Welcome to the ASG Endo Hangout with GI Fellows, EOS-Guided Transluminal Interventions for Pancreatic Obiliary and Luminal Obstruction. We have attendees joining us from all over the world tonight, and the American Society for Gastrointestinal Endoscopy greatly appreciates your participation. My name is Ellie Vergara, and I will be the facilitator for this presentation. Before we get started, there are a few housekeeping items. We want this presentation to be interactive, so you are encouraged to submit your questions at any time online by clicking the Q&A feature at the bottom of your screen. Once you click on that feature, you can type in your question and hit return to send the message. Please note that this presentation is being recorded and will be posted in the Fellows Corner section on GILeap, ASGE's online learning management platform, within a week. Now it is my pleasure to introduce our two moderators, Dr. Suha Abushama and Dr. Ferris Ayoub, who will help facilitate the incoming questions. I will now hand the presentation over to them. Thank you, Ellie. Thanks to the ASGE for hosting this webinar, to our panelists for their dedication to fellow education, and to all of you for joining. I'm Suha, I'm one of the second-year GI Fellows at Washington University in St. Louis. And thank you, Suha. It's my pleasure today to co-moderate with Suha and to help facilitate passing questions along, so we encourage the fellows to send the questions in the Q&A box and the chat box. I'm Ferris Ayoub, I'm one of the second-year GI Fellows at the University of Chicago. So, Suha, are you going to introduce our group of faculty today? Of course. We have Dr. Shayan Irani, who is Faculty in Therapeutic Endoscopy and Associate Director at the Pancreatic Center of Excellence at Virginia Mason Medical Center in Seattle, Washington. Dr. Irani's interests include pancreatic ovarian diseases, gastrointestinal oncology, barotessophagus, gastrointestinal stenting, EMR, ESD, radiofrequency ablation, and other advanced therapeutic and emerging techniques. He has been an author in over 90 peer-reviewed articles and participated in 12 clinical trials. He is also on the editorial board for numerous journals. It's my pleasure to introduce Dr. Ryan Law. Dr. Law recently joined the faculty at the Mayo Clinic in Rochester after spending five years at the University of Michigan. His areas of expertise include ERCP, diagnostic and therapeutic EOS, submucosal endoscopy, and endoscopic resection of large and complex colorectal polyps. In addition, Dr. Law is active in clinical research and the education of residents and fellows. Dr. Law is on the editorial board of multiple gastroenterology journals and has spoken on various pancreatic ovariary disorders across the country and abroad. And it's my pleasure to introduce Dr. Uzma Siddiqui, who is a professor of medicine at the University of Chicago and associate director of the Center for Endoscopic Research and Therapeutics and director of the Advanced Endoscopy Training Program. Dr. Siddiqui is also a founding member and current vice president of the Global Society Women in Endoscopy. Dr. Siddiqui's clinical practice is centered on interventional endoscopy procedures related to pancreatic ovariary disease and gastrointestinal oncology, which include EOS, ERCP, EMR, and ESC. She has published numerous manuscripts and book chapters on these topics and is a dedicated educator and mentor. And then finally, for our today's main speaker, Dr. Todd Barron. Dr. Todd Barron is a professor of medicine and the director of advanced therapeutic endoscopy at the University of North Carolina. Dr. Barron's clinical focus is in advanced endoscopic procedures and endoscopic treatment of complex GI disorders, particularly management of pancreatic ovariary obstruction through the use of ERCP and EOS. Dr. Barron has authored more than 600 papers and is the editor of a comprehensive textbook entitled ERCP. Dr. Barron, please take it away. Thank you, and welcome all of you to this exciting session. I think you'll enjoy it. We're going to take questions as we go along, and hopefully everybody will have fun and enjoy the presentations. Okay. So my disclosures are listed here. I pretty much work with anybody and anybody. So the goals tonight for this session are to provide a background for EOS-guided therapies, describe the various approaches, provide case videos, and certainly to answer any questions that you may have the best that we can given the time. We've got a lot to cover. So I do want to start out a talk about a little bit about EOS development, because really EOS is a relatively new, in the scope of things, relatively new. If you look all the way back in history, ultrasound was discovered in 1740. If you fast forward, ultrasound for medical diagnosis wasn't really until 1941. The first fibroscope that ever was tested was around 1956 by Basil Hershowitz, who had the first fibroscope. He was at the University of Michigan at that time. But if you scroll all the way down, it was de Magno's description of the first EOS instrument in 1980, and the first EOS in humans wasn't until 1982. So really, it's not very long that we've been doing these. If you look at the EOS interventional, the first vinyl aspiration was 1992, celiac neural isis, 96. Clangiography was described just by injecting under EOS and not really doing anything else with it. Colon-ocular adenostomy is about 20 years old, hepatogastrosomies and rendezvous 2006-2007 was gallbladder, and gastroenterostomy was only about six years ago. So again, it's still a relatively new field in the realm of it, if you compare it to, let's say, ERCP, which developed probably 20 years before. So some of the principles of EOS guided therapy for pancreatic ovular disease are that EOS therapeutics is performed using a trimodal approach, and that is fluoroscopy, your traditional endoscopic view, and obviously the ultrasound imaging. But of these, traditional endoscopic view is the least important. While experience is helpful, the sooner that you can let go of the endoscopy as the go-to imaging, the sooner you will master EOS guided therapy. And it reminds me of having to use the force and let go. So we train as regular fellows of what we see, what we see, what we see, and I think I can't emphasize as much that you really have to trust the EOS images and really only go to the endoscopic image at the very end of the procedure, as we'll talk about. So certainly experience is going to play a big role in how you do with these things. And judgment is the result of experience, and experience is the result of bad judgment. So all of us will have times when things don't go the way we want, but the more of these you do, obviously, the better you're going to get. And I think all of us, including Ryan and Cheyenne and Uzma, can say that we've had things not go perfectly well in these cases. You have to learn from things and continue. So there are two basic endoscopes, echo endoscopes we use for therapeutic that are linear. There's forward viewing linear and the traditional oblique linear. The forward viewing linear scope is nice to have for niche cases, but almost everything you can do with the obliques endoscope, there are some advantages in some situations to a forward viewing echo endoscope, but really we can do almost everything with oblique echo endoscopes. The thing about accessories are that there are only very few dedicated accessories for EUS guided therapy, and most accessories that we use are those that are already available for diagnostic EUS and any of the accessories that we use for ERCP. So what's one of the dedicated devices and really one of probably the only true perhaps one of maybe several dedicated devices are luminal opposing metal stints of which there is one available in the United States that really was developed specifically for EUS guided therapy. It has a cautery enhanced tip that allows you to enter into the area of interest with or without preloading a guide wire. If you advance only, let's say with a wire loaded in this, that's called the free to hand technique. Otherwise, you can puncture like you would with a 19 gauge needle, place a guide wire and then pass this over the guide wire. As most of you already know, these stints are available in diameters of 10, 15 and 20 and lengths of 10 and 15 millimeters in saddle length, but only the 15 millimeters available for the 15 millimeter diameter. Again, this is a close up view of a luminal opposing stint that's available in the United States. And by the way, that stint is only FDA approved for drainage of pancreatic pseudocyst and walled off necrosis. So it's really a lot of what we use are really off label that we use it for. I'm not I'm not mentioning particular devices other than to say that most of you recognize this self-extendable metal stint, which I use a lot off label by EOS guided interventions and non foreshortening stint with anti-migration features that's available required. So as an overview, of course, the EOS guided biliary and pancreatic drainage are increasingly being used, especially when access by conventional ERCP fails or is not possible. Examples that ERCP is not possible include duodenal obstruction by tumor or even benign disease, but most commonly by tumor or in the presence of surgically altered anatomy where you cannot reach the papilla or let's say a biliary anastomosis. So the EOS guided biliary interventions that we perform