All right, so our next case is that of a walled-up pancreatic necrosis. This is a 69-year-old female with a history of atrial fibrillation. She presented for a follow-up of abdominal pain and early satiety that's been going on for about two months. She had mildly elevated liver enzymes, which are more cholestatic pattern of liver injury, and her MRI, MRCP, at an outside hospital showed significantly dilated intra- and extrahepatic bile ducts up to 15 millimeters. She underwent an ERCP at the hospital, which showed concern for ancillary stenosis. They performed a large sphincterotomy, and they placed a 10-by-5 plastic biliary stamp. Unfortunately, the ERCP was complicated by a contained retrocranial duodenal perforation and severe post-ERCP pancreatitis, complicated by a large 17-centimeter walled-off necrotic collection. As you can see in the image, this is the large collection to the left that is abutting the lesser curvature and anterior to the stomach. The image on the right shows concern for disconnected pancreatic duct in the mid-body, likely due to this necrotic collection. She continues to have persistent abdominal pain, which is worse after meals and associated with early satiety and unintentional weight loss. The plan is to perform an EUS-guided drainage of this pancreatic necrosis and possible necrosectomy. Over to you, Dr. Khashab. Okay, thank you, Shuri. Hi again. So this case is a reminder to all of us that when we perform ERCP, it has to be for the right indication, and we still can see these severe cases. So this patient has walled-off necrosis that's symptomatic, and also has disconnected pancreatic duct, as you saw on the MRI. So here I'm examining the collection from the body, from the stomach, and we see it. We see some debris here in the middle and layering down. Very important to look at, like this, it's fully encapsulated. We look at the MRI and the CT, etc. We review it with the radiologist to ensure that. And the capsule has to be fully formed around the collection. We've had cases where we didn't pay attention that it was kind of semi-fully formed, not fully formed, and this patient can develop actual pneumoperitoneum afterwards. So this is perfect collection for endoscopic drainage. It's close to the wall. There are no varices in between. It's a straight shot. It's large. So this should be very easy for us to do. My plan is to use a, go ahead, give it to me, a 20 millimeter axis, and see if we can access the cavity right away to show you a relatively new device, the endorotor for necrosectum. We're going to use the newer device, the 6.0, that needs a six millimeter channel to go through. So in my experience, the newer device 6.0 powered endoscopic debridement device, or PED, works very well for this indication. So hopefully we can show that to you today. So what we're going to do, attach, is deploy the stent, show you deployment mechanism or technique, dilate the stent, and then we're going to show you a video that we submitted to the DEW on powered endoscopic debridement, the 6.0 device. And then you come back to us and we'll show you how to use the device in a live, in the live case. Any comments from the moderators? No, I think that everything you've said is in order of what we would do. I notice you're going to be using what we call the freehand technique, which I think most of us will do now, rather than a needle puncture and a wire, when we're comfortable with the device and a big enough collection where there's no concern. For those that are still a little bit squeamish, maybe or maybe not squeamish is the right word, but you know, not experienced, they can always go the old-fashioned guide wire, needle guide wire, and then put the Axios over wire, but you're doing it straight in freehand, which is what most of us do now. Yeah, and a good point, if you're still not uncomfortable with the device, you know, there is no downside with pseudocyst placing guide wires. Of course, there is downside with some cases like gastric genostomy, as you know, but for this, not a big deal. So what we want to do, you will see here the device, we want it to be perpendicular to the wall. We already measured the distance. The distance should be less than 10 millimeters because the device length is 10 millimeters. There is now a 15 by 15 millimeter Axios, so we can drain these collections that are within 15 millimeter from the gastric wall. So the perpendicular approach is good. We want to indent the cavity and then use the pure cut current or auto cut and we go in and we stop. We're in. Once we're in, we're going to push all the way down and we're going to lock the device. After we lock the device, we deploy the first flange and I see you have the EOS image. Now we're going to pull back until we change the shape of the flange a little bit and now we're going to deploy it within the scope. So very important here that I didn't mention on the previous case, when you deploy the second flange or when you deploy any flange of the stent, your catheter has to be locked. Otherwise, you're going to push the stent into the collection. So the catheter is locked as you can see here. Now we're going to deploy the stent inside the scope and now please go to the Endo image. So now the flange is within the scope. We're going to push it out. So here what I'm doing is I'm pulling away from the wall to give basically space for the flange to open and also to visualize. So to do that, you know, since our internal flange was opposed to the wall, we don't want to pull it out. So with me pulling away from the gastric wall, I'm just pushing the stent in a little bit so I don't pull it out