So at this point, let's dive right into and I think Dr Chang is on with us but he's also has competing meeting there but as in when you can join can please join us in the panel discussion. If you can. So one of the first questions here for you not only audience has been very engaged I'm very grateful for that. The position for the US scope for us guided transmural CBD drainage, is that supine for the patient left lateral ER supine people that you prefer the supine position. Right, yeah. Okay. All right. So we have been doing us CBD drainage for a long time, and we've typically only utilize it in those cases where either the pre test probability of failure is very high, or if we intra procedurally will have converted it with a second consent, and typically those patients have been prone, but I think that if patients are starting out left lateral to facilitate us and then easily positioned supine, that might be another option. Girish any thoughts on on that. You know, interestingly, we have three interventional is here, you know, Rishi and his sister swap the end. They were trained by different folks one does it supine one does it prone and they seem to have pretty equal success I do think that if one technique doesn't work they switch to the other. But Rishi has been very successful in the prone position on vast majority of these patients. I'll just say this and you both can quickly comment rebut on that I think us, the easiest position to do pancreas biliary us is the left lateral position, especially when you access the duodenum with the echo endoscope. So therefore, my personal preference would be if I'm electively going in, I'll probably want to start out with the, with the semi left lateral or maybe semi supine position and then for philosophy purposes you know it's never better than to have a good AP angle, no question about it. So that's that's a good question. Fantastic way to start the q&a here. Now the second question here is for us around the whole procedure so not necessarily transmutal but rendezvous, what are the ticks and trips and tips and tricks, if the wire would not traverse the ampula I'll tell you my own personal anecdote. So you punctured the bile duct and now you expect the wire to come through the papilla. And a few times in the beginning, years ago, it used to come out transmutally especially in malignant biliary structures. And then more recently, it came out, not at the papilla, because, you know, the papilla was in a very anomalous location and what we were poking on was actually the minor papilla. So all variations on the theme are possible, but Nantali, what is your approach when you see the wire coming through the duodenal wall, what do you do then? Like after the wire comes through the ampula into the duodenal wall, then... No, actually, the question is if it's not coming through the papilla, and you see the wire coming through any other location in the medial wall other than the papilla. Not a good place to be, but what do you do then? Well, I just pull the wire back and start again, you know, because it's basically there's wire perforation of the bile duct, as well as do it in a wall, right, which is okay, might be a little bit of bile leak, but as long as you can put a stent in, then you'll be okay. So I will pull back and pull back all the way to where your puncture site is, and then restart. And the second part of that is that if all your efforts fail to traverse a high-grade stricture, that's one of my issues with this technique is if you're not prepared to do a transmural drainage, then the rendezvous approach does have an Achilles heel, where if you run in, we don't quite have the same tools that IR does. What do you do at that point? Because now you have a 19-gauge hole in an obstructed bile duct, at that point, you're committed to something. So what are your steps? What do you do at that point? Well, if transmural drainage cannot be done at all, and you fail to perform rendezvous, basically, you need to call your backup, which is IR people, and have them help them putting in percutaneous drainage, and then you can try another day. Or sometimes, like the IR can actually do the percutaneous drainage and put in anti-grade stent. They can do that as well. A lot of them can, yeah. Absolutely. Most centers that are doing this type of work, the IR can do an anti-grade, percutaneous anti-grade stent down the road, although initially, they prefer to leave a temporary drain in place. And you know what? One thing I should mention, I forgot to mention in my talk, actually, when we do this kind of procedure, I think multidisciplinary is very, very important. We always have to have a backup plan. IR, number one. Number two is surgery, because a lot of time, you misdeploy the stent, create perforation, and you really can't take care of it. So then it's good to have. Absolutely. One of the main reasons that many of us, most of us do these procedures at certain centers and may not necessarily do it if we are also performing endoscopy at affiliate hospitals is because we have that type of backup support. And that's really important for new program developers, many of whom are on this call today, is that when you do this, you're not doing this in isolation. And