include the rendezvous maneuver and direct transluminal drainage procedures. These include trans hepatic biliary drainage, most commonly hepatical gastrosomy. The reason I made this vague is that the puncture site into the biliary tree can be through the stomach. It can be through the duodenum into the right lobe. It can be through the dejunum. In patients with surgically altered anatomy, it can actually be through the esophagus. If you go high enough, you put your puncture through the esophagus. So really, it's better known as trans hepatic biliary drainage, trans duodenal drainage through colon-ocular duodenostomy and then gallbladder drainage, which can either be trans gastric or trans duodenal. Not performed a lot is anti-grade trans hepatic drainage, meaning that you puncture through the liver and you pass stents anti-grade so that they end up entirely within the biliary system and not out through your puncture site. I won't really be discussing that in great detail. And then finally, EDGE for pancreatic biliary access in patients with ruin-wide anatomy. And we'll touch on all of these techniques as we go along. So in terms of to get an understanding of what the endoscope looks like in terms of how you puncture, you have this illustration. So I'll go from left to right. From left, you have trans hepatic puncture with the scope being in a very straight position looking up toward the patient's right side and most commonly, you're puncturing into a segment two of the liver. Segment three is a little bit lower, but the straightest position is segment two. The stomach is stable and you can really easily access the left lobe. When you're doing transduodenal approaches, most often you are in the long scope position and it's important to realize that your tip of the endoscope often looks toward the bifurcation or the hilum of the liver. And that makes choledochoduobnostomy fairly easy because you have a nice long pathway. But if your idea is to pass the wire for rendezvous going in the other direction, it can make your life a little difficult, but not impossible. But you have to realize that you're going to be looking up rather than down. If you get into a short scope position, which is more traditional, let's say when you do ERCP, you'll be looking down, but it is a little bit unstable of a position or can be unstable. And the other problem is that when you do your rendezvous, that angle, when you grab the wire, can be very, very acute. I won't go into that in more detail, but just suffice it to say that it's good to understand what you're going to be dealing with with the endoscope in these various positions. EUS guided gallbladder drainage, which we'll touch on later. I almost always perform them in this position, which is looking up in the duodenal bulb, and I perform them transduodenally, but they can also be done transgastrically as well. So this, I think, is the most important part of the whole session is some of these technical tips that I've put together when you're doing EUS guided interventions. And this really I got from just experience. So the first thing is that always carefully review your CT and MR imaging before undertaking the procedure. And that's true, obviously, you need to get in the habit of doing that regardless of what intervention you're doing to get really a good understanding, not just read the report, look at the images yourself so you can learn better and understand three-dimensionally what you're trying to do. And this allows planning of your EUS guided access, allows decisions regarding maybe your best approach, whether it be transduodenal or transgastric. The, why this froze again. There we go. Oh, all of a sudden it went crazy. So it was a big delay. Sorry about that. Back three, two, okay. Oh, no. Okay. Second tip is that you want to use needles and or guide wires that limit the possibility of guide wire shearing. Now guide wire shearing doesn't happen when you advance the wire. It's when you try to withdraw the guide wire back through the needle. Let's say you advance a guide wire and it actually went in the wrong direction and you try to quickly pull back. You can shear off that wire and it'll be inside the patient. Again, I'm trying not to mention specific brands, but there is one particular needle that's available that I'll show you that does not risk wire shearing. I actually don't use that needle. I use standard 19 gauge needles, but I use small diameter wires, 025 wires, and I've not had a problem shearing. The other thing to remember is if you torque the wire counterclockwise, a lot of times and slowly withdraw it, it will not shear. It's when you have it in a loop configuration, you pull back where you tend to get shearing. Waiting for this to advance. I don't want to go too crazy on the advantage. So here is a needle that's available from Cook Endoscopy. It's called the access needle. And you go in with the needle, but when you pull the needle out, you have a blunt catheter that really has a shoulder. Now, the good thing about that needle is obviously it works like I just mentioned. The problem that you might have is if you're in a very, very small duct, you're in with the needle, you inject, everything looks great, but the shoulder of that blunt part of the needle may not actually be into the duct that you're in. And once you pull the stylet out and you try to advance the wire, you actually don't have that shoulder into the duct. So it's not a problem when you can advance the whole thing into a big space. It's when you're dealing with a small space, and before you know it, the needle might be through the other side, and yet the shoulder is still lagging behind. So that's one of the caveats with using that device. Tip number three is after needle puncture, always advance as much guide wire into the duct or the pancreas that you can advance. And that really provides a safety net for you not to lose the guide wire. And for rendezvous procedures, it prevents wire loss, not only during the scope exchange when you're removing the echo scope, but when you re-advance the ERCP scope back over, if you only have a small amount of wire through into the duodenum, you're going to lose that wire even before you get there. So you really have to have a lot of wire, let's say for rendezvous procedures, way down into the duodenum, even into the trunum, or even back going the other way into the duodenum into the stomach. And it's easy to lose the wire during an exchange for a rendezvous procedure. My next tip is after the initial puncture, again, avoid using that standard endoscopic view that I talked about. The problem with saying, okay, my wire's in, let me just look at what I'm doing endoscopically, is number one is when you tip deflect away from your puncture site, you uncouple the echo with the view that really is the important view is what's going on with the wire inside the patient. Number two, when you back away and you say, oh, this looks great endoscopically, the angle that you're passing your accessories is not the ideal angle. The ideal angle for passing any accessory is the same angle that you puncture and put your guide wire down. That is going to give you the greatest mechanical advantage. And when you back away, all of a sudden there is a different, completely different angle than when you punctured with less mechanical advantage. So changing to the endoscopic view negatively impacts the wire angle. And it also risks wire loss because now you have a space between the scope and the aluminum wall. And if you push too much guide wire, it can now loop into that space. And it's almost like having your elevator open and pushing some device. It's going to have an opportunity to push away and down. Whereas if you keep that close tip and you're pushing against the wall, you have much less likely of losing the guide wire. So it's back to what I said early on is that you want to rely on the use of fluoroscopy and echo endoscopy, really not your traditional endoscopy. After your guide wire is in place and while you're passing your initial accessory, whether that be a dilating glue and a catheter, again, maintain, if you have to rotate, find that always your safest position is to find that nice wire on the echo view. And I'll show you when we do some of the examples of keeping that guide wire in your nice position. That's always going to be your safe place. And again, this provides the greatest mechanical forces and increases your success of passing a catheter. Okay. Tip number five, always maintain wire access until it's absolutely sure that your stem placement is successful. I hear people say, oh, it looked like the stem was really good. Everything looked good. I pulled the wire out. And then when I backed away and looked, something wasn't right. Well, getting access back after you've either misdeployed a stem on one side or the other of your wall, it can be extremely difficult. So you keep that wire in, it's really safe. You say, okay, I like the way the stem looks on one side. I like the way the stem looks on the gastric side or the duodenal side. I love the way it looks on the ductile side. We're all good. Then pull the wire out. But if you pull the wire out prematurely, you'll want to get it back and then, you know, the panic can set in. Because at this point, you can always pass additional stents over the wire to salvage the procedure. Let's say you chose a stem that was too short. Or so let's say you use the lumenal