It is my great pleasure to introduce the moderators for session two. It will be Dr. Todd Barron from UNC, Dr. Natalie Cosgrove from Advent Health Medical Group, Dr. Jason Samarsena from University of California, and Dr. Amy Tiber from Rutgers Robert Wood Johnson Medical School. And for the next live case, we will go to Dr. Manuel Perez Miranda from Spain. Okay. Good afternoon. Let me introduce to you my crew here. This is Mar, our endoscopy tech, Maria, nurse, endoscopy nurse, Rebecca, our x-ray tech, and then our visiting fellow, Viridiana from Mexico, Daniela from Colombia, she's going to present our case, and then the reigning fellow from Spain is Antonio, the tall guy here in the background. So good afternoon to everybody. We're going to begin with the first case. It is an 82-year-old man with a history of eight months of obstetric jaundice. And the MRI showed a 2.3 centimeters mass on the ampulla with dilapidation of the pancreatic duct and intra- and extrapartic biliary tract. He underwent an RCP on November 2022, there a tumor of the ampulla was seen, and a fully covered 60 per 10 millimeter stem was placed. The pathophysiology confirmed an adenocarcinoma of the ampulla, but unfortunately the patient declined palliative chemotherapy. He now presents abdominal pain, vomiting, and weight loss. The CT showed a local enlargement of the tumor with infiltration of the duodenum and an important gastric distension. The endoscopy showed a duodenum stricture non-crossable. So for this patient, we propose an EUS guided gastroenteroscopy. So this is the EGD. There was some food residue. We have plenty of time to aspirate all the bile. There is some solid debris in the stomach. We have also plenty of time to discuss whether this was pills or lentils. And this is what I want to show you is the posterior wall of the upper gastric body. This is where typically our DJ will be sitting. The method we will be using is slightly different from the one described by Dr. Thompson. We call it the dry-wet. So we don't flood the small bowel with fluid until after the echo endoscope is in position. So as we approach the pylorus, we see a very enlarged duodenal valve. And at the apex, what will be a type two duodenal stricture, there is these folds. We have the prior biliary sands, and despite this patient's severe gastric outlet obstruction, these strictures are relatively easy to be passed with the endoscope. That's probably what led to the predominant method in the United States for distending the small bowel directly through the endoscope. What we're going to do is use a three-layer catheter to pass a guide wire past the trides. So if this were a type one stricture, we wouldn't be leaving the wire in the second duodenum or third duodenum. We will be pushing it forward until the trides. So this is pretty much the same as placing a duodenal sand. The first step is just getting the guide wire across. The only thing we need to be careful in this case is not getting the wire tangled through the meshes of the prior indwelling biliary sand. Fernando, can we have the fluoro large on? So if you look at the fluoro screen, you see the tip of our gastroscope. You see the tip of my wire coiling in the angle between the second and third. And now, un poquito de zoom, por favor. I am pushing with this three-layer catheter, retira la guia, despacito. I'm trying to get my wire across the bend of, this is a trides angle. So the interplay between the floppy inner guiding catheter, empuja, and my flexible catheter helps, no, no, retira un poquitin. So the reason I'm sort of wasting time in getting my wire across, so you can see my fluoro, empuja. Manuel, can I ask a quick question? This is Todd. Yes, of course. Why don't you just use the echo scope for this part? I never use the forward-viewing scope. Well, you have the same scope ready, and you don't have to reprocess another endoscope. Yeah, we, retira un poquitin la guia. We could do that with the echo endoscope. But sometimes, retira un poquitin la guia, if we want to aspirate pre-existing content, mete la guia, it's easier just to use a therapeutic gastroscope and aspirate with the gastroscope. Yeah. Okay. Again, we have pretty skilled technicians, vamos a hacer intercambio, you'll see in a minute how fast they can exchange a regular metetherapeutic gastroscope. Well, it's not that it's changed. There is an inherent cost of reprocessing endoscopes that people don't think about. You don't reprocess an endoscope for free in the U.S. It's assumed that it's at least $250 to reprocess an endoscope. So it's really more the financial thing. We save in anesthesia. So our anesthesiologist is Propofol Pump, which is much cheaper than the fees of a regular anesthesiologist. So everyone can save in their own way. For us, reprocessing is not nearly as expensive. Again, some people would say, I'll save in an asobiliary drain. But