We will next go to Dr. Chris Thompson from Brigham and Women, who will be demonstrating an EUS-guided gastroenterostomy. Brigham team, you're live on. Alrighty, so today we're going to do a case of EUS-guided gastroenterostomy. This is going to be performed by Dr. Christopher Thompson, director of endoscopy at Brigham and Women's Hospital, professor of medicine at Harvard Medical School. So our patient is an 83-year-old female with a history of metastatic pancreatic adenocarcinoma on palliative risk, initially presented with intractable nausea, vomiting, and abdominal pain. She had a CT of her abdomen, which was concerning for malignant gastric outlet obstruction. She underwent NG tube decompression, and she had a surgical consultation, and there was felt to be no surgical options. On upper endoscopy, she had a high-grade obstruction in the duodenum sweep. Today we plan for EUS-guided gastroenterostomy for palliative management of malignant gastric outlet obstruction. We're up. Hi, everyone. Welcome to the Brigham. Chris Thompson here. You just heard from Dr. Steve Steinway. I have Sherry, my lead kind of advanced nurse in Chelsea anesthesia here. So this is our team. And Tabby right over here. So this is our crew. Welcome. We have a nice case you just heard about, and I believe you're probably seeing our quad screen view right now, and you can see our EUS in the upper right. We're using some interesting equipment today. So Fuji now has the Arrieta 850, so they acquired Hitachi, so we do have that system, which is, as you'll see later, capable of advanced features like shear wave. And we're using the 740UT therapeutic echo endoscope, which is nice because it has some features that we think are beneficial. One is, and we'll see this later as we deploy the Axios, the optics are set back, so you can actually see the elevator in the foreground. It's one crystal, so it's a little smaller, but also gives you about a centimeter more depth. So it's really good. It's designed for therapeutics. It has a four millimeter channel as well, so it has several advantages to the older systems. And with that, I think we're going to start looking for a target. So we already have our patient placed in a prone position. We've put down about 800 seeds of contrast, this mixed with saline and methylene blue. We've given some glucagon around a whole lot, and it's nice to have them prone because it kind of traps the bowel a little, it's not floating away from us, and now I'm looking for a target. And so we're trying to find an area, you can see our loops on the fluoro there, I'm trying to find an area close to the transducer here. This is really probably the best area. Unfortunately, I wanted to have something back here, but it's hard, it's just not as distended as you can see there, and it's a larger gap. That's probably too long for the 15 millimeter axios. So I think I'm going to come up over here to this area where I think I have a little bit of a better target. So we're going to look for any vessels in here. Hi Chris, this is Sai. So can you walk us through what goes through your mind when you're looking for the distal target? So I want to make sure that it's not tacked down into the pelvis, I want it to be movable. I also want to make sure that it's not too far away from the stomach. You can pull it up a little, but you want to make sure it's not too far away. That's about 12 millimeters there, I mean that's probably as far as I want to push it. So we do have a target here, and I like to double check everything once I get the stent down, because I tell you what, sometimes it changes your orientation just a little bit, just enough to throw you off, and that's kind of a close little narrow window we have anyway. So it goes down, you'll notice that Sherry kept it very wet the entire time it was going down, it has a hydrophilic coating, and so if you don't do that it can get catchy in the channel, you can even deploy part of the nose cone and expose a little bit of the stent. You want to make sure it is definitely kept very, very wet going down, just like old hydrophilic wires. Yeah, you never want to push against resistance. Oh Ken, how are you doing? Great. You know, I was wondering, you've got a nice target here, but how do you know that that's maybe not loop of colon or so? That's a really important question. I tend to try to watch as I'm putting the contrast down to see if it would kick over to colon. I'm pretty confident this isn't colon, just from when I was putting the contrast down and keeping an eye on it, but you know, with these things, times are the essence, and I'm you know, just want to make sure we don't have any issues with losing our window to do it. You have a vessel nearby, but I'm not worried, it seems pretty small. Yeah, put heat on. We have our setting on our Irby unit of five and a hundred of autocut. I'm pretty confident this is a decent spot. So you've upped the voltage. Yep, and it's pure