudocyst drainage? Depends on what stent. So is anybody doing plastic stents still or are we all doing LAMs or so how long do you leave a LAMs or a lumen opposing stent, Nanthali? How long do you leave that? No more than four weeks. No more than four weeks. I like that. Nuzat? Four weeks, but if I see vessels at the back wall, then two weeks. Yeah, I have to say, bringing them sooner and sooner. The one major downside of lumen opposing is the bleeding that comes from the back wall. All right, so let's keep moving. I'm going to try and do this a little rapid fire so we get these questions in. Please comment. I think Girish, you're best suited to comment on the role of glucose. I think cis fluid glucose has come back. It was there when we were training. It's back now. So comments on that real quick, folks. I mean, the data looks very convincing. It's just a change in paradigm and shift clinically and that's where we're at. So what are you all doing, glucose or CEA? So I'm definitely doing CEA. I'm not doing molecular profiling regularly. I am beginning to get, again, interested in low cis fluid glucose, but not doing it routinely. Nuzat? So I do it in the room. I just have a glucometer and just sip it up and see. And I will say that I still hinge my diagnosis on the CEA rather than the glucose. I don't know why it's so hard to change behaviors. And then with just respect to molecular markers, because I think somebody mentioned pancreagen, I think there's still no consensus as to where molecular markers fall in the algorithm. We use molecular markers, but we use them in very specific situations, mostly younger people, because we want to stop surveillance. And because, I mean, to be honest, frankly, I think the conversation about cis has now moved beyond mucinous versus non-mucinous. And really, we need to risk stratify, most importantly, to say, when can we stop surveillance? Especially because you're picking up cis in younger and younger people now. So yes, the short answer to you is I do it, but I don't hinge on it. Got it. Nantali? I don't do it. I still do CEA. Yeah. Yeah. One more comment along the lines of Nuzat is that the location of the cis, the age of the patient, the comorbidities, and the final decision making, that matters more. So if you have a young patient with a bad-looking cis in the tail of the pancreas, the decision is pretty easy. If you have an intermediate cis that is kind of chugging along for years and an 83-year-old patient who's in a wheelchair, you don't need—molecular marker is not going to help you. That patient is never going to whipple in a typical scenario. So that's how I kind of use the clinical decision-making, still trumps any typical marker. A very good question from Dr. Akwi Asombang. Thanks for joining us, Akwi. I know you've been all day, and we appreciate that very much. So the question is, if absolutely no clear window for FNA, FNB, does the brave Dr. Mishra ever go through a vessel? Yeah, I just faced this question, and do I use a core to go through? I mean, and these aren't big arteries. There's just some flow. I think that's a difference, is, you know, are you going to go through the GDA? Probably not. But if there's a little bit of flow over the lesion, it goes back to, is the information going to be that powerful and that necessary? Sure. So the answer is yes, but I would not put a core through. So I think what Akwi is asking is, do you do a trans-aortic station 4L, you know, mass or lymph node FNA? Now, there have been reports, both on the west and the east, of trans-aortic and trans-great vessel punctures without incident. So I think all I'll say is the arteries are much more forgiving than veins, but it is not routine practice to go through. I agree completely. We have had a catastrophic bleed in our practice. Yeah, me too. I don't go through a big vessel just to get a... But I'll go back to Girish's earlier point about, you know, when he mentioned, use a Doppler to check the needle pathway. Even after 25 years, it will someday save you a lot of heartburn because there are vessels that are hiding under riverbeds, and they're not There are vessels that are hiding under reverberation artifacts, under, you know, blind spots near the transducer, air in the balloon, if you have a balloon on. So be very, very careful, double check, triple check before you go there. And especially in patients who are going to go back on blood thinners, mildly coagulopathic thrombocytopenic patients, patients borderline, and or patients who don't have reserve for procedure related bleeding that they will not do well. So I guess this is a question for all three of you, what guidelines are the six or seven out there for pancreatic cysts do you follow? Very, very good question. I can't give credit because it says anonymous attendee, but otherwise I would have given probably best question of the session, which guideline do you follow? What do you do? The AHMAD guidelines. I was just going to say, I use my own guidelines. But I think all of us do is we