again, your point is fair. We can do the same thing, like placing the wire under a therapeutic endoscope, just to show the posterior wall of the gastric body, to aspirate fluid, to show the dilated duodenal valve, which were interesting features. I think that everybody gets that easier with a gastroscope. So this is our 8.5 nasobiliary drain. We are pushing into the trite at this moment. So the flexible, I was unable to manipulate the wire across the trite in no time. However, the round tip of the nasobiliary drain you just saw went very easily beyond the trite. I'm removing, can we have the endoscopia en grande? So we are doing endoscope removal, Antonio, the fellow, the senior advanced fellow is going to hold the nasobiliary drain at the patient's mouth. And then we remove the upper, therapeutic upper endoscope. And then we introduce the echo endoscope. While we are doing this, can you show our hands, Carlos? We are reconnecting the top, the top lower lock adapter for the nasobiliary drain. And you see why we call this a dry method. We still haven't injected a single drop of contrast, methylene blue or saline. The reason for that is that we want to avoid any confusion with what part of the small bowel we will be looking at when we have many distended loops. So now, Carlos, can you show the endoscope on my hand? We call this the parallel enteric tube. Everybody is giving this a different name. I'm just advancing the linear endoscope alongside the 8.5 French nasobiliary tube into the, through the esophagus into the proximal stomach. And now we use both EOS landmarks and fluoroscopic landmarks to make sure we land our stent at the trites angle, because the trites is the less or the least mobile part of the small bowel is where the duodenum enters the peritoneal cavity. So again, we see now, we see nothing virtually. Can you see my cursor, Todd? Here in the, over the transmission. So pancreas. Yes, I can see your, yep, I can see it. Air. And probably within this artifact, it is our drain. So this is the first landmark that we use. We look for the pancreas and the small bowel next to it. So that way we make sure we're not looking anteriorly towards the column. Second landmark will be fluoroscopy, right? Rebeca, un punto mas de zoom. So we zoom in. So I'm pulling backwards, backwards, my echo endoscope, podemos poner el rayo en grande? So this is the trite on fluoro and on EOS. Yet we haven't injected a single drop of fluid again, and we're going to pull the nasobiliary drain. Carlos, can you show my hands, please? So el rayo en grande, verdad? I'm pulling backwards, I'm pulling from the drain, and I want to get the coil tip of the NB drain right or as close as possible to the trite's angle. So Todd, you see the fluoro? Yes, I can see it. I'm shortening, I'm pulling, I'm pulling. I don't want this to come backwards to me like a spring, so I'm going to do it gently. I'm straightening, I will stop there because it's going to come by itself. Right. Yeah, but that's a good point, is you always want to put tube way ahead of where you need it to be because you can always pull it back, but you can't advance it once you took the scope out. The other I was going to say is we do them supine, which is fine, but you'll notice when they do them supine, where the tube in the stomach is close to the tube at the ligament of trite, that's where you know you need to focus where your endoscope is going to be, where the two are very, very close together. You know what I mean? So you have a greater curve going down, and then when it's in the duodenum slash jejunum, those two tubes by fluoro, when they're on their back or maybe prone, are going to be close together. You know what I mean? So you can park the endoscope right where the tubes come closest together, and that's where you also know you're going to find the right location. Yes. So I'm not really sure about what's the effect of patient position because the trite's angle is less small. I don't think the small bowel per se changes the relative position to the stomach. What it does change definitely with patient position is where the fluid is going. Is it going backwards towards the bowel or is it going more distally? So you see my cursor, this is small bowel moving. So can we have some buscopan, Dos Ampollas de Buscapina? So now we're going to put the contrast. So have the x-ray in, you see the US on the X-ray. We put 40 CC of contrast. Can we inject Viridiana? You see the collapse. There's bubbles air as we are flashing the MV tube. So, and it is distending very nicely and we are a hundred percent certain this is not the column, right? You see this is flowing distally and also a little bit backwards. So, this is it. And now we're gonna connect. Can you show her hands to the pump? Para. We stop injecting contrast. Manolo, Amy Tyberg, how are you? Hi, Amy. It's good to hear you. I have a question. Are you also