the collaboration from our surgeons and from our IR folks is important. And then at that point, these are what conferences and tumor boards and such are for, where you develop a single plan, and that is the plan. And if that plan doesn't go, then you have plan B and plan C and plan D. Girish, you have a comment? Yeah, no, thanks. I mean, as you know, by full disclosure, I mean, I've done a US-guided alcohol ablations for insulinomas with a fair bit of success. But the newer avant-garde stuff, the really cool stuff that Nathalie showed that you and she are doing, my colleagues here do. But taking a step back in a leadership role, there are some complications that occur. I think everyone recognized that. So the question that gets posed to me is, what's an acceptable complication in these really high-risk but very avant-garde and very useful procedures? And I have to look at it from the whole institution perspective is, yeah, we can't have complications after complications just because we're trying something new. Yet at the same time, people ask me, what is the published data? And Nathalie and I are privileged to hopefully be co-authoring this quality indicators in the US paper where we'll tackle this. And what I tell them is, this is uncharted territory. No one knows how many, we don't want any complications. So no one really knows the answer of what is acceptable in these. And I defer to you all doing this, that if something's not working right, having the appropriate backup, always having the patient's best interest. And I think it's OK to tell the patients that these are things that are very new and novel, but I think it's the best approach. Yet we don't really know. And I think that's not wrong. I appreciate that. Nathalie, any comments on the overall complication cloud, so to speak, that was very heavy early on? It's getting a little better as time goes on. We get better. Industry provides us with better devices. And what's your take on allaying some of those fears for some of the folks on the call today as they enter this realm? Yeah, for sure. I think the number one fear of doing interventional EUS is that complications. And sometimes the complications can be very bad. I do have complications too, as I just shared with you earlier today. But I think that for those who are interested in doing interventional EUS, I think training is key. It used to be that we've seen it, we've watched it, and then we start doing it. And if you do that these days, I don't think that's going to work, especially if you are in the beginning of the EUS career. So I think that if you're interested in doing this and want to minimize complication, number one thing you need to do is to find a place to get a proper training with supervision. The numbers don't matter. People who start doing therapeutic EUS, I'm sure that they have done plenty of EUSFNA, ERCP, the skills is there. It's just to learn how to do it properly under proper supervision. That's number one. Number two, even though you've gone through proper training, complications will always happen. You just have to learn to recognize it early and know how to take care of the complications. And as I said, multidisciplinary is your backup. It's a good backup because when you fail, then PTBD is always there to help. Right. And that's important. And I think proper planning and keeping the patient focus front and center is important. Now, a couple of questions around the aortic balloon that you described. How expensive is it? I think anything cardiovascular gets their attention very quickly. So we have the atrial septal occluder device. Now we have the aortic balloon. So a couple of questions on that. How expensive is it? How much dilatation does it achieve? And just go over the kind of the DIY on the aortic balloon. Just a little more detail for some of our attendees. Sure, sure. First of all, I think only us use the aortic balloon because we have an access to it. As far as price, I think it really depends on where you practice. Like in Thailand, we can have it without much of cost. But in the US, it might be different. So I think that depends. Number two, the purpose of using a balloon is not to dilate the stricture. But it's to help holding the water within the loop of bowel that you want to puncture. And that's really the purpose of using the balloon. Because when you blow the balloon, and when you have an NG tube here, then the water doesn't go beyond the balloon. So that's helped with the water insufflation of the targeted loop. However, if you don't have balloon, any kind of balloon, which now people don't really use balloon catheter anymore. So what they do is they just basically use a nasal cystic tube, put it there and just flush with water. The water is going to expand the loop of the small bowel. But you have to be quick because the water will go away very quickly. Once that gets expanded, then you just puncture it right then. So yeah, so that's the DIY thing. We just kind of came up with it. Because if you have a balloon catheter, it's a lot easier to do. But if you don't have it, it can still be done. Right. Now, that's important. And I think patient positioning will also help. But a large volume of saline will be needed to keep it