opposing stem that misdeployed one way or another. You can always pass another stem through that stem to save the procedure. So keep that wire in place until the very end. I think it's best to avoid cautery by using a needle knife or a cystotome unless it's absolutely necessary. I think cautery on devices where cautery is intended is a good thing. I think that sometimes I've seen, I've had problems with cautery when I could have gotten away without it. And for example, when I do my hepatical gastrostomies at the present time, I'm using balloon dilation completely and avoiding cautery whenever possible. Some of the exception is when you do pancreatic gastrostomies, meaning you're going through a very, very fibrotic pancreas and it's parenchyma. Sometimes you cannot complete those procedures without using some sort of cautery in a very fibrotic chronic pancreatitis situation. Cautery has been shown at least four or five years ago to be an independent risk factor for adverse events. Most biliary dilating balloons have a very rigid tip. It may pass through the stomach or new adenum. Again, if you use it properly in the right axis with your guide wire. And the other trick that I use a lot is that there are tapered patheter dilators that pass over an O2-5 wire. Even though when you open the package, it says designed for the ONA guide wire, you can frequently get an O2-5 wire through some of these very small patheters. You have to lube the guide wire up really, really well. And it can be a little bit difficult initially, but those will pass through amazingly well. And then that gets you up to 5 French. Your dilating balloons are mounted on 5 French catheters. So if you couldn't get the balloon through and you can get the 4-5 catheter through, that dilates you up enough to get your 5 French balloon through. And then once you get your dilating balloon, you dilate enough to get your next device or accessory through there. So that's a trick that some people were not aware of. And by the way, once I finish with the tips before we get to cases, I'll have Cheyenne and Uzma and Ryan talk about these things. When performing biliary transluminal drainage, obviously you want to use covered self-expandable stents. Use of plastic stents is an independent risk factor for adverse events because they're going to leak between the duodenal wall and the puncture site and likewise between the liver and from the stomach site. And that seals the tract when you use a self-expandable metal stent. When performing hepatical gastrosomies, always use a long stent, either 8 or 10 centimeters. If you go short, what tends to happen is in some cases you uncouple between the liver and the stomach. So it's always better to use a longer stent so you don't get a separation between the gastric wall and the liver with resulting peritonitis. And lastly, on my tips, I almost always place a Severn French double pigtail plastic stent through the metal stent, whether it's an aluminum opposing metal stent or not. The only time I do not place a plastic stent through a metal stent is when I perform gastroenteric anastomosis. That's the only time I won't place a double pigtail stent for a variety of reasons. I know there are some people that don't believe in doing that, but I always place a Severn French stent through the stents. So before we get to any case presentations, I would like to ask my fellow panelists to maybe chime in and talk. Yeah, Dr. Benner, we did get one question and you and the panelists can answer more about the cognitive decision on what to choose. The question was about if a patient has a malignant obstruction causing both obstructive jaundice and gastroduodenal obstruction. And they're asking, how do you decide between ERCP after dilation, if you can do that, and EOS-guided intervention versus IR-guided intervention? And we would just do the duodenal stenting. We appreciate your answer, you and the other panelists. Right. So I'll chime in quickly in my approach. And let's just say there are many, many, many ways to skin the cat. And like you said, there's ways you can put a duodenal stent in and do EOS and even use the gallbladder. We've reported that as a way of... But my approach, and I have a series now, 15 cases that I just finished editing, is I go with EOS-guided gastroenterostomy and EOS-guided hepatic gastrostomy, simultaneously same procedure. I don't even attempt the ERCP anymore. But again, that's my personal preference. I will say that I do the gastrogenostomy or gastroduodenostomy first and then do the hepatical gastrostomy second because I had a case where I did the hepatical gastrostomy first. And then when I went to put a long loop in the stomach, I pulled on the stent and separated the stent from the liver by introducing a long scope position in to get to the duodenum. So I do that part first and then go back to the short position and do the hepatical gastrostomy second. But again, many, many ways to skin that cat. Uzma, you wanna go first and then we'll go to Savannah. I was gonna say, I think, again, as Todd said, it depends on the center, the endoscopist experience. And for me, the patient and what's the discussion that's happened before the case. If I know there is definite duodenal obstruction preventing me from doing a standard ERCP, usually at our center, we'll always try a duodenal stent first and then either we could potentially stent through the duodenal while proximal to the stent, but the stent may get in the way or go to IR. But a lot of it depends on the discussion I've already had with the patient and their family because all these other things are off-label use and higher risk, obviously, for complications. I do the same thing that Todd does. Todd, if you haven't finished submitting it, I have about eight cases. I do the same thing. I do a double bypass. I have stopped dilating strictures. I think the fellow was asking if you would dilate a stricture and consider an ERCP. I think that's a little too risky and I've seen my share of perforations doing that and I don't think it's worth it anymore. I think you have an alternative and a safer alternative either duodenal stent and an ERCP or a double bypass like you do, which is what I do. The only exception is if I find a window for a choledochoduodenostomy, I'll do that first before I come back to a gastro-J. So it depends which anastomosis you'll do first, the distal one first and then the proximal one because I've had that same concern, will I dislodge a stent? Yeah, yeah. Brian. I would agree with everything everybody said. I think that you do whatever approach you take, the most distal anastomosis should be done first like Cheyenne mentioned. The other thing I would say is that, it's really important that people don't forget about the utility of the gallbladder in these situations. So whether you're gonna do a choledochoduodenostomy or direct gallbladder drainage and use the gallbladder as a drainage conduit for the whole liver, either can work. Typically in a situation with distal biliary obstruction, the gallbladder is pretty generous and a gallbladder drainage procedure is pretty straightforward. Generally speaking, in those situations, you're able to look at a CT or MR or talk with your radiologist and determine that the cystic duct is patent. You can surmise that it's patent if you have a hugely dilated gallbladder, but it's always good to double check. Right. I tend to pursue left hepatic duct drainage more so than choledochoduodenostomy because of the scope mechanics and the fact that you're working downhill versus uphill. So I agree completely with Todd in that use of cautery is kind of potentially wrought with badness. So mechanical dilation, if things go sideways, you have a chance that everything closes. The left hepatic duct tends to, like I said, be working downhill as opposed to uphill. The only other point that would make many, I assume several of the people on the call are advanced endoscopy fellows. One thing that we probably don't appreciate enough when we're doing left hepatic duct drainage is that the fully covered self-expandable stent, you can do the same approach you do with an Axios with the intra-channel release of the stent. And I would actually think about that because what that avoids is that avoids any separation between the liver capsule and the transmural wall. So instead of getting kind of two separate wastes, you kind of keep everything together, which I think ensures a little bit better in asthmosis in the long run. So by doing a intra-channel release of whatever fully covered stent you're using and then pushing it out gradually, I think is an optimal approach and something that a lot of people don't think about. Yeah. Thank you. That's a good point, Ryan, yeah. We had one more question for the panelists from the crowd. So the question is, if you're attending an EOS rendezvous and find a good window to access the bile duct in the duodenal bulb, how can you direct the wire into the duodenum? Okay. Well, I'll take that and then tell a couple of things. One is that there is a device on the market that will, it's a needle that does rotate downward or gives the orientation. You have to remember though, that the device asks for a bile duct of at least one centimeter, which in malignant obstruction is usually the case. But I can tell you personally, I don't use rendezvous for anything else, but literally somebody who has a bile duct stone that I need to do a sphincterotomy that I