cut, I don't want to have, you know, a blended current, not a big fan of that. I think I'm going to try to go out here. You also don't want to hit, you know, two loops of hour or anything, and that can be problematic. Yeah, you definitely don't want to loop a bowel interposed there, so you want to make sure it's flush up against the wall. Hey Chelsea, can we give another 0.5 of glucagon? This is kind of nice over here, but I don't think I can get into that. So there was a question about how did you fill the small bowel? So is it CD colon? Yeah, I go down with a hybrid colonoscope, and we fill it up, and then we come back with the EUS scope. Generally, there's plenty of time to do the procedure. We were waiting just a little bit, and it's starting to move again, so I'm hoping we can get to it here. Can we go on higher resolution with this? It's laggy too. I don't like the lag on the fluoro, yeah, please. Thank you. Not mag up, just go back down. Get rid of the auto-columnating or something, it's very skippy. So have you run into a situation where it's a complete obstruction, and you can't even get the wire or cannula through, and you cannot fill the bowel distally? Yeah, we have run into this problem a couple of times. It's rare, fortunately, but when you do, there's different things you can do. One thing is you can gain access through the bile duct if it's a proximal obstruction. I'm just going to go here, and it's, again, a little tricky. You can go through the bile duct, gain access with the coedoco, gastrostomy or duodenostomy, run the cannula down, and if it's a D1 obstruction or early D2, you can actually fill through a cannula through the bile duct. I'm reluctant to try to do it with an EUS needle, and just find bile and try to fill it. I don't know, I'd probably not do that, it'd be too aggressive. Blood vessel coming in the way there. Oh, we got something else here, maybe. Here we go. Fluoro for me? I'm going to have to do a short technique on the EUS delivery, but this is kind of what I have to hit right now, I think. Yeah, heat off. I don't know if I can get in on my hands here. What I'm going to do is, I don't have a lot of space, so I have to deploy the stent by using a syringe technique. I'm kind of pushing, I'm holding this still, the gray part still, as I deploy the plunger. We're slowly coming down with that plunger, I don't know if you can see, the gray part stays still in space, it is not... Right, you're using the push technique rather than pull technique. Yeah, we call it a syringe here, but yeah. I think we hopefully caught it. Let's look at fluoro. Yeah. Yeah, it looks like we got it there. All right, so now I'm going to kind of pull back. You can see the stent right there on EUS coming back, yeah, come up on the CO2. I'm kind of pulling back a little bit there, going to lock it again. Now there's two ways you can deploy it here. We can deploy it either into the channel of the scope, or you can deploy it visually. I generally go into the channel of the scope, it's my preferred approach, so I'm going to now unlock it and pull this back again here. And I'm deploying the second flange, the proximal flange, into the scope channel. There we have it. So now what I'm going to do is I'm going to put insufflation up higher. Let's go to six, please. I'm going to start insufflating at this point. To this point, I've really been suctioning the entire time, okay? So now what we're going to do is we're going to put the head of the bed up a little, because fluid's going to come out of that small bowel into the stomach. I don't want... She's intubated, but I don't want an aspiration, so the bed comes up just a little bit. I'm going to back up the scope just a little as well, and then I'm going to start pushing on the axios to kind of nudge it out. You can rotate away if you want as well, but I'm just going to kind of keep insufflating. That's perfect. Insufflating, I'm coming back, and now you can see the stent right there on the endoscopic screen. You can see it right there. It's starting to come out. You can see the elevator. I'll show you that in a second. Did you mix some dye in the fluid so that you can see if you have dye draining? I did. So this is macadam blue. Yeah, coming back. So I love doing that back in the firms. Yeah, I'm in the right. So I'm pretty comfortable with that now. And that looks good. So there's different things you can do. First, I want to confirm a few things that I do. Number one, I look for the methylene blue. That's good. I like to look for contrast in the stomach. So if we go to fluoro and go up to the stomach on the fluoro, you'll see contrast now in the stomach where there wasn't contrast there before. And you can see that coming into the stomach. That's great. And also, we'll look for air bubbles in the small bowel as I insufflate. And generally, if you go back to fluoro, we'll see that. And I'll go back down a little bit. And that's generally, you can