And we will go to Orlando Health next to Dr. Shyam Varadarajulu, who will show us a QUS guided biliary drainage or a gallbladder drainage. Hi Shyam. Hi Thomas. Hi Shyam. I'm with you. So what are you going to show us? Okay, that is the case that you have on your slide. This is a 56-year-old patient with malignant obstructive jaundice. The patient has got a 12-centimeter hepatic mass. So this patient very recently underwent an ERCP. His bilirubin originally was about 23.7. So that total bili is not 2.7, it's 27. So Dr. Bang did an ERCP. She placed a stent in the right system, got down the bilirubin to approximately 14 or 15. They were contemplating chemotherapy for this patient, therefore they want the levels down a little further. At ERCP, it was not possible even for the best technician to navigate the wire to the left system. There was an abrupt cutoff. So we are trying to perform an EUS-guided hepatogastrostomy today. So I've got a Pentax linear scope. I got my colleague Ramesh, who's a little overqualified to help me with this procedure. And I'll just give you a lay of the land. Steven, we need to show endoscopic view and EUS view now. So I'm advancing the echondoscope into the bulb, and then you see some pancreas. You see the biliary stent going into the common bile duct. And then beyond that, the pancreas looks okay because it's a cholangiocere. I'm not going to come up to the stomach, Thomas, and then I'll show you a few things. So you can see, where you see duct dilation, you see this huge mass that occupies almost the entire liver. That is the mass. It's completely blocking. It's about 12 and a half to 13 centimeters. So we have to do business with this and find some place where we can treat. If I go deep into the stomach, I get this biliary dilation, but I don't like this position only because it's almost impossible to navigate a wire through this. The distance from the gastric wall up to here is about eight, seven centimeters. So that's too far. And also terminates into the liver here. And then when you trace it, it takes an upward direction. So wire passage will be difficult. I'm retracting the scope, and this is about two and a half to three centimeters below the gastric cardia. So this is a reasonably good location. And if I measure this, it's approximately two centimeters distal from the gastric wall. So it's two centimeters that you can see here on my caliper. So the second thing is, one of the things that you have learned from enough complications is on my endoscopic view, the gastric wall is unfortunately very, very thick. The gastric wall commerce is about two centimeters in thickness. Let me see if I can get, I think, all right. So as I go towards the, yeah, I can see here, as I go towards the antrum, I can't inflate very well. So guys, so make sure the CO2 is working and the suction is good because we can inflate too well. I think it's nicely demonstrated how difficult it may be to find the magic location. Yeah. And also, Shyam, I think you have to reckon that you can't pass with the wire. So the wire has to stay in the relatively short powder and anchoring might be more difficult. So what we are trying to do, Thomas, is to just show, we'll try a different bottle. Which one? Water bottle? Some minor technical issues, Thomas. Let us see if we can get our inflation statement up here a little bit. I mean, the question is, is there a maximum diameter of the gastric wall for all these procedures, like also gastroenteroscopy or, we don't know enough. Yeah. We'll get somebody into this room. Just make sure suction is good. Thomas, the thing is, if the gastric wall is very thick, my challenge always, why don't we flush this? My challenge always has been that when you use a systotome or cautery to dilate the gastric wall, things get very, very challenging. What happens is the wire gets pushed out and things can get a little challenging. So that is my worry with a gastric wall. So here I am towards the antrum. I think we also have to admit that the procedure with our technical aids are the worst ones. So Megan, look at your suction and so forth. You know, for GE and for cysts, you have this yo-yo stent or different ones, but here you have to get the wire in, you have the needle, you have the risk of sharing off. So I think there's a huge need, which we have been telling to industry for about, I don't know, 15 years. There's a huge need to improve on the excessive... Gene or somebody who can do something better. Well, that's a time for Ken to invent something new, right? Yeah, we're still held hostage to the Sotinger technique for transhepatic, transgastric. And you know, unfortunately in the US, we don't have the six millimeter systotome. That already would be hugely helpful because we're limited to basically bougie. A 10 French systotome is simply too large and causes too much thermal injury. So I really reserve transhepatic, transgastric as an absolute last resort. And I always dread doing them. I'm with you, Ken, on this one. I think we always go as a last resort with a transhepatic drainage. This is not a procedure I enjoy. I would rather prefer this procedure over PTC. It always makes me a little nervous only because lots of things can go wrong with a transhepatic drainage. The technique is very, very poorly standardized and that is my concern with these procedures anyway. So we're just rebooting a few things, but we are going to get ready with this. What I'm trying to do is to puncture the dilated left radical, and after we do