while talking to the right here and we're going to start seeing it. So now my catheter is all the way in. So can you please zoom here, zoom in on the device. So now some extra because the catheter is all the way in. So for us to have additional pushability, you see this groove here, we put our finger and push it out of the scope and here you go. So that's just a little trick to get this out. So now next is to dilate and then do a necrosectomy. Typically, if my plan is not to do a necrosectomy and the patient is not sick like with infected necrosis, I just leave this stent to expand on its own. It's a self-expandable stent, right? We don't have to force it. So that's another way to do it. I'm hoping today to show you the powered endoscopic debridement. So I think it's a good opportunity to see if one can access it. Once I put the forward viewing scope, we'll see if we can access it in a nice way. Sometimes if there is bad angulation, then it's difficult, then it's not worth it. But this is just an opportunity to show our audience how we use this device. As you saw, everything we did is without any fluoroscopy. So there's absolutely no need unless it's a bad position, small cavity, or you need a wire. With small symptomatic collections, like collections in the duodenum, around the duodenum obstructing the body, it can be very small. And you want to coil a wire sometimes in them. And this is where we use fluoroscopy. So this is a 20 millimeter balloon. Let's just hold on, hold on, not yet. So very important is to have a stable position. The last thing you want is when you inflate and then you move, because you're going to, this large extent. Go ahead. This is 18 to 20, right? Okay, let's go to 18. And slowly so that it doesn't kind of suction its way into the cavity. Okay, let's go to 20. Okay. So the plan after this is to change scopes to the XTQ scope. The XTQ, I think some of you may have it, has a six millimeter channel that allows us to place this device through it and access the cavity down. So why don't, so we're going to show you a video now. Why don't we switch back to Shruti to show the video and speak over it. And then we'll bring you back and show you how to use the endorotor or the PED 6.0. All right. So this is a powered endoscopic debridement device, like we talked about. It's a single device that allows high performance suction, tissue dissection, as well as irrigation, all in the same setting. And as you can see, it has two parts. One is the motorized catheter right here, as you can see. And the second is a system console. The motorized catheter, the older version of it was a three millimeter catheter, which went through a 3.2 millimeter working channel gastroscope. But like Dr. Khushab mentioned, the newer one is a five millimeter catheter that can go through a therapeutic gastroscope with a working channel of around six millimeters. The system console is the system that consists of a purge and suction system, along with foot pedals to activate the cutting and vacuum portion. In this case, you can see an endorotor device angulating against the necrotic cavity. And the previous debridement was suboptimal. So the pieces that we're going to present right now are using the endorotor device for debridement. So this patient underwent multigated luminoposing metal stent prior to performing necrosectomy. And as you can see, the lambs was partially occluded after placement, and the patient continued to be symptomatic. There was still significant necrosis present within the cavity, so decision was made to use the novel five millimeter endorotor device. And as we previously said, this device consists of a fixed outer cannula, as well as a hollow inner cannula with sharp teeth, as you can see in the video. And this goes to a larger diameter endoscope. The cavity is carefully entered, and we're under constant endoscopic visualization during this process. And one needs to take note that the angle at which the device is placed needs to be at an angulation between the catheter and the device. And we're performing simultaneous suction, irrigation, as well as vacuuming all at the same time. This is continued till majority of the cavity's necrotic component is reduced. And as you can see, the larger opening diameter of this newer catheter allows more amount and volume of necrotic tissue and debris to be suctioned. The speed of the catheter is around 1750 revolutions per minute with a negative pressure of around 620. This is the cavity view at the end of necrosectomy, and as you can see, there's healthy granulation tissue that's noted. We also elected to place seven French double pigtail stems to allow further drainage and keep the lambs in position. This is a CT scan showing the cavity on day one, the cavity on day nine after placement of the lambs, and you can still see persistent necrosis and the cavity present. And finally, the CT on day 14 after using the endorotor device, and you can see the cavity has reduced in size significantly. This is another case also using the endorotor device. In this case, you can see that, again, under constant endoscopic visualization, you're achieving a large amount of tissue debris that's being suctioned. You also take note to avoid any bleeding vessels or visible vessels that you can see endoscopically. Both solid and liquid components can be suctioned and continuous necrosectomy and ablating can be done. This is a comparison showing the newer five millimeter powered endoscopic device compared to the older three millimeter device, and as we saw in our video, the five millimeter device allows more optimal necrosectomy compared to the three millimeter