I am charged with doing a very quick wrap-up, I'll try my level best to do it really quickly. I think most of this I will submit back to ASGE for putting it together as an enduring material. So, bear with me as I share this wrap-up real quick and then we'll do the final closing of the course. So final takeaway, Dr. Emma talked to us about setting up a practice and spoke to the importance of knowing why you're setting up the practice and measuring the quality and the metrics. She also mentioned the role of EOS in diagnostic applications. It's not a fishing expedition and definitely has some very specific indications. I spoke to the F&A, F&B technique and the fact where F&B has a very solid role, pun intended, in salvage procedures and the overall safety is quite safe and well tolerated. Dr. Nantali spoke to the avant-garde interventions, biliary drainage, gastro-genostomy. They have some devices that we don't. Some of their devices are cheaper than ours, but proper patient and device selection as well as some important caveats such as direct puncture with the lambs as opposed to wire guided. This seems to be the one sentiment I hear all over the world with gastro-genostomy to prevent the jejunal loop from moving away. That's very, very important point if you're going to dabble in this. And then of course for ablation, the key message here was it seems to be effective, a little bit more data on neuroendocrine tumors, more studies needed in the adenocarcinoma and other realms, but certainly appears to be safe. Dr. Mishra spoke to us about pancreatic cysts and the fact that involving guidelines from multiple societies need to be reconciled and really take into account the important thing to differentiate is mucinous versus non-mucinous and the newer modalities are certainly available. Some appear to be more widely adopted than others, but more data is needed. Dr. Mishra also spoke to cancer staging and certainly highlighted their centers and their own contributions in the re-emergence for EOS and rectal cancer. The fact that staging with EOS for pancreatic cancer is not anymore something we hang our hat on. I think CT scans have gotten really good. We talked about the importance and the technical, you know, sophistication needed to do a high quality ampullary EOS and that even in the West, every so often we get called upon for gastric staging. I will not go through Mishra's top 10. They will be in the enduring material hopefully, but they are listed here. The top 10 was really done justice to by Girish today and I'm grateful for that. I spoke a little bit about contrast elastography and mediastinum. This data will be available in the enduring material. I think contrast enhanced EOS and elastography combined seem to have a great potential, but I think at this point still the tissue remains the issue and we'll see where this paradigm goes. Dr. Chang finished up with his pioneering work in the endohepatology realm covering for us his approach to liver biopsy, his approach to portal pressure gradient measurement and the brand new kid on the block, shear wave elastography and how he goes about it. So the top of the top for me and hopefully for all of us here or many of the audiences still there is know why you set up your EOS practice. Diagnostic EOS can be harder. You can make anything look like anything. That's important and that's where tangential imaging comes into play. Early endosynographers be very careful that you can really make anything look like anything. Know your layers, know your layers and know your layers. Ask help for difficult cases. No shame in that. I remember Nuzat mentioning early on, don't forget the power of the phone call. You ask for referrals, you get the referral, you do the case, be proud of your service, make the call and there's nothing that will be better marketing for your practice. Ensure quality metrics that will speak to your growth and the reliance that people will have on your service. When you're passing the echo endoscope, it still remains one of the largest and most robust scopes in endoscopy. If you have difficulty passing it, especially at the UES, stop and think of an alternative strategy. Mediastinal cysts, do not puncture them. There is no good outcome coming from that. Dinesh reminded us that using Dopplers in your needle path is always a good idea. And again, for international EUS, Dr. Nantali said, training, competency and appropriate technique along with some novel devices are the road to success. This is really avant-garde stuff that is penetrating deeper and deeper into practices outside of the Far East and Europe. Devices may be cheaper in Thailand, we were reminded of that. And I think we'll have to negotiate or renegotiate our prices here in the West. And Dr. Chang finished up with the fact, reminding us that endohepatology really is a one-stop shop where you could do three to five procedures for the liver patient. It's emerging fast, but the key is to work with your hepatology and transplant services and to avoid the post liver intervention bleed for biopsies, particularly the Z-track technique and using Doppler is really effective. The absolute final slide in a masterclass, we have teachers, we have students and the learning is an ongoing process. My teacher, Mark Catalano for EUS was detail-oriented and is now professor of medicine at UC Houston. And he trained with another legend and a master, Michael V. Sivak. So with a tribute to both of these masters, I formally end the presentations in this course and I want to do a formal thank you to all the faculty who are still here with us, including Nantali. I think she's still in and out of there, she's in Hyderabad, Dr. Chang, Dr. Mishra, Dr. Amit and the staff and the team at ASGE who has endured us all day. But above all, we want to thank everyone who has attended today's course and been with us for pretty much all day and has been very, very engaging and probably close to 100 questions that we addressed live and in type format. So thank you again, everyone, and hope to see you at DDW and you will have this material available as enduring material going forward.

ASGE

enduring material

practice setup

quality metrics

F&A technique