see the contrast rolling back up. And then we'll get those bubbles in a little. Yeah, I see the air filling the small bowel now. So that's like three confirmations that we're in the right spot. And you can see the stent there beautifully on the fluoro as well. So it's in the right spot. It should do a great job. So now we're. Sorry. Go ahead. Oh, I wonder if you have to do like a combined direct access like EUS guided choledo-duodenostomy and GE for like a panc head mass. Which one would you do first? Well, I don't want to drive by a stent once I deploy it if I can help that. So I would probably do the choledoco first and then do the gastroenterostomy second. So I think that it's, you know, it's just a little safer. I think you're less likely to dislodge that biliary access point than you are the gastric one. So we'll take a look. I'll show you a little bit of the features of this EOS scope too for a second, but that's about it. These procedures are fast when you do them right. You can drop the CO2 down to four, please. You know, they're quick procedures that, you know, generally you know, we did a study and we saw these are routinely well under an hour from wheels in to wheels out. And when we compared it to surgery, you know, surgery is considerably longer if they're doing a surgical gastrojejunctomy and just getting all that fluid out here. And these patients do just as well as the surgical GJs, but actually less recurrent obstruction, which is quite interesting, and it's even in the setting of carcinomatosis. And also there's fewer complications. The complication rate is less than half that of surgery. So clearly it's a it's just a better approach than a surgical GJ. And also it's much more durable results than a than an enteral stent. You know, the secondary occlusions are far less common around 8% to 16%, maybe distal obstruction with a 16% with this versus, you know, over 30% with enteral stents. So Dana-Farber was very reluctant, you know, we have a big cancer center here. They were very reluctant to have us do these initially. So we had to get patients from elsewhere. Then we presented our data. Now, this is this is the only thing they'll accept. The only way they will take an enteral stent is if this is not technically feasible. So it's nice that they're very on top of it and they sent us the patients earlier now. So they're not even fully obstructed yet because there's no worry about the enteral stent migrating. So they'll send us the patients, you know, when you can still get a scope through and fill the small bowel, which is great. What are your current contraindications for GE now? Well, there's no contraindication really, I guess. Not pre-procedure. Intra-procedure, there's several, right? I mean, if you have an enteral cancer coming up and you're gonna have to put it through cancer, that's not good. If your bowel is tacked down with carcinomatosis and the bowel is not mobile, you don't want to do that. If there's too long a gap, you don't want to do that. So, you know, between between the stomach and the small bowel. So several reasons why you might not want to do the procedure. So we always consent for an enteral stent as well as a GJ. But I'll tell you, it's rare we don't do this. I'm not worried about ascites. You just haven't drained it off beforehand. And as long as you're not going through it, you're fine. And I'm definitely not worried about carcinomatosis. You know, we've had we have a publication showing it's a preferred approach in that setting. Now, distal obstruction might be a contraindication. You really know you have a distal obstruction in the ileum. This is not going to do any good. So in that setting, and you're sure that there's a distal obstruction, I would probably not do this procedure. But an enteral stent is not going to be any any more effective either. So that's that's that's one thing I guess I would I would be on the lookout for is distal obstruction that's been confirmed. So Chris, this is Thomas. Do you do you suggest that's it now? We don't need any randomized trial surgery. Do dental stent. Everybody has to use it. Yeah, I don't think we need one. You know, now, I mean, we do these several a week and it's just it's just better in clinical practice. Now, if we want to, you know, talk about best practices, I think we could get some studies that look at that. We can do some economic studies that look at it. I personally am not going to be waiting for a randomized trial to do this. OK, this is our standard of practice right now. It might help to get others involved. It might help at cancer centers to have that level of evidence. So I wouldn't say we shouldn't do one, but I don't think we should wait. I think there's enough evidence that if you do it right, these are very safe and they're durable and they get better results to the patients. And we have very conservative oncologists here. And if it won them over completely, I think there's merit to