device. The number of sessions required was lesser. The mean procedure time is also reduced compared to the three millimeter device, and follow-up imaging also shows near complete resolution of necrosis. Again, comparing the two devices just in a picture format, the main difference, like you can see, is the larger diameter of this catheter, allowing more tissue suction and necrosis, going through a larger channel scope. You can get up to three times larger cutting window for debridement and eight times greater volume of tissue that can be debrided. Some of the technical and clinical advantages include high dissection speed, performance, reducing the risk with manual instruments and blunt dissection, like we see with conventional necrosectomy, eliminating the need for instrument exchanges, 360 degree rotatability at the distal aperture, which optimizes access and challenging anatomy. Some of the clinical advantages, like we saw, were shortened procedure time, lower risk of stent-related complications, reducing the risk of bleeding, and reduced need for multiple necrosectomies. So in conclusion, the novel five millimeter powered endoscopic debridement device is a unique tool in our toolbox that overcomes some of the inherent problems associated with conventional instruments. We still require more comparative data and studies and a larger series to confirm these favorable outcomes. Dr. Batter, do you have any experience with this subcomment, Susan? I do not. I've had very, very good success with some other tools. I don't have anything, I don't have anything certainly against using it. I think the device does have a cost to it, and I think there's a cost to the actual box, if you will. So there's some cost involvement with it, but certainly anything that would help to hasten the procedures in those people that don't have a lot of experience, because they can be difficult and time-consuming, and everybody has their own ways of doing these collections, and what works for them may not work for somebody else. But I personally do not have any experience. Linda, do you have? Not for necrosectomy. I've used it to try to resect residual colon polyp if it's scarred down and things like that, but I have not used it in a walled-off product collection as of yet. But I wanted to ask you, Todd, when do you decide to actually do necrosectomy on first? Yeah, that's a great question. So as you know, I was one of the people that was an early, early direct necrosectomy adopter, and I've gotten away from it a lot. I found with the large diameter lambs that a lot of patients don't need a necrosectomy. People you think for sure they're going to need it do amazingly well. So I tend to, if it's an outpatient with debris, I give them antibiotics, and I tend to give them longer-term antibiotics because they're contaminated. Tell them to call me if they're not doing well, if they're not clinically doing well, I bring them in. If they're an inpatient and they're really sick and debilitated, we've been imaging them, maybe I'll do it to hasten the resolution. But if I looked at our data personally, I think our number of direct necrosectomies has gone way down over the last four or five years, you know? Yeah, I agree with you because our practice used to be what you said, which is be very aggressive, try to breathe as much as you can in the first setting, but now it's almost 180 degrees the opposite where we just put the 15-20 lambs in and then say, hey, you know, let the gastric acid break it down, give it time, give them antibiotics, and let's watch and see. Right, right, right. And I definitely don't do it on the first intervention, even if I have an inkling that I might come back and do it. I think that, you know, just get in, get out. Yeah. The risk of dislodging early on when you grab tissue and all that, it's just easier just to get in, get out. I agree. And do you like to put a double pigtail through it if there's a lot of debris in that cavity? Great question. I put a double pigtail stent through every lambs I place other than a GJ, every single one of them. So what I do is I preload the Axios with a wire, go in, burn, deploy, deploy the wire, do an exchange off the device, and just throw a 10. If it's a 15 or a 20, I use a 10 French stent. If it's a 10, for other indications, I use a 7 French stent. And it takes maybe two more minutes to do the procedure. You do it all with the echo scope. And it's, I think there's, for necrosis, I think it prevents you getting a big glob caught in the middle of the stent where I've seen people come in sick. So you can still drain around it. It prevents maybe bleeding from contact on the other side. I think it prevents maybe buried Axios, not being able to get them out because you can always have a pathway. So there's a lot of reasons I think to do it. I know there are naysayers, and that's fine. We don't have the science to say that's the way to go. I can't, I would say if somebody says I don't do it, that's fine too, but that's my approach. Okay. So we're coming to the end of this session. So you're going to get this done in three minutes. It's already done. So, you know, so our device is inside the cavity and this is the 6.0. You see, it has a rotatable blade and you see it goes 1,750 revolutions a minute at a good pressure, actually, suction pressure of about 620 millimeters mercury, as Shruti mentioned. And then when we rotate the blade and apply suction. So because of the size of this collection, of this instrument, this works really well. And this has been my experience. I echo everybody's opinion on like, we now do necrosectomy much less than we used to