in position without any balloon support. So I think as you kind of do a few of these cases, you realize what works, what doesn't work. And of course, we in the United States are, you know, get all these devices much later than all of you folks. So we learn by watching you as well. There was a question around a needle, a dedicated needle for these procedures, a needle with a side hole, other types of modifications to prevent shearing. I'll say that we've had a few shearing of the needle of the wire while doing these transluminal procedures over the years. And it's very frustrating in the moment, especially when you realize what actually these wires are made of and how traumatic they can be if they are unsheathed in the middle of a procedure. So comments on dedicated needle progress? Lots of people use access needle. They think that helps minimize the shearing of the wire. But a lot of experts, and this is experts opinion, a lot of them say that access needles don't really help very much. They don't see the differences between using, you know, a conventional 19-gauge FNA needle versus access needle. So that's, you know, a personal preference. Number two, what can we do to minimize wire shearing? A lot of experts, again, they use a tourmal wire. You have tourmal wire in the, yeah, they use that to begin with to negotiate. And once the wire goes inside, then they change the wire to a jack wire. And especially, oh, okay. You guys don't have six French sister term. We do not. That was another question. Yeah. And you also don't have a dedicated ES dilator, which is only available in Japan. So, you know, these are the new equipments that have been invested, you know, but it's not widely available. Right. So the takeaway from that for me and for the attendee who asked these questions is that, you know, there is a gap in device development. You know, we always have some industry folks who are listening in and collaborate with us on this. I think these are the gaps that many of us are trying to work on to further refine these techniques. And it's the same with, like I was going to say, with respect to complications, you know, a good issue, you know, ERCP in the 70s and 80s and 90s, the complication profile, touch wood, it was very different than the complication profile for standard level one, level two ERCPs that we have now. And these are in great part related to techniques, sophistication, better understanding of best practice, prophylactic, you know, stents and so forth. So every such novel paradigm that comes along is, you know, it develops in an iterative fashion. And we expect, we hope, and we are fairly certain that in times to come, that all of these transluminal procedures will benefit from similar progress in technology, in understanding and in techniques, refinement. So let's see what other questions we have here. You know, yes. You know, go to that, but there are two questions that I think I, you know, again, full disclosure, I don't do a lot of the interventional stuff, but there was a question on celiac plexus block in pediatric patients. I can just tackle those because we published actually on both of those. We had one of the larger series in PEDS patients. We published actually two or three papers, some very small case series, but the largest series that we had was about 45-ish patients and looking at the benefits or does it change management and the vast majority of patients for pediatric EUS. Yes, it can be done. We use the same scopes, the linear scopes, you know, the Olympus, they have a P linear versus a T. In general, I would use a P, but I just did a younger patient just this past week with a larger scope and it was fine. So it can be done and it should be done. The couple other caveats, I think Nuzat mentioned chronic pancreatitis in different age group patients, smokers and diabetics. I would add pediatric population to that same, that group in that the pancreas in pediatric patients, you can't apply those chronic pancreatitis criterias because at first it was like everybody has chronic pancreatitis. And then I realized that, you know, not every child has chronic pancreatitis. It's just that their pancreas looks different. So you'll see a lot of that speckling and hyperphosine strands. So be careful about calling chronic pancreatitis. But, you know, answering the gentleman's question, I think, yes, we can do it. It helps. And I find that there's really no other major complications. I've done EUS in an 18 month old to biopsy. And, you know, it always puts everybody on the edge when you have a child, because of course you don't want a complication anywhere. But it's certainly in children. There's a sense that, you know, you really are protecting this baby and child. And then the only other thing with the celiac plexus block is, you know, there were those needles that were side ports. I just use a 19 gauge to do the blocks. And Peter Dragunov and I, we published back when I was in Gainesville 22 years ago. So it's a little bit of an outdated paper, but it talks to the technique of a celiac plexus block, and that's published in Endoscopy. And the only other thing to add to that is, you know, Mike, bless his soul. I mean, I'll get teary eyed, but he taught us so much. He