that with a 19 gauge needle, we will inject some diluted contrast, get a lay of the land, get a wire inside. We prefer to use a O2-5 wire. And then after that, we dilate the tract and then deploy a stent. So, Shyam, could you show us how among those black tunnels and tracts, you select the right one? Don't hit vessels? So, Thomas, the general preference is to go to the second segment or the third segment, which usually corresponds to just at the level of the gastric cardia. We have changed all these things, which is at the level of the gastric cardia, three to five centimeters below the G-junction. And unlike an ERCP, we want to perform these procedures in a left lateral position so that you can get an orientation of the liver segment very well. The catch always will be when you're looking at these segments, not to deploy a stent through the distal esophagus. The distal esophagus can be a killer because you're ultimately finding at five centimeters through the G-junction is where we go with this. So therefore, you want to be very cognizant of where you're going to puncture it. We're just going to switch the scopes for a second, Thomas, only because, as you can see here, I'm struggling a little bit with the insufflation of the gastric wall. So let's go very quickly and change the scope. Yeah, that's fine. In the meantime, we have a good message for Ken because there was somebody saying in the chat that the six French sister tomes from Taivong is now available in the US. I don't know whether I'm allowed to say that. But I'm European, so I hope you can forgive me. So in the United States, Thomas, we now have access to the six French sister tomes for the last couple of weeks. Taivong has been approved. So I think they have a six French sister tome and an 8.5 sister tome. So we do have those stents available in the United States. Very, very recently. Previously, we used to use the needle knife catheters. We used to use bougies and so on. But now, yes, because of Taivong, we have access to the six French sister tomes. That's great news. Are you going to use it today? Yeah, that's exactly what we are planning to do. We are going to use the six French sister tomes. Is it working? All right, let's drop. So the procedure has been switched from miserable to, let's say, poor with regards to accessories. So just a quick, yeah, scope turnover. And then I just wanted to show the gastric wall. So here we are at the antrum. And if I pull back, you will find that the gastric wall is very thick. And I measured it to be approximately two and a half centimeters in thickness. So this is always my challenge. When I puncture, dilation can become very challenging unless you're very tight and in sync with the gastric wall. So, okay, let's get EUS on the monitor and let's go with a puncture. Hey, Shyam, this is Amit here from KU. So why do you think the gastric wall is so thick there? Is it just... That's a good question. I don't know whether it is from cancer related change adjacent to the gastric wall in the liver. That's a very, very good question. But I have no idea at all. But it's very thick at that location. So that, to me, is always a little bit of a concern. So now let's go, Ramesh. We've got a 19 gauge needle. I have selected a Boston Scientific flexible 19 gauge needle, which is my usual go through needle. You can use any needle here because all that we need is a conduit for passage of the wire. So here is a good location. And I've already measured it. If I turn the other direction, I've got a lot of branches. I want one good central puncture. So here's my needle coming out. I'm exactly at 53 centimeters, which puts me a little below the gastric cardia. And then once the needle is in, as you can see, your anatomy will change a little bit. So Ramesh is giving me a little bit of traction. The majority of this procedure should be performed under endoscopic view and not endoscopic, EUS view. And we should resist the temptation to go with an endoscopic view. It's purely under EUS and purely under fluoroscopy. So now please get me fluoro view, fluoroscopy. And Ramesh is now injecting diluted contrast and he's getting a layer. So you can see that stint going down to the liver hilum. It's going to be a little tricky, Ramesh. Agree? We have to navigate our wire down. Right. And I think, and then, and then I am. Yes, Thomas. Is that left side? What is that? Is that really left side? What is it? Is it left side? Yeah, so that is a good question. I think so. Yeah, I think it is because of the, it is left. Are we happy? The right anterior is coming out of the left duct. Yeah, I think so, Thomas. Right, it's, we can. So what we are trying, Thomas, is, let me, give me a second, is to find, see here, this is all left, turn around. I mean, x-ray, I'm not so sure. Because patient is on the left lateral position, okay okay sorry okay patient is in the left lateral position. And what I've done is fluoro please again. And yeah, I think, I think this is the this is as good as it's going to get Thomas left lateral, but I'm not happy to pleased with the direction of the contrast them as what happens is the tumor gives me only one access, this is the only location, I can, I can have access to for draining this. If I go towards a central that's a huge tumor mass. And for me the major concern on this particular case is going to be wire shearing for my colleague is going to help me because that angle is a tough angle. Okay, Ramesh, I think we are good here. Inject very little more contrast. Let