haven't been able to calculate for a stone removal. And that's almost always in the setting of a big diverticulum in the duodenum. So I prefer malignancy just to do transmural drainage. And to me, a rendezvous always sounds like a great thing until you actually start doing it. Okay. But getting back to the point is you can rotate the scope, manipulate sometimes right, left, up and down. So it's not looking straight up. If you can even get it almost lateral to the bile duct wall, you can almost always bounce the wire down. So it can be done. You don't actually have to be looking straight down to get the wire to go down. It can be just, like I said, across, but straight up is bad. But usually you can somehow manipulate by either pushing or pulling the scope subtly or turning right, left and get it to go sort of this way across and then bounce the wire across down and it'll go. I was going to say that rotatable needle though is off the market right now. But also it's a predetermined angle that it rotates to when you pull the stylet out. So again, depending on the size of duct, I don't know how useful it is. And probably, like you said, Todd, just using fluoro and your EUS image to try to angle the scope tip. And that angle that you first puncture the duct with is going to determine the success or failure of the procedure, essentially. Yeah, you want to be careful not to pull back too short because then you might fall out and that's tricky as well. That's why finding that in-between position is good. Todd, you mentioned when you pull the wire back, you pull it back counterclockwise. Why not clockwise and why? Yeah, I figured the counterclockwise, that I know clocks the counterclockwise direction. It's intuitive. It has to be different. Yeah, why one way versus the other? Is this like screw on, screw off? Plus lean to the left. I don't know. It just works for me. But because I always do clockwise on the way in. So I feel like I'm just backing out when I did the reverse on the way out. The mechanic in you. Okay, fine. Good answer. Good enough. Tidy, tidy, lefty, loosey. Okay. So we'll get into the case presentations now. One last question, Dr. Ballantyne, before we get to the case presentations. There was a question in the chat about why you prefer to do gallbladder drainage through the duodenum rather than the stomach when you're doing Get US Guided? Well, early on, people in Asia told me the only time they had occlusion of luminal posing metal stents for gallbladder was when it was in the stomach. And they would get a lot of food that would pass through into the stomach. So I prefer to do them in the duodenum for that reason. I also wonder if the length tends to be a little bit farther in the stomach because the gastric wall is thicker and you're usually in the antrum. So if you're using a 10 millimeter device, it can be a little tight. Now, of course, now we have the 15 millimeter saddle. I also wonder if the stent ever dislodges, if you might have a better chance of getting a more permanent fistula going through the duodenum. The stomach wall always closes. The duodenum wall doesn't always close. But I've never not been able to get one in the duodenum if that's the question. Yeah, so the other problem with the stomach is trituration, right? The movement, and I've had a couple of stents inward migrate into the gallbladder from the stomach. I think it's the antral forces over there. The food thing about food getting stuck in the stent, I think that can happen in the duodenum too, but that's contingent on a downstream obstruction. So if you have a high grade duodenal stricture and food sits around in the duodenum, you'll get that in the duodenum as well. So then you can sometimes relieve that with a duodenal stent. Right, okay. And that's the other reason I always put a double pigtail stent. True, that's one of the many reasons I think I don't want to delay our presentation, but I always put a double pigtail stent. So if I'm using a 10 millimeter luminal posing stent, what I do is I preload the guide wire, I do the gallbladder spree hand, I exchange off the wire and just load a seven French double pigtail stent right on and push it in. It takes another two minutes from the procedure. I don't change endoscopes when I do those. Dr. Barron, we don't want to keep you from going to the case and the nice videos. We do have several questions, but we can leave them until the end. Okay, so rendezvous, let's start with rendezvous. Rendezvous procedures are conceptually the easiest. I think people think, well, a rendezvous, it's pretty safe. You know, you can't cause a lot of problems and it seems pretty straightforward. So in reality, problems are what we talked about with the passing the needle, getting the wire to go, not only integrate, but going through the papilla can be somewhat difficult. Certainly wire loss is the big problem, right? As we talked about. And the one thing you have to be really careful, let's say the wire looks absolutely perfect. You take the echoscope off, you go down into the stomach, you start going to the duodenum and your wire is gone. One of the things you have to be careful about is if you don't have somebody putting tension on the wire as you're going down next to it, it gets pushed into the stomach and it starts to loop in the stomach and it actually flips the wire out. So you have to have somebody giving traction so you don't have an excessive loop on the stomach. So there are a lot of ways you can have wire loss and then you're got to start over. And the other thing, and I would love for one of our panelists to tell me how number three can predictably not happen. And that is getting your wires crossed when you go back down. Now, the problem is you grab the wire, let's say everything's going well, you grab the wire and the duodenum and you start pulling it back through the scope. I think if you get the wire to come all the way back through the scope, everything's good. But invariably what happens with me is that you're having somebody push the other part of the wire and you lose the wire inside the scope. So now you have to pull the scope out, right? And you've got the wire held with your elevator and you pull it out, but now you have to backload the wire through the scope. You go back down and the next thing you know is your two wires got crossed in that process. And that can be a heck of a thing to try to get yourself out of when you have your wires crossed. Anybody else want to help me with that? You know, what I tend to do is I'll have the nurse hold the wire to one side of the mouth and I'll try and go from the other side of the mouth and get back in. And then have them feed the wire and you'll be able to see that second wire a little bit easier and then you're less likely to loop yourself around it. And I'm sure you've done this as well. When you see that loop forming in the stomach, if you feed that wire from the mouth, the one the nurse has secured for you, I think you can undo that loop and get around the loop. It is a pain in the backside, I agree, but that's my little trick. I hold it to one side and I make sure I go in from the other side of the mouth. And I don't do a lot of rendezvous, like you mentioned, so I've not had to do it. It's only in benign disease. So it's becoming less and less of an issue. I agree. I think it's a problem with a lot of difficulties. Isma, can you help us out there? Usually if I'm doing it, we'll have both ends held, you know, outside the mouth. And then depending on what I'm doing, sometimes I'll just go next to the wire rather than back load and go over the wire. That's a very good point, is if you've got the wire stable, you just put your ERCP scope in it and follow the one coming out of the papilla, because a lot of times you just don't know it. You've had trouble cannulating it. Once you have the wire there, like you said, you can cannulate right next to the wire coming out of the papilla. Yeah, you just need to know the angle and, you know, where the opening was. So that might help. Yeah, Ryan, any thoughts? The only thing I was going to say, so I keep it off, one off one side of the mouth, the other off the other. I have had a couple of times where I've got wires crossed. And when I get to the point where the wires cross, usually in the stomach, I will take over the wire through the duodenoscope, put the occlusion balloon way, way out of the scope, inflate the balloon and ride the occlusion balloon all the way down to the ampulla and then ride the scope over it. And I don't know, I can't, I'm not smart enough to tell you why that's worked at least twice now, but it has worked. It just kind of helps separate things out as opposed to trying to get the scope to ride over the wire when you can't see where or how it's twisted. But I've used that a couple of times and it's been successful. All right, that's helpful. All right, so we have a rendezvous, which actually I think is a video that Ryan supplied for me. And you can see he's puncturing the duodenum. You can see the needle is looking sort of laterally and he nicely got the wire to go distally down. You can see there's plenty of wire out actually almost in the jejunum and you need that. And then he was able to put the scope in and grab the wire and now he's working over the wire it looks like with a balloon just to get himself in and then deployed a expandable metal stand covered as you can see here. Ryan, did you want to add anything to