So, this is a little bit of a potpourri. I was asked by Dr. Koh and my colleague to please focus on some of the practicalities of pragmatic aspects of dealing with this particular topic with video illustration. So I've decided in the short time that I've got of 10 minutes to focus on access, which is basically solved by the combination of EUS and ERCP. So we look at the use of EUS and how it can help us with failed cannulation, altered anatomy, duodenal obstruction, drainage of the gallbladder, of course, and hepatical gastrostomy. Hopefully I'll be able to get through most of these. First of all, here's an example of a failed cannulation. Basically a patient presented with a distal bile duct stricture, elevated liver enzymes, high ALK-FOS, and we get down there and we see that the bulge of the bile duct is sitting within a diverticulum. So, let's see if I can get this mouse to come down to where I want it. There we go. So basically we go with standard cannulation technique, go with a sphincterotome. We see there are a lot of folds that are telescoped around the bottom of the bile duct. So one of the standard conventional approaches is to take clips, try to evert the folds outside the diverticulum to give you access to the orifice, and unfortunately, unsuccessful in this particular case. So at this point, we opted for an EUS guided rendezvous from the duodenal cap. We advance a wire down from the duodenal cap and down into that diverticulum. Let's see, here we go down here. And once the wire is successfully coiled in the diverticulum, and we're happy we're through the orifice of the papilla, we remove the EUS scope, go down with the duodenoscope. And when we're down with the duodenoscope, now we have a wire for rendezvous. Now the teaching point here is we don't use that rendezvous wire to go back up the duct. It's just a guide for a sphincterotome. If you put the sphincterotome over that wire, you'll end up coming out into the duodenal cap. So you want to independently pass a wire up the bile duct, not using the rendezvous wire, which gives you access and gives you sort of like a double wire technique for rendezvous. So this is a very nice procedure when you have very difficult cannulation and the standard approaches do not work. We ended up putting a stent in here for future access. So let's move on to the next scenario, which is, let's see how I do this, go inside here. Oh, there we go. Thank you. So basically, again, this is a patient with sort of abdominal pain, elevated liver enzymes, MRCP shows isolated dilated ducts in the left hepatic system and intrahepatic stones. So now, what we're stuck with is, let's see if I can do this, this is, oh, there we go. I'm sorry, this mouse is really tricky. I need those hands of those women up here. You had the gentle touch, I think. Somebody did. Anyway, basically, the problem with this patient was previous Roux-Y gastric bypass. So the only way we could have a chance to evaluate the intrahepatic duct system with cholangioscopy was to go and use the EDGE procedure. So here we are with the EOS scope in the gastric pouch and looking for the lumen of the stomach. And once we're in the lumen, injecting a large volume, about a liter or so of methylene blue and diluted contrast. That gives us a target to get the axios stent from the gastric remnant into the excluded stomach. So now we're going to create an axios entry point. You can see here, pulling on the wall of the stomach and then releasing the proximal flange in the scope and then releasing that. The one thing I would say here, let's see if I can, oh boy, anyway, I think I'm going to give up on this. Anyway, we basically, we have now the axios entry point into the excluded stomach. We wait about two or three weeks if it's not urgent. It was not in this case. Then we go through the axios stent. Now we can do it like in a standard fashion. So go down with the duodenal scope, it allows us to identify the stricture with cholangioscopy. Go in, have a look. We could not do this with double balloon ERCP. It's very, very difficult to do cholangioscopy through the double balloon system, but we can get up there. We see the stricture, we see the stone and we can biopsy. So the EDGE procedure has been extremely helpful for us in the Roux-en-Y gastric bypass patients, which gives us far more therapeutic opportunities that we don't have with a standard double balloon ERCP approach. Okay. Let's go over here. Then we're going to try up here. I think I'm being jinxed. Can we advance the slide? Thank you. Okay. I just told that. So the next scenario of access to the biliary tree is malignant biliary obstruction. So we have malignant duodenal obstruction. If you have your cancer totally invading the duodenum, you have no access to the papilla at all. And of course you have duodenal obstruction simultaneously. Let's see. Oh, there we go. Good. I don't know. Am I doing it or are you doing it? Whoever's doing it, thank you. So here we are in the duodenal cap. Again, EUS guided cholangiography. We can see the stricture of the bottom of the duct filling up there. You see the duodenum totally occluded. And then we can pass a wire up into the bile duct. And in this case, we use a four millimeter balloon, which at this most would work, I would show you. But anyway, we're dilating up between the duodenal cap and the bile duct. And once we dilate with the