do before. And if you look at randomized trial, less than 15, 50% of patients will need necrosectomy, like the tension trial. That was, that's probably a landmark trial in our field. Also, we need to make sure that we know what we're doing here. If we come close, what do you think that is Todd here? That's a vessel probably. Yeah. So that's why we have to be careful with this. Okay. We have to see, and we have to look at the MRI and the CAT scan. Sometimes clearly you see the splenic artery or splenic vein passing through those. And of course, bleeding can be catastrophic. So now I see this cavity not bad at all. So this is just to show you how it's done here. So you see your suction, you insufflate, you suction back, keep doing this. And the device is flushing water through the system. So it's automatic flushing. You don't have to do it. And if you spend an hour or so, this thing will be completely, completely gone. The, because this patient, every world of necrosis, I, I place a, I place a double pigtail, as you guys mentioned, this patient clearly has disconnected pancreatic duct as evidenced by MRI. So of course there is a risk of a leak and recurrent collection after we remove the axis. So it's good to leave a double pigtail within the axis. And then I can take a wire and then double pigtail. And then that's it. So we'll put a wire, we'll put a double pigtail. Another method of this, I put the scope out. I actually pull the double pigtail to, with the forceps inside the scope and just push it out. If you don't want to use a wire. So that's another easy method to do it. There's a couple of audience questions, Moen. One audience question is what happens when the endorotor device touches the wall of the necrotic collection? Is it prone to damage? Yeah, you don't want to do that. I mean, we want to, we want to obviously just see what amount of necrosis is and, and touch that. If you're on the surface of the collection, it means you need to do this, you know? Yeah. Yeah. So, so definitely need to avoid the wall, need to avoid vessels. You know, the, the vessel we just saw could easily be the splenic vein or, or you know, a branch of that. So, so very careful doing that. But again, you know, any type of necrosectomy, we're using snares, large capacity forceps, you risk the same thing, right? If you get a raptor and pinch that vessel, it's going to bleed. So same thing, any necrosectomy, you've got to be mindful that generally safe, but things can be catastrophic. There's another question, Moen, from the audience, because you were talking about disconnected pancreatic duct syndrome here that this patient looks like they have. Do you place transpapillary PD stent in this situation? Yeah, no. I think this is an old way of doing it. We thought we, there is no need for any transpapillary approach. So in our experience, transmural drainage, leaving permanent double pigtail stents, we call them permanent, but it doesn't have to be permanent, right? Once, once this fistula through the double pigtail stent forms, it's chronic, even if the stent migrates, then this fistula physically diverts the juice from disconnected segment to the stomach. That's what I believe happens. I don't think the stents will stay here for the next 30 years, you know? Yeah. Yeah. Moen, I'm sorry, I have to drop off right now. We're done in five minutes. We're done in five minutes, Todd, so you're good. Thank you very much. Nice demonstration. And thanks to everybody that joined. Thank you, Linda and Ali. I probably has gone to sleep, but everybody involved in the ASG. So thank you very much. And thanks for inviting me, Moen. Thank you, Todd. So while, since we're thanking each other now, so while deploying the stent, I want to echo what you just said. I'm very thankful to all three of you, Linda, Todd, and Ali for making this really educational. All participating centers and the staff at the centers, the faculty, and hats off to our team here at Johns Hopkins. You know, they are working in the background to coordinate all this effort between the centers. You know, like Linda, Shuri, Venkat, the media team, the camera persons, the CRNAs, anesthesia, nurses, fellows. This is a huge effort, and it takes a lot of work and preparation to make this seamless. We hope the audience has enjoyed the sessions and the procedures, and we look forward to having them in future courses. So the next course actually will be during DDW on Monday, I think Monday the 23rd. It's a full day of live endoscopy, global live during DDW from the ASGE. We'll be broadcasting live from 16 centers around the world, starting in the Far East and ending up on the West Coast here. And this is going to be a great show. Please join us. It's complimentary for DDW registrants, and I think it will be a major session. It'll be a lot of fun. So here we're deploying this double pigtail. This is the last point, and go ahead and yep. So what I will do is I will push it out of the scope here, and that's it. So we'll follow this patient up with the CAT scans. Remember with LAMs, we don't do a CAT scan in four weeks and six weeks. Sometimes they collapse very quickly. You don't want the internal flange to be rubbing on vessels and causing sudden original bleeds. So we get short-term CAT scans, and we like to remove the LAMs before complete collapse. So this is all I have to say. Lastly, really many thanks to the ASGE who is trusting us with this, and the ASGE staff who have done tremendous and amazing work to put this together. I'm very thankful, and we'll see you at DDW.

pancreatic necrosis

ERCP

necrosectomy

EUS-guided drainage

double-pigtail stent

ASGE