that? You made it look easy. I think the biggest things are a lot of wire and be patient. So I think of all these procedures there's different aspects of each one that you have to be really patient at a particular time with the rendezvous. I think you have to be patient the whole time because there's so many points where things can go sideways. And there was a question from one of the attendees. How do you account for the blunt end of the wire being in the biliary tree during your rendezvous? Do you cannulate and then remove the wire and then turn it around? No, so the, oh, I see. So the floppy end obviously is the one you're gonna grab. The one you're gonna work over, as you said becomes the blunt end in the biliary tree. So what I do is once I get really good access and I'm stable with whatever I put over it I take that wire out, turn it around and put it back in. That's what I do as well. The other thing you can do if you're really, really concerned about tenuous access is that over your first rendezvous wire, you can use, this I learned from Todd, you can use a cytology brush catheter with the brush removed because it gives you a second lumen. And then through the second lumen pass a second wire. Now you have a safety wire. Once you have the safety wire in place you can remove that double lumen catheter and then just work over one of them. Right, there is a Haberham catheter which does the same thing, the double lumen catheter. But a cytology brush works great, it's cheaper. That is so, the next one is actually one of mine although Ryan gave me hepatic gastroscopy. Just to remind everybody the position that you're going to be working in. This was a case that I put in a video GIE that I'll fast forward. A patient that had a Whipple, it was unclear why 20 years before she had a Whipple but had a long limb that couldn't be reached. So we weren't sure of the exact anatomy. So I'm going to get to the puncture. So here's dilated ducts, you can see here. All right, so actually my puncture was a little bit farther than back, sorry about that. There we go, so this was the puncture into the duct. And as with Doppler, obviously you can see the ducts of interest. Why it's playing slow, I don't know because it's not coming from my computer. But anyway, take a look at this guide wire as it's coming down. And what I mentioned earlier is keeping that wire access under a fluoroscopic vision. So what we ended up doing was we ended up putting a stent right to left to drain the right through the left. And what you're not seeing there is also a self-expandable stent. But I'll go to the next slide. Todd, not to interrupt the presentation but there was a question also from the audience about risk of bile leak when you're doing these procedures. So if you get a fully covered self-expandable stent, the amount of bile that you might leak during the time you puncture, dilate and get your stent in is relatively small. Patients often will have some pain because even a small amount of bile, I don't know why this is happening. Even a small amount of bile will cause patients to have pain. If this doesn't play, I'm gonna quit. But so if that's why you wanna use a covered stent to seal between the stomach and the liver, you get a complete seal with a appropriately placed self-expandable metal stent. Plastic stents are gonna leak in between them and you for sure get a bile leak or obviously if you have a complete misdeployment or you lose access entirely and the procedure goes south, then you're probably in for a big bile leak. If you can't complete the procedure yet, you've dilated the gash or wall, the bile duct, the patient needs to go straight to an interventional procedure where they can drain the liver and then maybe even put a drain between the stomach wall outward to get your puncture to collect any bile. And the patient probably will do just fine because the gash or wall will close by other video would play. This is Ryan's video showing a left hepatic duct puncture and advancement of a guide wire into the duodenum. By the way, you can also do the rendezvous through a trans gash or trans hepatic approach. And sometimes actually I found that to be an easier way to do a rendezvous because you don't deal with the wire going in and out of the duct at an acute angle, if that makes sense to anybody. And here's deployment of the stent as the final stage. And again, Ryan would attest that he really didn't look at this at all until he was ready to deploy that part of the stent. Sometimes what I'll also do is deploy the part in the liver with me looking under echinostomal close up against the gash or wall, I'll deploy the one part of the stent inside the liver so that when you back away, you don't have to worry about is the whole thing gonna slide back? And then you can take your time in deploying the part of the stent so that it's stable and you have the inner flange into the stomach. Well, now we'll proceed to colonogoglanostomy. We talked about the two approaches. I'm gonna show you some first some images of a case that I had done. This is obviously a very, very big bile duct that was easy to puncture. You can see the needle past, these are just images. For a colonogoglanostomy, it's fine if your wire goes antegrade or retrograde. It really doesn't matter. As long as you have plenty of wire out, in general, you can deliver a stent on a colonoglanostomy one way or another to stop this one antegrade. You can see the wire. This is what I wanted to emphasize is I keep this position the entire time that I'm doing any of the procedure. I don't wanna see anything until the very end on the duodenal side. I'll keep this image with this trajectory in place. This happens to be the luminal opposing dental stent that it's hard to see, but the end that's on the bile duct side is deployed. And you can see the second end now is deployed in the duodenum. And as I mentioned, I always place a plastic stent through that stent, but that could have easily been done with the scope looking upward position. This is- And I think for the, also for these luminal opposing stents, so in the US, the smallest diameter is 10 millimeters. You know, these flanges are over 20. You definitely need a dilated bile duct to put it into. Yeah, yeah, that's a great point. I think in general, they're really oversized for most people's bile ducts because like you said, the flange is like 21 millimeters, I think, with a 10 millimeter stent. And three-dimensionally, that's bigger than most people's bile ducts. So I agree. Ryan, I didn't know if you wanted to comment on this. This is your case. Yeah, so I remember this case. This case was terrible. So two other points I would make with the axios and the bile duct from the duodenum. The pigtail, in my view, that putting a pigtail through it is mandatory. It may look great when you have a two and a half or three centimeter duct, but as soon as that duct collapses, what happens is the contralateral wall is gonna obstruct the wall of your lumen-opposing stent, and you just create a repeat obstruction and cholangitis. If you put a pigtail through it, it'll change the axis or the axis point of the lumen-opposing metal stent, and that won't happen. So anytime you see an axios or a lumen-opposing stent, that's necessary. The other thing that I would say is that with EUS, when you're looking to drain that bile duct, take a little bit of inventory under ultrasound about where the cystic duct takeoff is, because sometimes in a distal biliary obstruction, the cystic duct takeoff is pretty close to where you're puncturing. And then if you're putting in, whether it be a fully covered metal stent or a lumen-opposing stent, you can actually obstruct the cystic duct with that. So it's something to try and see if you can. Sometimes it doesn't come into play, but oftentimes it's very close by. Just something to keep in mind. Those are great points. I've actually gotten away from doing cholonogluotin osteoporosis with about now over 200 hepatico-gastrosthesis, and there's a lot of reasons why I've preferred, but I've gotten away from doing them, and I've also gotten away, if I do them, for using a lumen-opposing metal stent. And I prefer to have a straight up trajectory for a long pathway. And I use the self-expandable biliary stent partly because of what Uzma said. And I think sometimes what I've found is that the livery system is so stiff that you're angling, even though your wire looks good, it wants to go across the duct before it goes up because it's a very stiff catheter. So unless you have a perfect landing pad, sometimes you're actually going across and you can even hit the opposite side, and sometimes you can run out of the livery system before you get enough in to deploy it. So all those things have made me, and maybe I'm just not doing it right, of getting away from using lumen-opposing stents for colonoglutinostomies. And I think that if you're gonna have a disaster, you're less likely to have something that could be salvaged with a colonoglutinostomy if you can't fix it and everything goes to hell, excuse my language, is that you have a problem with your genome, it's a really difficult place to operate, you have a retroperitoneal problem, and if a surgeon ended up wanting to say I was gonna operate the new adena, but now for whatever reason you've made that a minefield, I just, I tend to say that things are, you can get away with more stuff up at the stomach high around the area of the liver