us see if this has changed anything. Inject again. Okay, I think. Is that the fluoro please? Yeah. Okay. All right. Let's try the wire. So, this procedure can always be salvaged until we use a system and perform a dilation. If I'm just going to perform a cholangiogram he's on antibiotics. I'm okay with it. But once I dilate this, then it is a point of no return. So Ramesh is using a zero to five inch wire is an Olympus wire with a curved tip. It's the busy glide wire. So we're going to try to see if we can get this wire down in the direction that we want it towards the high lump. Go for it. Perfect. And if not, would you be happy with peripheral location? Ah, that's a good question, Thomas. Am I happy with the peripheral location? No, but I will take what I get. Okay, see, that is the angle. Let's let's say satisfied. That is that is a challenge. No. Let's retract that needle a little bit and give him a little bit space to see Ramesh. That is not the best angle, right? Huh? You? No. You, do you think we should? Yeah, I think so. I think it'll be good if we can take it the other way. But if we have to, we will do that because it's going to be uncovered stent. See what you can do. But what I will want to do is I will not shear this wire. Okay. Let's pull back a little bit. No? So what I'll do is this, fluoro, change my angle a little bit. Does it help you? No? No. Well, let me say, I don't think I can pull my needle. But what I'll do is I'll see my wire scope moment is making things more complicated for you. Right. So see that. See if you can push it down. I think you're outside now. But make sure we are not shearing, Ramesh. It's very important not to shear this wire. Yeah. Did the needle come out, Shyam? Did the needle come out of the bile duct? What is that? Is the needle is still in the bile duct? Yeah, I'm going to look at it, Amit. Give me a second. I think I'm in the, I'm still in the duct, I think. See that? I'm still in the duct. Yeah, I'm in the duct. Yeah. So let's not push our luck. I will not shear it. If you're having resistance, I would rather pull the needle out. I don't have no problem repuncturing this, but I don't want to shear this. Okay. Okay. I have to pull it out complete. Okay. See? It's not coming. See that, Thomas? The needle is stuck. I'm going to just pull it back completely. Much safer. Pull the needle. Much better. Take that wire out. I think it's an impossible angle to get down. Yeah. Thomas, we may have to go with what you previously were alluding. We may have no option, but to take it towards the other side. I don't like it, but that's what we may have to do. I think what we have seen in the afternoon up to now, and I don't know whether the others agree, is that there are not so many options about the location. No. And the question always comes, is this right for the patient? It's not about what we want to accomplish, but is this the right treatment for the patient? So the best options GE had, because it was a huge cyst, but even for the GE, and here even more, it's really difficult. So we're going to just repuncture, Thomas, and then we're going to take the angle it allows us to take for decompression. Shyam, you had the wire, it's a pretty big duct though, right? Would you agree? I mean, the one that you had the wire deep in, that's a decent sized duct. I know it's going peripheral, but with an uncovered stent. Yeah, it should get your job done for you. Whether it is ideal, I don't know, but I think it should get it done for us. So let's go back again, Adit Ramesh, right? So where are we? Plural for a second, please. So yeah, so back at that same location. So, Adit Ramesh, at the end, the alternative would be a temporary left side percutaneous drainage? Yeah, I think it's temporary percutaneous drain. That's correct. That is what we will do. Obviously the patients prefer to have an internal drain, but we have already talked and explained to them that the options are quite limited in what we can offer. So they're quite understanding of the situation. There is a fair chance of a rendezvous getting down and placing a stent via ERCP later. It'll be awesome, Thomas, if we can do a rendezvous, but I don't think it's going to happen with this anatomy. So let's inject and let's go with where the wire is going to allow us to go. I mean, with the percutaneous access. Yeah. Okay, I see where we are. I think, yeah. So I should come back a little down, don't you think? I'm too much towards the periphery. So pull back. Few more. Dr. Varadaraju, thanks for the nice demonstration as you're working on it, we will go to another institution and we'll come back to you after. Sure. Shyam, we are back. Okay, Thomas. So Thomas, I'm going to show you what we had done. Okay. So you see the wire. The cable. Okay. So Stephen, we need to show EUS and the fluoroscopy image. So we have the wire in the liver. It's going towards the hilum. Unfortunately, the only one who is anywhere near it. So, okay. So the stricture, Thomas is very long at the hilum. Let's go to the next image. Yep. So, Ramesh was able to navigate the wire to the liver hilum. And then we realized the stricture is very long. So go to the next image. Here you see the systotome, the sixth French systotome had no resistance going in. Next image. And then we got some sort of a cholangiogram. So to confirm our position, next. And the systotome was applied, reintroduced, next. And then the tract was died. Shyam. Thomas. We are just seeing one image, I think. Oh, Stephen. No. Can