giving glucagon or some other agent to kind of paralyze the small bowel? Or when do you administer that? La bomba. Sorry, Amy, I didn't get you. Venga, la bomba. So, we connect. Sorry, can you repeat your question? Yeah, of course. I was just asking when, if you're gonna give a glucagon or some other agent to demobilize the small bowel. And if so, when is the right time you think to give it? Yeah, but when we, yeah, when we are there, I mean, or at the beginning of the procedure because it doesn't usually take longer. So, Todd, any question? This might be the transverse column. No? Are you convinced this is small bowel? Manolo, it's Jason. Hi, Jason. Wonderful presentation so far. La bomba. I think, you know, what was nice was, you know, we saw a GJ procedure earlier this morning and the technique was going down with a ultra slim scope, filling the bowel and then coming back with the EOS scope. And what we could appreciate was just a lot of loops of small bowel. And, you know, it was difficult to appreciate, you know, if we were looking at small bowel or colon. And I think with this technique, you demonstrated beautifully that, you know, you're kind of checking things on multiple levels horoscopically, you see the echo endoscope in close proximity to your nasobiliary drain. I think what you're going to be able to see on EOS shortly is you're going to actually see the tip of your drain. And I think this is one of the best signs that you're right on target. You're not going to be in the colon. One of the techniques that I've been using recently is I actually do a double scope technique where I use the ultra slim gastroscope, the XP 190, and I go past the stricture and I leave the scope indwelling. And I can often see the, and I use that as my device to fill the lumen. And I pass the echo endoscope alongside. I can oftentimes see the tip of the scope as I'm puncturing the bowel. The other thing, sorry, somebody had interrupted me. That's why I didn't answer you. The other thing with this technique that you're doing is if you hook it, we hook up the nasobiliary tube to the flush pedal and we mix our bottle with contrast, of course, saline and methylene blue. But when you step on the pedal and you put Doppler on, you also see swirling of contrast, which also confirms that you're, at least in the small bowel, the colon's not gonna give you the swirling with Doppler when you're hitting the flush pedal. So that's another way you can kind of confirm you're looking at the small bowel. But I don't think there's any question in this case. So exactly, Todd, that's the other thing. So we have the water pump connected. We would not start, we have injected a little bit through the pump. So we only injected 40 cc of dilute contrast through the MB tube. So as Jason was hinting before, we may look for the drain. Ken has written or published about that, but it really, why look for the drain when there is no question? What you're looking for, what you're looking at is the small bowel. So the other thing that you mentioned is until I don't have my Axios catheter ready in place, there is a vessel there. Yes, my fellow is warning me. He is very smart. He is also highly hireable. Regrettably, he will have to remain in Spain. He's a man committed to his family and all of that. So yeah, he's always there. This vessel is always there, but we have nicely distended target. The axis is not perfect. What I like here, I'm pushing the tip of my catheter is how perpendicular this is coming. So what I want is a 90 degree angle between the wall of the small bowel on my catheter. So I don't go tangentially and push the small bowel. Let's see about the angle, about the landing space, so to speak. I think this is good enough. So our experience, we've measured this, is that if we put a fluid, can you step on the pedal, bomba de agua, por favor? So this is the artifact. This is the like Venturi effect that Todd was mentioning. We see. I'm gonna freeze the image and measure. Typically, the small bowel will be stand up to three centimeters, which is here 26. Okay, not that great, but it's good enough. And then the most important point from what I want to demonstrate is what we call the boiling water sign. How to make certain that we are in the small bowel and not in the peritoneal cavity, because with the tip of the hot axios, we literally boil the fluid in the small bowel. And we see that on ultrasound as white bubbles. So I'm pushing on the wall and at the count of three, I'm gonna burn through and we're gonna see the boiling water sign. One, two, three. These are the bubbles. So if I'm doubting, I can step on the pedal seat bubbles again. This is the small bowel and nothing else. I keep pushing my catheter all the way until I feel some resistance. I'm hitting the contralateral wall. This is a blind spot, but I don't care anymore because the tip of my catheter is inside. I'm