and salvage it with other interventions than you can, but that's just my tank and I might be wrong on that. I would agree with everything Dodd said, I tend to go through the liver as well. I also think going back to the point that we made earlier about- Hey, Ryan, you're gonna wanna let them watch this, this is how you misdeploy anaxios in the bile duct. Oh, okay, I've seen that up close and personal before. Oh yeah, so this was a case that I did, Todd, yeah, you're right, this is the video I shared with you. So this was me reconstraining the stent and trying to get back through because I recognized it was pulling out on EOS. And even though I maintained that EOS, now over here, it looks like the stent is kind of opening. And I said, I don't have much of a choice, there's all this air collected. And as soon as I opened, you see just a whole bunch of blood. And then when you rotate around, you can see what happened, that stent had actually double punctured the bile duct and was really close to the portal vein. I said, okay, the stent doesn't belong there and I pulled it out, but I didn't give up on him. So over here under fluoroscopy, I can see a shadow in the bile duct and I managed to get a catheter into the distal bile duct, but I don't want a stent here. I need my wire to go upstream because that's what I'm trying to drain. And so with a lot of patience and a lot of luck, after a few wire passages kind of went through the bile duct, you'll see it go through there, that's not where it belongs. I finally managed to get it turned upwards into the intrahepatic ducts. And then I said, okay, I should have chosen a tubular stent instead of a lumen-opposing stent, that's the hole in the duodenum. And then finally an appropriately sized stent. So I had put together a series of every location where you can misdeploy a lumen-opposing stent and this was on that series. I mean it highlights also that these stents aren't necessarily made for this purpose, right? So absolutely. The other thing is I misspoke earlier when I said you could go up or down. That's if you're using a wound opposing stent. If you're going down with a tubular stent, you're basically including anything coming above you. So it defeats the purpose, like you said, with establishing your drainage. So there was a there was a question, Dr. Barron, on the panelists. Is there any data on the comparative safety of colodocal duodenostomy versus hepatic gastrostomy? You said you prefer, you know, the latter versus the former. There have been studies that have suggested, I think, that colodocal duodenostomy is a little bit safer. I question though, having now done, I can tell you I've not had anybody have to have surgery with an HG. I've not had any that I couldn't salvage if I somehow misdeployed them at the same procedure. And I think it's safe, but people tend to want to, for whatever reason, are attracted more to colodocal duodenostomy is my sense than hepatic gastrostomy. I think and when it's all said and done, I think you need to get really good at one or the other and then pick your approach. I know that's hard to say if you're just starting. You might feel more comfortable doing one versus the other one. They each have their own tricks, but I don't know. What do the other panelists think? I was going to say I've always stayed away from hepatic gastros, but now that you're telling me you've done 200, maybe I should switch more to that because I have the same concerns you do about the colodocal duodenostomies. When they go bad, it can be a terrible situation. And the reason I got really good at doing them and like doing them was I saw I really started doing so much surgically altered anatomy that was referred to me where a colodocal duodenostomy wasn't even an option because I saw a lot of surgical hepatico-genital and asthmatic strictures that were sent to me that I did integrated therapy with and published on that. And some of the gastric bypasses, I went straight to an HG. So there were cases where I got comfortable because I didn't really have the other option. So that's when I got really comfortable with it. I just kept doing them. My interpretation of why that happens, and maybe I'm wrong, but I think for most people starting out are going to do some biliary drainage stuff with EUS. Typically in those situations, the common bile duct is huge. You can see it from the moon. So puncturing it is the easy part. Everything after the puncture is a pain in the ass. For the hepatic gastrostomy, you know, your puncture target is often very small and a little bit more difficult to hit. Even if it's dilated, it's still probably only three or four millimeters. But what people need to realize is that everything after you get access is much, much easier. Yeah. The wire almost always goes, you know, with some exceptions, almost always just go straight over because you're looking in the right direction over and down in the biliary tree. And, and, and if even if you don't pass, let's say the distal obstruction, which you don't have to, obviously, you can double back wire all the way back up the duct. So you really get a lot of wire from a safety perspective. Before I get to the video, this is actually One thing about hepatic gastrostomy is I think that you should caution people as the portal vein runs just completely parallel to the biliary tree. And I cannot tell you the number of times I've gotten into the portal vein with a wire and wanted to double and triple check that I was in the vein in the bile duct and not the vein. So you have to be super careful about that. I cannot stress that enough. You mean for the, for the colonoglodonosomies? No, for a hepatic gastrostomy, just make sure you're not getting into the portal vein. It runs completely parallel with it. Yeah. You may get a cholangiogram that looks great, but make sure your wire is doubling in your bile duct before you do it. Here's the key. When you, when you first inject, you go in with your 19 gauge needle in contrast. And when you inject, if you're in the bile duct, it doesn't disappear. Like when you're in a vessel, it can look like the bile duct, but you wait 10 seconds, that contrast is gone. There's one exception to that. If you have a nice big fat portal vein clot. Yeah. But I mean that by and large, I can tell you that's, that's generally not the case, but I hear you. It's completely true, but just be mindful of the portal vein running close to the bile duct. Yeah. Yeah. It can be true. This is a gallbladder case I actually did yesterday morning. And, and then I'll go back to the video. So here's the position of me in the duodenum looking up. Here's a gallbladder in a cirrhotic low platelet count with cholecystitis. You can see a ton of sludge in there. Nice angle. I went freehand. So I took the luminal opposing stent with cautery preloaded guide wire, but did not use a needle, went straight in when they're this big. It's a really easy target. It's really hard to miss. And then that's, so that's what you're seeing right there is a little bit of pulse. Then I deployed the first flange, put the wire that I already had pre-deployed and made sure I had plenty of wire. You can see the deployment of the inner flange inside the gallbladder. Here is backing up the stent toward position of being above on the inner surface of the gallbladder. And here is the final deployment, both periscopically and endoscopically with sludge coming out of the gallbladder. And I ended up putting in a, what I didn't show you was the seven French double pigtail stent after taking the, the luminal opposing delivery system out. I'll go to the gallbladder that Ryan gave me, which is a very nice case that hopefully plays. Um, so this gallbladder for some reason, Ryan, this gallbladder doesn't look like it's got a lot of sludge. We're using it for a, uh, ability decompression. Yeah. So this is actually a, um, 34 year old, uh, lady who had it on fallacy as a kid and her abdomen was a complete disaster. And she had recurrent cholecystitis and the surgeon didn't want any part of her. So, um, the plan was to drain this, uh, with the luminal opposing stent, bring her back in four weeks and can convert her to kind of lifelong, uh, set of a few pigtails in there, uh, because surgery really wasn't an option. And, um, nobody really felt like percutaneous therapy was a great option. So in that image, I agree. That's not classic cholecystitis. She didn't have a ton of pus on the day that we did this, but it was a bit more of a stage procedure. Yeah. And the point you make is a good one in that all my gallbladder cases, I, um, take them out four to six weeks later. I use a standard upper scope because it looks right at the lateral wall of the duodenum, remove the luminal opposing stent and put two, like you said, double pigtail stents through the track. Cause you don't want these things to stay in, uh, long-term because of some of the potential adverse events. Uh, but obviously at four weeks, then you have a, uh, a complete, um, um, you know, track so that it's safe to remove them, uh, just like taking them out of, let's say any other, uh, track that you have a nice form track. Um, it looks like you're putting a pigtail stem through the, um, so I didn't mean to talk over your video, but that's a, again, a very nice demonstration. So edge procedures are becoming, um, fairly commonly performed, um, where we, uh, connect, um, either the gastric pouch or, um, sometimes, uh, and sometimes