we show the... We have a delay. Now we see the systotome. Yeah, reference image. Do you see the reference? Ah, there we go. So there you see the wire, Thomas. Next. Wire towards the liver of hilum. Next. There's a tight stricture. So there's only like four centimeters of viable duct. And then it's a very, very long stricture. Next. And then afterwards, we confirmed it with a cholangiogram. Next. Next. And here is a four millimeter balloon dilation of the transgastric intrahepatic tract. Next. Okay. So now, Thomas, since the dilation is done, I'm working purely without endoscopic view. We have got an eight centimeter fluoro, partially covered metal stent from Boston Scientific. So the challenge will be how much of stent is going to be really inside the liver. I'm afraid we will have about four centimeters in and four centimeters out. And this is done under semi-blind view. I did not dilate completely because there's always a risk of leak. You can see how easy the stent goes on EUS view, fluoro now. And there, it has to take the turn. The turn has been taken. Ramesh, what do you think? Good, right? I think we're going to, because if I push any further, Thomas, there's a stricture. So I'm going to stay right there. Let's slowly start deploying Ramesh. So we're going to start deploying. That is a stent coming out. Keep going, Ramesh. Keep going. Keep going. I'm going to keep pulling back, pull back. So Shyam, this is your excess stent for further manipulations. That is right. I have full back. So I'm going to pull back a little bit more. What do you think? Yeah. So on EU as you can see the stent getting deployed. I'm going to keep pulling back, Ramesh. Are you okay? Yeah. Okay. I'm going to move away from the stomach a little bit more before I move away. Fluoro. Good. Okay. Now I'm going to move away from this. So this is the only time in the procedure where we are going to show, we are going to go on endoscopic view. Danny, come here underneath. And then I want you to pull the scope slowly. So I'm having another assistant help me with pulling the scope away from the patient so that we can get endoscopic view. Yeah. Slowly pull. Fluoro please. So we're going to just pull back. I want to pull back. So hold on. Now, this is semi-blind, I hope. And then we have CO2 on. So I see stent here, right, Ramesh? Yeah. So I'm going to pull back a little bit more. I want to pull back and you pull the stent back. Pull back, pull back. Okay, Ramesh. You can deploy. I think we are in the stomach safely. Yeah. You can deploy. That's it. So the stent is on the gastric side and one half is going to be on the hepatic side. So everything is out, Thomas. And then we will, the catch here is to make sure the stent is going to be not into the esophagus, but in the gastric cardiac region. So you can see it's all red and, yeah, inflating. Yeah, I see bile draining here. And we are having a little bit of vision issues, which is not uncommon. I would like to show endoscopic view. There we are. So here is stomach. I'm going to decompress the stomach a little bit and show you guys where the stent has been placed. It's going to be somewhere in the gastric cardiac. There you see the stent on EUS. It's coming into the stomach. And it's actually a little funny location. It's right in the stomach. So what we need is, Thomas, is an endoscopic view. I'm going to let you go back to Ken and I'm going to have a gastroscope to show you how the stent looks. Okay, can we do that? Yep, we'll do that. Let's get a gastroscope. So we like your positioning of the needle. So let's see now where the stent is positioned. Shyam. Thomas, so this is just a quick EGD view. You don't want the stent in the esophagus. So here is the gastric cardiac. Advance the scope. You can see bile flowing. And then here is a stomach that ejects out. And we have positioned in the body of the stomach. And let's show the fluoroscopy view. And you will see that the stent is bent backwards, and things are draining. So that's pretty much it, Thomas. It was a little difficult. Hopefully this will result in some palliation of jaundice, so that he can get his chemotherapy. Shyam, any utility of putting plastic stents to this? No, I know in this one it will be difficult. But do you put in a double-pigtailed plastic stent through this? Probably not needed, Thomas. This is a 10, 8 millimeter by 8. It seems to be working. I don't see any kinks in it. I think if I put in a plastic stent, where am I going to leave it? It's going to just pass. And then right at the proximal, the duct ends with a cancer. So I don't think the proximal stent is going to do any good. At least here you can see towards the periphery. There were some liver radicals, and everything is draining. The contrast is draining very well. So I don't think the plastic is going to be successful. I've got a nice coated portion at the GE junction area, so there will be no leak. Things are draining nice. And for this patient, this is as good as it's going to get. Right. So you are relying that the left side will be drained through the side holes? Because the stent is in a good position towards the hilum. But I agree, that's the best we can do. Yeah, that's the best we can do. Correct. So thank you very much for keeping patients and suffering through this. It was, I think, the toughest case up to now. Brilliant. Thank you. Thanks, Thomas.

QUS guided biliary drainage

malignant obstructive jaundice

hepatic mass

EUS-guided hepatogastrostomy

transgastric approach

metal stent