take it in context with the patient, the information, the age, the appearance, you know, what the patient wants, all those things matter. Yeah, yeah, I think. Nathalie? Yeah, I agree. And if you look at the guidelines, you see that the population of the patients they're mentioning in the guidelines are different. And so I think you have to take everything into the context and look at your patients and everything is individualized. Yeah, very good point. That is the most important word is individualized and customized approach. I use the common sense guidelines. You know, if common sense says, you know, do something, you do it. I must say, I don't think anybody in America really follows the five year cut off at the AGA guidelines suggest. I think it's practically impossible to do that in the environment we work in. But yes, we have an increasingly lower threshold to stop surveillance in patients where the final destination is unclear. I do invoke shared decision making a lot in this. And, you know, I think, you know, in some ways, some of the more practical guidelines, such as the Fukuoka guidelines, the revised Sendai criteria and the ACG guidelines are some of the ones that I really like. They talk about increasing cyst size over time. They talk about hiatus stigmata, worrisome features, and really where surveillance and FNA will alter management. If it doesn't alter management, nobody's going to touch the patient. You need to revisit what you're doing. All right. So another question by Dr. Akwi is how do you approach a discussion of pancreatic neuroendocrine tumors, specifically when they ask you, Doc, is this a cancer or what are we talking about? Why don't we have clarity on this lesion? What do you do with that? Pancreatic neuroendocrine tumors. I'd send it to non-theleted. Yes, I was going to say, send them all to non-theleted, put them on a 747. And off we go. Right. Well, you know, we got to get a tissue diagnosis, look at the size of the lesion, look at the patient's clinical conditions and take everything into account and then make a decision. Yeah. So, you know, they are indolent. A number of them are absolutely indolent. Very good point. And you have to. So the question is, it's like, you know, once you see something, how do you unsee it? Really is that right? So we do. We don't recommend resection on all of them. Actually, we resection, you know, recommend resection only above a certain size. And if it's growing, otherwise they go into the surveillance protocols and, you know, it's not really clear, like whether the biological behavior of those that become functional and those become that have a malignant behavior is different than those that remain indolent. So I think that there are lots of unanswered questions, but the short answer is we treat them as indolent lesions when they're found incidentally, unless they're above a certain size. That is correct. And I want to welcome Dr. Chang. Sorry, I didn't see you earlier. The message box was hiding you. Welcome. And thank you for joining us. Do you have any comments on any of the questions so far? Anything you disagree with? And of course, your word will overrule all of our statements. No, I'm just, I'm just basking in the wisdom. So I'm enjoying it. Thank you. Thanks, Ken. A couple more questions and then we'll get right to you. You know, so I think you're absolutely right. The majority of these smaller lesions are indolent. They don't change much over time. Yes, we do tell them it's a cancer. It is a cancer. Anything that has a potential to metastasize is a cancer. But we do put a lot of emphasis on the WHO grade of these lesions and at the age of onset and whether or not they are part of a syndromic presentation. Sporadic nets behave differently. Syndromic nets behave very differently. And so all of this needs to go to the tumor board. These are not discussions that need to be entertained alone. Girish, you are the master of rectal EUS. We have learned that today. Do you give antibiotics for solid rectal lesions? For FNA or for just, I assume it's for FNA. Yes. Yeah. Anything. I mean, I give antibiotics for anything rectal that I'm going to FNA, any sidewall, any of that. I just think, I think, I mean, it's a very limited data. And, you know, I know again, we'll invoke Mike, but Mike did a study looking at bacteremia with rectal stuff. And there wasn't, you know, there is bacteremia, but it's not significant, but I just think rectal despite a bowel prep, despite antibiotics, I think if you don't give antibiotics, then you could be asking for more trouble. Yeah. I think, I think it's just not worth it. I don't know that there's great data on this either way, just like for pancreatic cysts. We, as you alluded to earlier, we are still giving antibiotics for the most part, even though there was at least one, maybe two studies that you know, suggested that it may not be necessary. The same thing with endoscopic peg tube placement you know, the data on giving the cefazolin dose is not, not huge, but look at