even sometimes more commonly, the jejunal limb just passed the gastro jejunostomy into the excluded stomach and then do integrate ERCP for those patients who have a gastric bypass. Um, I'll quickly mention that you can either attempt through ERCP at the same time, although you have to be very careful that there's a risk of that. If you dislodge the stem during the ERCP, now you have, you know, a perforation on the gastric side and the other side, um, they can almost always be salvaged, uh, with putting in a, um, stem through that stem. Um, and again, because of the lack of time, I can't go into detail, but you have to be prepared for that. Otherwise, if it's a semi-elective procedure, um, let's say they're having intermittent pain, biliary colic, dilated bile duct, you can come back and, and at four weeks and do your ERCP safely, dislodge the stem, get your ERCP done. It doesn't matter. Uh, remove the lumenal opposing stent and move on with life. Um, because of, again, because of time constraints, but I've always prepared to salvage. If I feel like I have to do an, uh, an ERCP that day, let's say a cholangitis, they can't wait. Um, then I either do an hepatic gastrostomy and do it that way, or I do a luminal opposing stent single stage procedure, and then, um, prepared. Again, I don't have time to tell you how I can, we can do that another time. Um, I want to give you a quick case of a woman with a cubic recurrent pancreatitis. This is one of my cases that removed my gastric bypass. Um, she, uh, had her gallbladder out before you can see she has pancreas divisum on her MRI. Uh, not a great case that you want to do a laparoscopic assistive procedure with a surgeon watching you do a minor papilla cannulation. Um, so we did the, uh, luminal opposing metal stent. This is the way I do them. I, uh, puncture the excluded stomach confirmed with contrast. Um, then with the needle in place, I distend the excluded stomach with putting your flush pedal to the needle and putting in 500 CCs. Then in free handing, I don't do it over water. This is probably one of my early cases. Um, I do the luminal opposing metal stent. I came back, you can see now my ERCP scope is through the luminal opposing metal stent. I'm in the minor papilla. I did a minor papilla cannulation, minor papilla sphincterotomy, and stent placement, um, on that patient. And here's the, the final, uh, image in that patient, um, with that. Um, again, because we're running out of time, really your, your pancreatic guided interventions are, are limited to, um, uh, either rendezvous procedure, uh, direct transluminal drainage, which is basically a pancreatic gastrostomy or fluid collection drainages, because almost all fellows are really exposed to all kinds of fluid collection drainages that are now seemingly relatively straightforward. I'm not going to mention that, um, tonight. Um, I'll give you a quick case of a woman that was 16 years after Whipple for pancreatic cancer or ampullary cancer presented to our ER with weeks of smoldering pancreatitis, abdominal pain. Um, I do now almost all my Whipple, uh, pancreatic interventions with anti-grade approaches with EUS by puncturing and either, uh, and getting a wire through, um, and performing a, um, uh, dilation and doing everything anti-grade including follow-up with an ERCP to dilate strictures and replace stents as needed. Uh, so in this case, you can see, uh, she had developed a stone at the pancreatic, uh, jejunostomy, uh, dilated pancreatic duct. Um, you can see we were able to easily puncture, um, and have a nice run, uh, across into the jejunum. Uh, we got a guide wire through, balloon dilated and placed, uh, a double pigtail stent. Uh, unfortunately this lady was well into her 80s. What I, what I told her I would do if I were her would have me let this mature, come back and work anti-grade, resolve the stricture, resolve the stone either, uh, with anti-grade approach with or without, uh, pancreatoscopy anti-grade that we've published on with a cholangioscope or pancreatoscope EHL. And she said, well, I'm maybe 70 years old. Why don't I just leave this? And so I actually, uh, not heard back from her. I'm now several years into this waiting for her to pick up the phone and call me. Uh, but so far I have not heard from her, but I have a series of patients who I've done anti-grade, uh, therapy both with and without Whipple procedures, uh, using ERCP scopes subsequently to this, uh, procedure. Um, uh, I'm going to stop real quick. I'm going to try to let Cheyenne give his amazing case, uh, that'll wrap up the whole thing. But, uh, in conclusion, you know, therapeutic U.S. is certainly rapidly advancing. Um, there are parallelisms to what we do to percutaneous, uh, or interventional radiology procedures and with ERCP with regards not only to evolution and performance of the procedures. Um, I think we have a long way to go with getting more and more devices that are, uh, really, um, deliberately designed for what we're doing. Um, and I think that will come, um, EOS guided therapies are likely to place many, uh, percutaneous procedures that we're having our patients go through right now. Um, I think that's just a matter of time and certainly it plays an increasingly important role in, uh, therapeutic endoscopy. Um, so I'll stop here and let, uh, Cheyenne and hopefully we can get some more. And if there's enough enthusiasm, um, I'm told that we can come back and do a part two for another endo hangout, um, and maybe cover some things that we didn't cover, uh, or maybe cover things a little bit slower than we had to go through tonight. Um, but go ahead. So this was an interesting case of an afferent limb syndrome, a biliocutaneous fistula, a bilioendrocutaneous fistula. And can we fix all of that endoscopically? So this is her story, 53 year old lady, multiple surgical necrosectomies, Whipple for necrotizing pancreatitis, and then multiple enteroenterostomies for bowel obstructions. And she was referred to us with a three-year-old percutaneous biliary drain that had been in there to treat an afferent limb syndrome and recurrent cholangitis. She came back to us after they put in two percutaneous biliary drains, because she was leaking around one drain. So the IR doc over there thought maybe a second drain will fix the problem. And it didn't, obviously she came with leakage around two percutaneous drains with recurrent cholangitis. So this is a CT, there's pneumobilia, there are two drains going in through her left lobe of her liver, through a central scar over there and into the afferent limb. So the afferent limb is completely decompressed. So we tried to do an DBE ERCP, but she had so many adhesions, we got nowhere basically. So these were options do nothing. There was really no great window for an afferent limb gastrojejunostomy to decompress her. And so I thought, okay, we can do a hepatical gastrostomy, drain her bile duct into her stomach. So I took her for a hepatical gastrostomy. But as you know, when you approach a hepatical gastrostomy, you're often getting the posterior ducts. And so this is an EUS hepatical gastrostomy. There's the needle puncture into the left intrahepatic ducts. I can't tell which duct the percutaneous drain is coming in, but I said, as long as I decompress the biliary tree, she should be fine. She'll get adequate drainage into her stomach and she should be okay. So this is a balloon dilation. And then Todd, like you mentioned, sometimes you don't have a choice, but you go through the esophagus. So this was an esophagus connection. And I put in a seven French stent, which I also always do with all my anastomoses into the right intrahepatic ducts. So this was my questions for the panel, but we'll skip them. So over the next two weeks, what happens is there's almost no change in her drainage. She's still putting out 250 cc of bile from her skin. And the thought was she has a downstream obstruction because of that afrin limb. So maybe this EUS hepatical gastrostomy is not enough. So what next? So I said, fine, you can't stop at one procedure. So I took her back for another thinking, let's treat the downstream stricture. And this is what we did. So through her hepatical gastrostomy, I pass a balloon catheter and down over there, you see that yellow arrow, you see a afrin limb stricture. And I managed to get a wire through that stricture. And I thought, okay, let's dilate this stricture. Let's treat this traditionally because I couldn't get there with the double balloon scope, put in a couple of pigtail stents, and we'll get some nice downstream drainage. Now she has drainage into her stomach. She has drainage downstream. She should heal, but her output only dropped by about 150 cc. She's still putting out bile from her skin. So I said, okay, maybe the problem is because I'm not in the segment of her liver that had the percutaneous drain and that's the chronic nuisance. So I took her for a rendezvous with IR and with IR's injection, I still couldn't see the duct they were in. So I took out the existing hepatico-esophageal connection, which wasn't doing much for the patient. And then I said, the only way I can possibly identify this is by inflating a balloon in that particular segment. So I had a small balloon inflated over there. And then on EOS, you can see that. And now I can identify the actual duct where the percutaneous drain was coming in. And so I punctured that, hit that balloon, and then that's how we rendezvous. And so now