Yeah, Daniela, can you please summarize this case? It's similar to the previous one, slightly different. This is a 56-year-old patient with a 15-month history of an adenocarcinoma of the pancreas. He has also liver metastasis. He underwent two surgeries this time. They were fully covered, 60 per 10 millimeter stems was placed. He's now presenting abdominal pain and intense pain. The operative endoscopy showed duodenal stricture, and the last EUS showed dilatation of the pancreatic duct besides of the pancreatic mass. So for this patient, we propose an EUS-guided gastroenteroscopy. And for controlling his pain, we propose a pancreatic duct drainage. So thank you, Daniela. So in this patient, as Dr. Thompson mentioned in his presentation, as opposed to the previous patient, gastric outlet obstructive symptoms are very subtle. A patient reports fullness, early society, pain. So he was endoscoped at the referring hospital. They saw type 1 duodenal stricture at the apex. And in conjunction with this, his tumor markers were very high. I mean, they progressed very rapidly. So we're not really sure if the gastric outlet obstruction is the main reason for his symptoms or is the PD obstruction because he reports pain right after meals. So it suggests in conjunction with the EUS image that you see. So we see a mildly dilated PD. Dr. Miranda, sorry to interrupt. We are having some video issues. We cannot see you. So what? They cannot see what our endoscopy or our x-ray or what? We cannot see any of it. We're frozen on the room view. We have a frozen room view, Manuel. So they're trying to fix the, sorry. Hi. Hello. As you may remember, this is a patient with a longstanding metastatic pancreatic cancer who suddenly experienced a tumor marker increase and a vague abdominal pain, early society. So two findings, not very high grade duodenal stricture in the apex that you see now on the endoscopy screen, on the endoscopy monitor. We just got our three-layer catheter through and on the x-ray, you see what we did while we were off camera. We have a straight linear EUS scope in the stomach. We had a 19-gauge needle puncture of a 3.6 millimeter PD, which is not terribly dilated, but it was dilated. We've performed pancreatogram showing an abrupt cutoff in the distal PD. We aimed for rendezvous with different wires and eventually we gave it up in favor of pancreatic gastrostomy. Can you, Antonio, show the still image? So we use, this is balloon dilation and a straight seven French nine centimeters pancreatic stem that you will see when we withdraw the linear EUS scope. By the way, we follow Dr. Barron's advice of not using a different endoscope for guidewire passage. So this is the linear EUS scope that we use routinely for EUS. So we're using it as a gastroscope. You see the stricture at the apex. Again, not very tight. We could pass it, almost pass it with a linear EUS scope. The tip of my wire is near the trite. While I was speaking, I failed to coordinate with Maria, but we can fix it that. We have the, again, an 8.5 French nasobiliary drain pre-flashed with saline ready to feed through the scope over this 0.035 inch wire. And again, because we are trying to relieve these patients' symptoms with two endoscopic procedures, namely gastroenteroscopy and pancreatic gastroscopy, we hope to see some improvement, even if we won't be able to attribute to one or the other the improvement. Of course, celiac plexus neuralysis would have been an alternative. And there's a question of when to use EUSPD in pancreatic cancer patients for pain control versus neuralysis, which is easier and more readily available than EUSPD. So pretty straightforward. This will be similar to duodenal stenting. I'll try to get close to the bulb and the apex to avoid any kinking. Now I use the fluoro. Can we have the so I try to coordinate with Maria. Pull on the wire. Maria, pull on the wire. So now I push it through. I'm same area of the trife. If I keep pushing, I'm going to go into the first jejunum, which is OK. I did. I just did. I'm going to remove the linear EUScope. Antonio is going to hold it. You see the PD stent sticking out from the posterior gastric body. Arnie Ray guy I was talking to you about. Yeah, it's a 99. Yeah, I did you for him at normal. OK, so I'm like. Hello, we're getting someone else. I mean, yeah, you want to be super careful, right? You don't want to knock up your your small pancreatic stent, huh? So your question is, I'm concerned about dislodging my pancreatic stent or what was the question? Yeah, no, do you need to be careful so so you don't. Of course you do. This is as. Of course you do. This is the only anchoring design features on this stent is the internal flaps. So yeah, you can dislodge it. It's difficult to dislodge a stent with an endoscope, but not impossible. I should say that probably it's easier to dislodge a LAMS from the duodenum when you've done Cholitochondroadenostomy or gallbladder drainage. If you try to go and and do ERCP than than one of these plastic stents that are relatively more difficult to dislodge. Again, you see the same the same structure here. Collapsed small bowel next to the pancreas. So we try. We're doing EOS. We try to use EOS landmarks. And again, we're going to use our fluoro landmarks and inject. So we're looking at the tip of the PD. We're putting we're going to put some contrast. This is the air in the collapsed trites. So you see the contrast on fluoro on EOS. And it's moving. We should give the patient some Buscopam and some Provofol. So we now use the 20 millimeter axis. We have it wetted. We have it ready and we do not distend maximally. Un poquito mas de mojado. We do not wet it. Sorry, we do not distend the small bowel until after our LAMS catheter is ready and pointed into the target. What we call target acquisition. So we started. Yes. I'm sorry to interrupt. Again, very nice demonstration. We will have to transition to another room. Do you have any closing remarks? So the closing remark is that gastroenterostomy is has been reported in many different technical ways, but currently the dominant strategy is free hand insertion with adequate fluid distinction that can be achieved with a number of techniques or approaches. The nasobiliary drain or parallel enteric tube seems to be pretty reproducible, although this remains to be proven conclusively. So thank you very much for your attention. Bomba. Nice job. Thanks. You're welcome.

pancreatic adenocarcinoma

liver metastasis

EUS-guided gastroenteroscopy

pancreatic duct drainage

gastroenterostomy