it. I have a slightly different perspective on this, and I don't see these as, you know, a duodenal stent and gastroenterostomy or gastroenterostomy as competitive. I see them really as complimentary. And we do know that there is a significant maldeployment risk. Obviously, experience plays an important role. But when these maldeploy, we can take a patient who, you know, can benefit the most from these minimally invasive procedures we do and have the worst outcomes if they have to go to surgery. So we have to always keep that in mind. So my personal practice is if I can get a duodenal stent in first, I'll just throw that duodenal stent in. That just takes five minutes. And then if it looks like it has a longer survival rate and the duodenal stent is not working optimally for the patient, then I'll complement that with the gastroenterostomy, which will be very easy because I can get a nasal enteric and oral enteric catheter down to get good filling of the small bowel. So I see them as complimentary. Yeah, I view it as these people have a very short life expectancy and I don't want them to have to come to the hospital. So if you can offer it and you know that you do it with confidence and you have a very low complication rate, I don't want them coming back times in the last few remaining months of their life. I want them to have it and forget about it. And these stents have been shown the intervention free time is 217 days. That's on average versus enteral stents where they're coming back in a few weeks sometimes. So I think that, you know, if you can offer this, I believe it's a better approach, honestly, because these people as palliation is about quality of life. And this definitely provides a better quality of life, provided you can perform it safely and you're comfortable doing that. I'm about to remove the scope. I think I'll just show you one. One thing here is you can actually see the transducer in the foreground there and the elevator right there. It's kind of neat. So you really the optics are sitting back on the on the on the transducer and on the on the elevator. So it gives you a different perspective and you actually get kind of a longer range of motion to that elevator. So you get like a 90 degree bend, which is which is sometimes favorable and more complicated procedures. But I think I'm going to slide on out. Chris, do you dilate the stent or you just leave it to dilate itself? So I used to dilate it. You know, I don't anymore. I see no, no. Some sometimes I'll dilate if a small bowel to small bowel, like I'm treating a candy cane syndrome or something like that, trying to do an enteroenteroscopy because I worry that maybe the small bowels too far, far apart or something. And if you dilate it, the stent shortens a bit. But in GGE, I stopped dilating a couple of years ago and I haven't seen any, you know, any downside to that. Patients tend to do great and they can actually eat regular food again. That's something we didn't talk about. Enterostents, my patients actually eat salad and steak on these things. It's crazy. You wouldn't think they could. But when they're out like six weeks or something, they actually go to a regular diet and they never tolerate that on an enterostent. So that's just another thing that's kind of really surprising. It's not like I recommend it. They just do it and they report it. And it seems like another advantage of the stent. When would you bring the patient back to upsize the stent? So, you know, so I'm not sure. Upsizing, if I have, say the person is living a lot longer than expected. I do change the stent out at nine months because I've seen the coating break down and that becomes pretty difficult. If the coating breaks down and you start getting tissue eroding into it and growing into it, you can't remove it. They get pain with that. That's not good palliation either. Right. So I always will get in there by about nine months because that's the earliest I've seen it happen was about a little less than a year. So I want to give myself some room. So I take it out in nine months and at that point I will upsize it. I haven't brought them back routinely to upsize it before that time period. And there's a question from the audience asking about comparison between the freehand technique and over the wire technique. Can you comment on that, please? Yeah, so we published on that many years ago in one of our early cases. I'm going to take this and we used, you know, very, very early on. It was before Boston Scientific acquired it and whatnot. So old, you know, old school, we would put a put a needle out and a wire through the needle. And we found that that wire was pushing the small bowel away. So it led to more intraperitoneal stent deployments. So we completely stopped that. And we went to the free freehand kind of technique. And we've never had the problem since. So I think that the wire does a lot more harm than good in this procedure. I think in other