I got a wire to come through that duct out through her skin. And the dilation was a little bit tricky. I couldn't go anti-grade with my EOS. And so I had to actually dilate by the wire through the abdominal wall. So even a Sohindra stent didn't work. So I went the other way through the skin and dilated it. And I went ahead and deployed a hepatic gastrostomy into the leaking segment. So I said, okay, now I've solved this problem. She should stop leaking. The output went down, but it did not resolve. And I thought, okay, that PTBD was through just a ventral scar. There's no muscle there whatsoever. And maybe that tract is now after three years epithelialized. And so I said, okay, let's go back in, let's do a cholangioscopy and see what's going on. And so that's a regular pediatric gastroscope going into the left intrahepatic ducts. And there's some debris over there. And here's the fistula from the skin side. And I'm pretty sure it's that, but I passed a wire down through the skin just to make sure. And then I went ahead and ablated that tract with APC thinking that's been epithelialized because the drain's been in there for three years. So I burnt the heck out of it through the skin, deployed another hepatic gastrostomy. And this time I put in a nasobiliary drain over there to give some additional suction. And that's just showing how this nasobiliary drain is going up to wall suction and low intermittent wall suction to try and dry that area out and help it to heal. And so she did, she closed the fistula two weeks. I said, yay, bravo. But 12 weeks later, no, a story didn't end there. Now she comes back and the fistula open and there's actually food coming out of her abdominal wall. I said, oh, that's not good. So what now? I said, well, I have access to your bile duct. Let me see why it's foods coming out. And I got into her intrahepatic ducts and here's the problem. Her hepatic jejunostomy, the surgical one had completely deheased. And this must have been an old dehiscence. And there's a whole bunch of food sitting in there with an abscess. So I said, okay, let's clean this out and see what we get. And so I just meticulously piece by piece by piece, celery, corn, it doesn't matter every piece of vegetable I took out from there. And this is the only time vegetables aren't a great idea. Otherwise you eat vegetables. And I cleaned it out, passing it down through the afferent limb till I cleaned out that abscess cavity just completely. And you could see the hole, the breakdown between the liver over there. And that's the abscess cleaned out now. So I had about a three centimeter abscess and a dehiscence of this hepatic jejunostomy. And I went ahead and deployed a big nasogastric drain, nasogastric tube that I put in through the hepatic gastrostomy down in that afferent limb to dry this area out. And so finally with this, 10 days later, she closed her skin. And this is what allowed her to close this fistula. I've left her on a low residue diet. And she's now three years almost out from this intervention. And she's not had a recurrence of a fistula. So she had a reasonably good outcome for someone this young with a really tricky, challenging problem. Great case. I was going to say for the fellows out there who have maybe not seen a lot of therapeutic EUS, this is confusing for attendings also. And I don't know for part two, if depending on the level of the fellows and what they already know, we could even start with a little bit more basics on the equipment we use and some of the techniques and go step-by-step through them. Well, there's a reason I didn't start that as the first thing. Anyway, we have three more minutes. Maybe we can answer some questions the best we can. There's a question about how you can establish these novelist services at a regional medical center. Right. That's a great question. Sorry, what was the second part? Oh, that's it. How do you get surgery buy-in and so forth? Yeah. So part of it depends on if you're an established endoscopist, let's say that goes to another center. I had to do this when I moved to UNC. I was an established endoscopist, but what I was offering was not established. Right. And so it does take a lot of work. You have to continue to perform well. You have to continue to try to reach out to as many disciplines as you can. And it takes time for people to trust that this is new and that this is something that benefits the patients. I think there are certain cases that are tipping points. So I remember I was doing gastrointestinal ostomies and they would come to the point where they say, I want to do a dental stent and do not do a gastrointestinal ostomy. And I said, one day they're actually going to come to me and say, do a gastrointestinal, they'll request it, some of the naysayers. And if you do enough of them and they see within the hospital, they weren't their patients, let's say, and they know about them, they hear about them and the patients do well long-term, there's tipping points that you'll get people to buy into it, but it is hard. You can try to have multidisciplinary conferences, join multidisciplinary conferences, show the cases that you've been able to do. You know, the problem is that you have to be able to do them without causing lots of complications, because the first thing, if they see the first case went bad, they may not give you a second chance. And so sometimes you have to actually start slower with things that you know will succeed. And then the more it builds on, it builds on, it builds on. So it's going to be variable depending on the center you're in, how open the people are that are around you to wanting to try new things or to have new things. But a lot of it is educating of what can be done. A lot of these specialties don't have any idea that we can do some of these things. And it's, you know, that's, that's all I mean, Cheyenne, you probably can add and Ryan. Yeah, so maybe do a grand rounds at your hospital when you start. So start educating like that, give a talk about it, build a relationship with your surgeons, your interventional radiologists, and help them out. Once you build that trust, where you've helped them out with a difficult situation they've been in, then say, Hey, how about trying something like this, and then they'll slowly start trusting you. So when I did my first gastro J, five years ago, Todd, I had a surgeon write me up for it. And he's the same surgeon who four years later, gave a grand rounds and asked me to join him and present and talk about gastrogynostomy. So you just have to slowly win them over and understand you'll have struggles, but just be patient, slowly. So again, with therapeutic us, it's it's not a solo sport, you know, you're working with radiology, surgeons, oncology, and, you know, you need to kind of get everybody on board. And I think having those discussions is very important. My first USGJ, I had the chief of surgery, see the patient right, you know, let GI try this, and you know, it went well. And then from then on, they refer us cases. But I think those discussions are very important to establish the practice. But also, they don't they don't even know what you're capable of doing, you know, and every practice is different, like Todd's place, they don't mind him doing a hepatic or gastrostomy, and they'll take them for a whipper. Yeah, still, I have to get them on board with that concept. And so it's each place is different, just work with your surgeons and build that relationship, because you'll need them, they'll need you. All right, well, I think we are a little bit overdone on time. I would like to thank all of our panelists and our Dr. Ayub and Dr. Abishama and the ASG for putting on this session. As I mentioned, I'm certainly willing, if there's interest, to sort of take this another another round, because it is hard to cover everything in this area in one session. So everybody have a good evening. And most of you know my email because it's in all my publications. If you have questions or want to reach out to me, I'm happy to take any questions by email, and I'm sure the other panelists would be happy to do the same. Thank you. Thank you. Thanks, Reddy, Ali. Thank you again, Dr. Baer and Dr. Irani, Dr. Law, Dr. Siddiqui, Dr. Ayub and Dr. Abishama for these excellent informative presentation and being here with us tonight. As a final reminder, please do check AGE's calendar events and we will continue to feature relevant sessions to our Endo Hangout series. Save the date for the June Endo Hangout session, which will be part of a bigger two-day event entitled The Best of AGE Endoscopy from DDW. The Endo Hangout session will be on Friday, June 11th at 2.30 p.m. Central Daylight Time. During the two-day virtual event, we will also feature the AGE Fellows Session, which typically happens during DDW. The AGE Fellows Session is scheduled for Saturday, June 12th. Make sure to go to the AGE website to register for the two-day free virtual programming happening on June 11th and 12th. In closing, thank you again to our panelists and moderators for this excellent presentation, and thank you to our audience for making this session interactive. We hope this information has been useful to you and your practice. This concludes our presentation.

rendezvous procedure

endoscopic guidance

fluoroscopic guidance

puncture

duodenum

jejunum

wire

scope

balloon dilation

covered self-expandable metal stand

therapeutic endoscopy procedures

collaboration