the downside. Even if you have one patient a year that gets a pancreatic abscess, that's a disaster. And we don't know that that patient will get it or not, but you know, if the burden of doing something is minimal and the burden of having even one negative outcome is quite significant, then common sense tells us to do, even if the data is not out there. So that's the way I would look at that. When do you perform RFA of a distal biliary intraductal lesion? I think Nathalie, you had a intraductal lesion, right? If I remember, would you, when do you do that? Distal, okay. I would do distal CBD RFA for ampullary adenoma with intraductal extension. So after ampullectomy, I would do a sphincterotomy and then I would do RFA. Yeah. Okay. Very good. Anybody else has a comment on that? Can you have a comment on that? No. Okay. All right. Explain the door knock technique again. I know that's Dr. Chang's favorite technique, the door knock technique. How do we explain that? Yeah. So when you have a small lesion that's mobile, if you do your standard to and fro, as your needle's moving, your lesion is moving with you. So the idea is to try to run faster than the lesion. And so the way to be able to go really quickly with only a short distance is by taking your little safety and locking it to where you want to maximally throw. And then you pull back, even if it's two centimeters, and you can door knock. You can move using your wrist. You can move that really, really quickly so that relative to the lesion, your needle is agitating back and forth within the lesion and scraping more cells into the needle. Absolutely. And we talked about that earlier, but it's good to always revise that. And I think one of the final questions before we go to Dr. Chang's talk is a question that I think will remain with us until we meet at DDW, because the question is, can you describe your EOS reporting or share your EOS reporting for pancreatic head mass and for cysts? And I would only say that there will be a price for that sharing, and that'll be a drink at DDW. Unfortunately, the attendee is anonymous. If they reveal who they are, we will definitely bring the pamphlets with us. But no, there are criteria described for EOS reporting, endoscopy reporting, and the ASGE guidelines. And I certainly would encourage you to look those up. Any final comments on what really needs to be in that report, Nuzat or Girish? What should a good EOS report, what are the top five things, let's say, that really should be in there? Yeah. I mean, for pancreatic stuff, so I hate to keep bringing this up, but Nathalie and I are part of this quality indicators in EOS, and Anne-Marie Lennon is actually going to write the entire pancreas part. And I think she's one of the most experienced folks in there. And as a consensus in our preliminary talks, as a group, we feel like the role of EOS for staging, primary staging for pancreatic, whether it's a T1, T2, T3, it may not be as significant. And so I know it's a roundabout way of answering the question, but I think, you know, we were so fixated on, is this a T1 lesion? I mean, I think, but T2, T3, and the number of nodes, it's a little different with pancreatic cancer than as opposed to, say, esophageal or rectal cancer. So I think we're going to have some more information on that. Answering, you know, you always want to comment on the vasculature. I think that, you know, if you see it, the abutment, the effacement, all those things are critical. So be as descriptive as you can be, how much of the length of the vein, the splenoportal confluence, but I think hopefully I hit it a little bit, is that we're just not as good as we thought we were in terms of, you know, identifying pancreatic tumors in their primary stage. In terms of their local regional involvement. Yes. Absolutely. That was a great point made today. Any other comments? Well, I'll just say, we don't use the U.S. for pancreatic cancer staging at all, actually. Yeah. And then the second thing is, I think the report should be such that when you read it again, you're not embarrassed. So basically. That is true. That is true. Especially, God forbid, if it comes up for review, it can be a problem. But there's one final, I lied, there's one final question. How do you find, the textbook has a lot of descriptors on benign versus malignant lymph node. How do you distinguish if you're just not sure and you're just looking at it and looking at it and looking at it? Well, if it's accessible for FNA, go ahead and FNA. Lymph node with cancer, first pass should be positive. I've almost never had a malignant lymph node from adenocarcinoma that did not show malignant cells on the first pass. All right. If it's benign, that's a whole different discussion. And already alluded to that. With that, I do thank the faculty. If you can stay here, please, towards the end, that'll be fantastic. I know many of you have other responsibilities.

pancreatic diseases

endoscopic procedures

pancreatic cysts

neuroendocrine tumors

malignant lymph nodes