four millimeter balloon, we put in a fully covered stent with the anti-migration flanges. And this is a very effective way to obtain drainage in an obstructed duct. In fact, there are three randomized controlled trials showing that. Two of the three show that as a primary therapy, it had a better outcome. So once we've sort of got this stent in, we dilate it, we have good biliary drainage. And again, once that's established, we can go from the duodenal cap. We can throw a wire down across the obstruction of the D2 and put in a uncoated duodenal stent. So we achieve double drainage of the duct and palliative drainage for the outlet obstruction. So again, that perhaps is one of the easier approaches that we have for EUS guided drainage when we have lack of access to the papilla. Okay. Let's see if I can do that. There we go. It works. Now, the third thing, or maybe the fourth. The fourth approach is drainage of the gallbladder. And in this case, this was a younger man. There we go. A 46-year-old man with muscular dystrophy, was not a candidate for surgery, had a previous cholecystosomy tubes put in twice for acute cholecystitis. So he came back. He wanted something more permanent. And this, again, is quite easy. He had a big gallbladder full of stones. We went from the antrum, which is usually the easiest approach. Again, putting in the axial stent where we can get a good entry point, and then release it from the scope. And we used about a 15-millimeter stent. And the advantage of this afterwards, we'll dilate this up, is that we can then go in and we can clean out that gallbladder, get rid of the stones. So dilate the axis up to about 15 millimeters. Then we go back with the stone. We're a little bit just below the pyloric channel as well. So it's an area where we want to be careful. But we can go with baskets. We clean out the stones. And this will stay there. Actually, we kept that stent in for about a year. We went back two or three times. He had multiple stones in that gallbladder. And we cleaned it out. And he was a much happier person, not having to come back for cholecystostomy drains. So finally, in terms of our access, let's see if I can get this. Did we get extra time for my mouse problems? No. OK. Union rules. And the final access approach we have is for hepatical gastroscopy, transgastric access to the liver. And this I consider perhaps the most challenging of all the US access combinations we have. Ordinarily, you like a left hepatic duct at least five millimeters. We want to drive the scope down below the GE junction so that we do not have the stent coming out at the GE junction. So in that case, because segment two is a little more superior in the liver, when you first see the liver, as you go down from the GE junction and you rotate counterclockwise, you want to push in a little bit further, try to get to the segment three duct. To get to the segment three duct, it's a little bit easier to drain. OK. There we go. And in terms of how you create the hole into the liver, I think the easiest way to do that is we used to use needle knives. That's full of complications. So now we use a 19-gauge needle, a wire, and then we try to dilate the tract. The most successful way to dilate the tract is to use a very sharp 543 or 345. There are two companies that make this. That's a very, very stiff catheter. And because you're traversing the stomach on the lesser curve higher up, the muscle is thinner, the wall is thinner. You can get to a direct mechanical entry point. And then we dilate it with a balloon. But if you can't do that, and you live in the United States, and you have an excessive amount of money, what you have to do is you can take an Axios, a hot Axios. Don't use the stent. Just use the hot Axios to create your tract through the stomach into the liver. And then you have a beautiful tract. We don't have the six French cysts at home here. So here's an example. Oh, God, this is all working now. So here we are. We have a big dilated duct on the left side. Patient had previous stenting of a higher stricture, but had recurring buds of cholangitis, elevated bilirubin. And you can see here from the left duct, we're filling up a totally undrained left hepatic lobe. So what we have to do at that point, again, using, in this case, we used a Sohindra dilator. We got through. And then we placed a transgastric stent. The only point to be made is you've got to make sure that you have enough of the stent in the stomach to allow for expansion and contraction of the stomach, movement of the liver with diaphragmatic movement. So we like at least three centimeters of the stent sitting in the stomach. And also, we want to make sure the uncovered part of the stent is in the liver. We don't have the Geobor stent and some of the specialized Taiwung stents yet. So in this case, what I did was, I'm going to get shot here shortly. I don't know. Strangle me. Do something. Get me off the podium. Do something. In this case, what we did was, again, was we put a fully uncovered stent, wall stent, that would not be dislodged from the liver because it's uncovered. And then to prevent the bile leakage between the liver and the stomach, we just insert a second covered stent. And it's a way around not having those specialized stents. So amen. Thank you very much for your attention.

EUS

ERCP

access techniques

cannulation

endoscopic ultrasound