We will next go to Dr. Mohin Kashyap from Johns Hopkins, who will show us an EUS-guided direct transgastric ERCP procedure. Johns Hopkins team, you're live. Please go ahead with your case. All right. Good afternoon, everyone. We'll be going over a case of endoscopic ultrasound-directed transgastric ERCP today. Our patient is a 47-year-old female with a history of obesity and laparoscopic gastric bypass five years ago. She presented with right upper quadrant abdominal pain and was found to have choledogolithiasis and acute cholecystitis on her right upper quadrant ultrasound. She had elevated liver enzymes and a bilirubin of 2.8. On the ultrasound, there was a four-millimeter stone with mild dilation of the common bile duct and intrahepatic duct, as well as innumerable gallstones. This is a long axis view of the common bile duct, and you can see the hyperlucent stone within the duct there. The decision was then made to proceed with EDGE procedure with Dr. Khashab today. Okay. Hi, everyone. Can you hear me? We can hear you. Okay. Excellent. So can we put the EUS view, please? All right. So linear echo endoscope, we are in the pouch. And we see, we're looking here at the remnant stomach. So we're going to distend it, although it looks good already, but we're going to distend it further. Fill it, and then we'll do the gastro-gastrostomy. So I'm using a 19-gauge needle that you can see here. And you can see the needle in the lumen. And let's show fluoroscopy, please. All righty. So live fluoroplase. Going to inject here. And this is important. We're seeing that the contrast is flowing towards the fundus off. And confirming this is the stomach, and we are injecting intraluminally and not intramurally. I'm going to give a milligram of glucagon, let's attach the pump, please, just to slow down gastric motility to retain the fluid. And then I'm going to attach the 19-gauge needle to a pump with saline and contrast. And I'm going to start pumping some fluid here. Can you guys help this thingy? Hi, Moeen, it's Amy Tyberg, how are you? Good, how are you, Amy? Fluoroscopy, please. OK, so we're filling the stomach. You see it's a little out of shape. Yeah, go ahead. Oh, I was just going to say if we could see the EUS view with the fluoro view. Yeah, can we put EUS and fluoro side by side, please? Yeah. Thank you. All righty. So I place usually 250 cc's. Sometimes the stomach, the remnant stomach, is completely collapsed. So the test injection initially is very important. You want to see it's flowing towards the fundus. You want to make sure you're not injecting intramural, which happens. So once I see the stomach is distended, then we go with the 20-millimeter axis. So the initial puncture site is not important, because this is just for filling of the stomach. We will move. We will be guided fluoroscopically. We'll guide the placement of the stent fluoroscopically with preference to create the anastomosis coming towards the gastric body. You want to avoid the antrum, because of just weird ERCP angle, and also embedded LAM syndrome. You want to avoid the fundus, because it's vascular. So I like to go to the body. Fluoro, live, please. So it's off. So you see now we are actually in the antrum there. But again, it doesn't matter. Very odd-shaped stomach. But we see this all the time. The stomachs, for some reason, are odd-shaped in these patients. Fluoroshot. So I think this is good. So I'm going to take this needle out. And then I'm going to now use fluoroscopy. Live, please. So angle towards maybe just a little higher up there. So where's the off? All right. Live, please. So this is probably as good as I can get it here. The body there. It's tricky because it's so J-shaped. Yeah. And so you have, okay, you have, you're seeing, you're seeing EOS as well, right? Yes. Hold it here, Sophie. Hold it here. Good. So I use the 20 millimeter axis so that we can do same session ERCP. I know you guys have seen a lot of axis today, so we're going to skip the details of that. Okay. And so recently there have been a talk, there's been a talk of changing the setting. If you use the VIO 3 instead of the VIO 300, maybe you need a little bit more power. More voltage to get in a fluoro shot. So we did increase it a little bit. I think it goes smoother, maybe sometimes too smooth. I'm going to be careful. And so you guys see the EOS image there? Yes, we see it. All right. So we're going to use the... Okay. Well, we're going to go in and we are in. You lose view because of the depth. I think the higher voltage for this procedure in particular might be important because you have to go through two pretty thick stumps. Yeah, exactly. There's scarring and you know other factors that make this even more tricky to get the... If you guys noticed the flange opened slowly. Uh, Fleur please. Uh, so we're gonna back it up. I'm gonna just jiggle it a little bit here. Plural please. Can you match plural? I can't see well. Do you guys see it open there? It's a little hard to tell because of the contrast, I think. Yeah, off. But it looks open on US. Yeah. I'm having a hard time pulling it. So what I'm going to do here. My scope is very, very short here. So let's see if we can change the