deploying distal flange coming backwards. And then in case any doubt because of that blind moment, we can go back to fluoro. So we can put, and now when we have the distal flange deployed, this is the moment when we put the methylene blue. So you see our fellow Dr. Viridiana. Please inject, Viri. So we put the methylene blue right now so it doesn't get diluted. And now I deploy proximal flange intra channel as Dr. Thompson demonstrated. And we do step number five, which is pushing the second flange out of the echo endoscope. This is, and then we see the methylene blue. Again, we get confirmation. And then because this patient is not intubated as we would probably not intubate a patient for a duodenal stent placement, we take care to suck all the fluid. We also take care to avoid any retching with adequate sedation. What were the cautery settings you have for your axios for this? Oh, that's another very relevant question. We make sure there is no window cut. So it's pure cut, high wattage. So typically what we want to do is cut through the wall of the stomach and the small bowel like a hot knife on butter. So we're going to go and melt it without any difficulty. So we would increase to effect five, 120 watts. So this is slightly higher, what is recommended for more conventional LAMS indication. Yeah, we do the same thing. Like you said, you don't want to push the small bowel away with the tip of the axios. You want it to cut through right away, so. Manuel, this is Natalie. Absolutely beautiful presentation. Thank you. I have two questions. I apologize if you answered this already. What size LAMS are you doing and are you routinely doing freehand now? So never pre-loading with the wire. Never. We only did over the wire. I completely concur with Dr. Thompson. We only did the wire when there was no hot axios. And since the landmark paper from Tokyo University by Dr. Takao Itoi in 2016, it was really the first to describe the effect of the wire pushing the small bowel away. Yes? So we always go freehand these days. We just need to make sure the target is adequately distended. So you see where the axios is sitting, upper posterior body. This is very consistently where the trite is, regardless of individual anatomical variations in the configuration of the trite's angle itself, which is very reassuring when you try to... It's also probably why we may have better outcomes functionally than surgeons do because there's a thing called the Magenstrassen. You ever read about the Magenstrassen? It's the gastric- The what? It's called the Magenstrassen and it's the gastric highway. So people have actually done physiologic studies and- Oh, yeah, yeah, yeah. Okay. So you're along the gastric highway and sometimes when they do their surgical, it's on the anterior wall of the stomach and it doesn't really give you the same effect. So I think functionally, we end up getting a better effect sometimes than a surgical GJ. You don't see these patients that have delayed improvement like they do sometimes surgically. And as you know, some of the surgical ones just never open up even though it's wide open, they can't eat. You know what I mean? Yes. This is again, what you're saying resonates with Chris Thompson comment that patients really eat better. Yeah. It's oncologists who notice that because they follow the patients up in their clinics. And in the beginning, when we started doing this 10 years ago, they said, don't do the duodenal stent, do this other thing that you're doing now. And so we've actually measured not only gastric outlet scoring system, the GOGS that I think it was you who invented, that thing, the one, two, three or zero, one, two, three, four, but also measure quality of life on the improvement in other aspects like constipation, abdominal pain. It's really something with these gastroenterostomy. So like probably everyone else, like you or Chris at Brigham, we've moved from gastroenterostomy as salvage for fail, rarely technically, most often clinically failed duodenal stenting to our primary approach for palliation of malignant gastric outlet obstruction. Yeah. Very nice demonstration, Dr. Miranda and team. Thank you. Jason, we have another GJ. It only takes 10 minutes. If you want us, we can do it on camera. Would you go somewhere else? As I said, we don't have anesthesia. So we will be having a new patient on the table in 10 minutes. And this is a patient with pancreatic cancer, type one duodenal stricture. And also he has abdominal pain. We will be doing a combined gastroenterostomy, pancreatic, US guided pancreatic duct drainage. If there is time or this is convenient for your program, we can do it on camera. If it's not, we will do it off camera. So it's up to you. Thanks for letting us know. We'll come back to you if possible.

EUS-guided gastroenterostomy

obstetric jaundice

pancreatic tumor

dry-wet technique

fluoroscopy

ultrasound