procedures, it's very helpful if you're dealing with the bile duct and whatnot, it can be helpful. Right. The gallbladder, maybe as well. But really, in this procedure, when you have a mobile, very mobile at times, small bowel, it's sort of like spearfishing, you know, you got to sneak up on it. You don't want to give it the idea you're going to try to do this. So I think that the needle and the wire are a bad idea because it does tend to push the small bowel away. Chris, what about putting a wire through the axios and when you punch or pass the wire into the bowel, just you have access in case of maldeployment. Does that make sense? Beautiful. Love that. Yeah, I love that idea. If I if I had any concern in this case about a maldeployment or even if initially when I went in, I was concerned about it. We definitely run a wire through that. That is really an important thing to have in your in your in your toolkit, something to keep in mind. And that can save you because if you do have a misdeployment, you need to you need to close that hole, right? You have to you have to know where it is to do that. So a wire is very helpful in that regard. Well, Chris, there is a there is a related question. We realize that basically nothing can go wrong, but if it goes wrong somewhere else, the question is what happens if stent is maldeployed or separation between stomach, small bowel with a hole? Is that necessary surgery or can you? No, no. So so I tend to publish if I have a complication, I tend to publish it because I think it's good. We learn from it and others learn from it. So I've published a couple of complications. Now, it's been a while since we've had any. But, you know, and we've done hundreds of stents. So I think it's very safe now. But the complications that I had were using the wire to push, pushing the bowel away and deploying a stent in the peritoneum. And then what we ended up doing was just going right next to it. You know, and eventually getting in. And then we pulled the stent out and clipped it closed. That was fine. The person did not need surgery. Things get more complicated. What you can do is actually if you if when you're when you're kind of trying to access a small bowel, if you cut all the way through the small bowel. So it's through and through. It's through the first wall, the small bowel through the second wall. Now, you can if you recognize that and back up and deploy the stent, you should then go through and close that hole. OK, the bad thing is if you don't recognize it and you actually cause like a bowel obstruction because your stent is is all the way through the small bowel in the peritoneum, trapping the small bowel. I've never done that, thank God. But that seems to be something that'd be a bit of a problem and hard to fix. You'd have to try to pull it out. And then I probably put a stent next to it. I haven't done this yet. I hope I don't have to. I probably put a stent next to another axios. And I pull the thing out, then drive through and try to close the holes. And if it didn't work, it'd be surgery. Right. So that'd be a bad one. And then one thing that has happened to us that we published as well was the bowel one time was very much tacked down into the pelvis and the stomach was pretty big. So I thought I could grab the bowel and pull it back. And I did. And it looked OK. And we sent the person home. And two days later, they came back and the stent was dislodged and the small bowel just popped back down to the pelvis. That person did. That's our only axios GE that needed surgery. They needed surgery. And the surgeons could not even do a GJ anastomosis because it was just too too far away and the bowel was too matted together. So they did like a venting peg or something and then ended up being being OK. But yeah, those are things to worry about. But if you if you're very methodical, we published a scamp on our exact protocol, what we came to after, you know, a couple of years of really trying to hone this in with a multidisciplinary team and come up with best practice for this. And it's pretty slick. I mean, it's a very efficient procedure that can be done safely. Now, regarding the position, you always do it prone. There's a question from the audience prone versus supine. And what's the advantage of prone? Yes, always prone because it kind of it keeps the bowel from moving around too much. They're lying on on the bowel. The abdomen being kind of pushed into the bed helps trap the bowel a little bit. Any advantage you can get is helpful here. So we don't want that floating away as we're trying to get into it. And so it helps to kind of trap it by having them lie on it. And we found that that's something that's very helpful and leads to, we think, fewer misdeployments. And do you think Dr. Thompson, Dr. Steinway and the Brigham team?

EUS-guided gastroenterostomy

Brigham and Women's Hospital

metastatic pancreatic adenocarcinoma

nausea

vomiting

abdominal pain