angle. That's better. You know, my catheter is stuck. I haven't seen, I haven't heard Todd saying anything. I think he's scoping right now. This is Natalie. At this point, would you consider putting a wire? Yeah, yeah, that's what I'm thinking here, but I can't pull this. The stent is stuck for some reason. Okay, let's get a wire, put it through, please. We'll see the flange there once I turn, but... I was just curious about, it's Jason, by the way, what was your rationale for kind of using the fluoroscopy and picking a different target in the stomach? Just coming up to the gastric body a little bit more than the antrum, that's it. Dr. Keshav, as you're working on this, we'll go to another case, to Dr. Miranda, and then we'll come back to you in a few minutes. Okay, sounds good. So what happened, I couldn't pull back the axis, and it turned to be that I had a bad angle on the EOS scope. So I straightened the scope, then it pulled, everything was good. And dilated the stent, sutured it, and did an ERCP, removed sludge, and placed a stent. So can we see a fluoro picture? Okay. So can you give us endo picture now? In the end of you, yep. So let me just come back here. So this is the stent. And so it is sutured, two sutures, one on each side to kind of balance the forces when you go through. So the way you do this is, it's like going through the pylorus, you want to kind of look above there, see where this is one of the sutures, and then push down, and then go right, towards the pylorus. So this, the stomach was a little odd shaped, here actually is going towards the fundus. Flora? Flora shot? Okay, so you want to be careful fluoroscopically to just turn your scope appropriately. So to overcome that here, just with the right turn, with the right, with the small wheel, you want to turn right and go towards the pylorus. It wasn't very easy on this patient, just because the stomach, as you guys saw initially, it was a little funky. But everything else was accomplished with ease. How long are you going to leave the, so you put the bilirased stent in, I missed the point, was there obviously was a stricture in the distal duct? You know, patient came with jaundice and acute cholecystitis, and so this is just to hold her until she gets her gallbladder out. I think they want to wait six weeks until they take the gallbladder out. And anyways, patient has to come back to remove the axios. So what I'll do is I'll wait for her cholecystectomy, and then if that goes well, we'll bring her, we remove the bilirased stent and remove the axios. So my algorithm is, as long as, if we're removing the stent within four, six weeks, the fistula is not chronic. I leave it alone to close by secondary intention. If you've been doing work for a year, you know, bilirased stent upsized, sat out dealing with a benign stricture for a year or so, then the fistula becomes chronic and better to close it right away because the chance of it closing by itself is small. So the one thing we did, just to talk about the same session. So my algorithm is to use a 20 millimeter stent, dilate at least to 18, suture, and then you have a friendly position for your EOS going in like this one. So if you can accomplish all of that, you can do the same session ERCP pretty safely. But using 15 millimeter stent or trying to go in without suturing the stent, you're going to have intraoperative migration every now and then. Mo, and this is Natalie. So if all those clinical conditions are met, is it your default to do a single session if you can? Yeah, that's what I meant. Sorry if I wasn't clear. So if all of these are met, then I do single session. And I will say 95% of the times you should be able to do that. So Moina, you're always putting stent, even if you're pretty close to the surgical anastomosis where it's a little bit more adhesed, you're always suturing the stent down. Yeah, you'll think that, Ken, but there is a gap in between. So it's better because if, I mean, it's a pre-perforation once it migrates. Most of the time you can salvage it through the scope stent, bridge both stomachs or put axis within axis. But let's say it's a mess, so why deal with that? The suturing part is five minutes. It increases cost, of course, but it just allows you to do efficient ERCP stem session and basically start working on the pathology right away. Perfect. When you're suturing, are you placing the tower through the stent and doing both sides capture? No, you don't want to do that because you risk it getting lodging on the stent and pulling the stent out when you're pulling the scope back. So you're suturing the flange that's inside the pouch. Yeah, yeah. Inside the pouch. And you really want to get deep sutures. You don't want to get superficial sutures because if you have some angle on the scope and you have a lot of friction, you're going to still dislodge the stent. And a lot of times there are folds that you can grab so you don't need to use the helix. If you don't have a fold, better to get a helix to get a deep suture. Perfect. Thank you. Thank you, Dr. Keshav. Another great case.

EUS-guided direct transgastric ERCP procedure

choledogolithiasis

acute cholecystitis

gastric bypass

stent placement