shared so much with all of us. You know, anytime he needed a slide, no worries, whether it was for vascular or, but, you know, he taught us about the celiac ganglia. And I think he was the first to describe what celiac ganglia looked like on EUS. We thought they looked like lymph nodes. I still have a fair bit of success with celiac plexus block, even in chronic pancreatitis patients. But, you know, it's an individual discussion. You know, I think it works great for pancreatic cancer, neuralysis, be very careful and cautious in benign disease and discuss the risks up front, because Mike also taught us that you can get, you know, abscesses and, you know, spinal injuries. So you better have a good indication to do a celiac plexus block on a patient. That is true. And irreversible paralysis has been reported with the neuralysis cases very rarely, but it does happen. And very true that one of Mike's seminal contributions was in the, in the celiac procedure and the celiac plexus block and neuralysis procedures. In the... Vivek, I was going to, I was going to tell you about this question, which I would like to address. This is about intra-deploying the proximal flange inside the scope. Yeah. So what happens is that when we deploy a stent, especially for pedicle gastrostomy, the stent seems to migrate into the bowel duct. So when people started doing this, you know, we adapted it from ERCP. So we want to see the entire stent before we deploy. And we found that when we do that, then the stent seems to migrate inside the bowel duct. Therefore, we started to change the practice to intra-channel stent deployment. Meaning once you get half of the stent deployed inside the intra-pedic duct, then you start deploying the rest without pushing out the stent any further. But then once the stent is completely deployed, half of it is still going to be in the channel and the other half is in the liver. So you know for sure that the stent won't migrate inside. And once you complete the deployment, you then push the wire outside the scope while slowly withdraw the scope. And that way the stent is actually going to fall into the stomach as you're slowly pull out the scope. So that's the idea of doing intra-channel stent deployment. Yeah, for LAMs, it depends on the kinds of LAMs. For example, if you're using heart axias, the deployment technique is one thing. But if you're using Naki stent or Taewoong stent, the deployment is different. So the best, as far as LAMs, the heart axis is the one that we recommend doing intra-channel deployment. The other two, I think it's better to look at it under endoscopic view. Right, and those are the two most commonly practiced approaches for LAMs. And just on the topic of devices, we only recently got the six and eight French LAMs here. So we're trailing behind a little bit, but we catch up pretty fast. We are on the one o'clock hour, which is the lunchtime. So unless there are any pressing questions or comments from either of you, I think we probably should break for lunch and allow everybody some time and regroup back here at two o'clock eastern, which would be one o'clock central, and many, many other time zones that I cannot recall and recount here. But thanks to Nantali for staying up late, master lectures. Thank you so much for doing this, and we will see you again at another session. Nantali, your schematic and video and STEN deployment, I was just like, you know, we do this, we bow down to you. So amazing. You know, yeah, it's video editing. Whatever it is, it's very impressive. Yeah, I just want to be honest with the audience that when you do this, it doesn't always go like the way you see on the video. So, you know, a lot of things happen, but this is all a video editing. But the concept is there. Before I go, yeah, one last question I want to answer. The size of the bowel duct. Well, a lot of people say that you can puncture a non-dilated bowel duct. Both radiologists do that. Both advanced endoscopists do that. But to me, I think non-dilated bowel duct is very, very difficult to puncture. You want to see like a big one, at least, you know, like one centimeters. Now it's easier, especially when you're starting to do it. The distance between the surface of the liver and the targeted duct should not be more than 2.5 or 3 centimeters. The longer, the more difficult, the more complications. Very important point. And we have learned this the hard way in the era of IR PTCs, which is why we don't typically do PTCs in PSC patients or in non-dilated patients. Same principle applies here. Very nice of you to bring that up and highlight it for the audience. Thanks again, Girish and Nantali, and for the team who's still on and will be hopefully back in the afternoon session. If you think this was a great week, we have Girish Mishra and Ken Chang in the afternoon session. So, you know, I would take the break and come back here at 2 o'clock. We'll be here and we'll see you then. Thanks again. I'll see you. Bye, Nantali. Take care. I'll be back. Oh, thank you. Even better. Thank you. I'll go and have dinner and then I'll be back. We'll see you then. Take care.

EUS procedures

wire manipulation

insufflation

celiac plexus block

dilator deployment

device development