We will next go to Dr. Shayan Irani from Virginia Mason, who will show us an EUS-guided Colbrader drainage. Excellent. Good morning, everyone. Good afternoon. Good evening, wherever you guys are. I thought I'd start by introducing the team. Marty Kolstad is our CRNA. She's waving from below. Shay and Anna are our two nurses in the room. They do our technical work, our nursing work, and everything else, and keep me on time and schedule. And Matt is our x-ray technician, going to help us with fluoroscopy if we need it for this case. All right. Shall we start with the case? Okay, so this is a 55-year-old gentleman who is way, way older than his stated age. A lot of comorbidities, tobacco use, prior drug use, and substance abuse had a thromboembolic event and a pulmonary embolism. When he was really sick, he could not get anticoagulated because he also had a complication of an ischemic bowel and probably a shocked liver. And so they put in an IVC filter. The cardiogenic shock led to a large amount of small bowel resection, and that left him with an end ileostomy. And he's also struggled with osteomyelitis from the drug use before. So we got to see him in June for abdominal pain, nausea, fever. He was transferred from another hospital with very mildly elevated liver function tests. His alkaline phosphatase was 142, transaminases were normal, bilirubin was normal. Next slide. And on his CT scan, he did have a small stone in his bile duct, but for some reason the outside hospital did an ultrasound of the gallbladder as well, which showed a shrunken gallbladder, but a thickened wall, and they thought maybe there was some features of cholecystitis. So they did my next favorite test, which is this lovely Haider scan, and sure enough, it was positive. So he got transferred over here with the hopes that a hepatobiliary surgeon over here would take his gallbladder out. And the surgeons looked at his surgical history, his comorbidities, his heart failure, and said, no, thank you very much. We should not operate on him. He should go see GI. And that's how we got to see him. But when I saw him with that stone in his bile duct, I started with an ERCP, and there was frank pus in his bile duct. And so I wasn't convinced this was cholecystitis. And obviously with a stone in the bile duct, that can make the Haider scan positive as well. And so we treated him for cholangitis, put in a couple of biliary stents, and then he got better. His fever resolved, his white count normalized, he felt great, and he went home. And so he called me a couple of weeks ago saying, hey, I felt great for two weeks, but I started getting abdominal pain again, which felt like I'm still having stones. What's going on? I thought you fixed me. I said, well, I fixed one part of you. I didn't fix every part of you. So we got a set of liver function tests, and they were just minimally abnormal. And after the ERCP, they had completely normalized. And then two days ago, he called me telling me he's having some low-grade fevers again. So he got seen by our surgeons again, and they said, yep, I don't think anything's changed with him. Please do what you need to do. And so I thought, let's assess his gallbladder and make sure he's not having symptomatic cholelithiasis and make sure his biliary stents are OK as well. So before we got on camera, I just finished an ERCP. Matt, can we go through the fluoroimages, and then Terry, put me on fluoro. There you go. Thank you. Stop there, Matt. Go back. Keep going back. Perfect. Stop. Next slide. And so what you'll see is he has this very interesting jog at his common hepatic duct, and there is no definitive stricture over there. Next slide. And the bile looks nice and clear. Next slide, Matt. So I just swept his bile duct. There was minimal debris related to the stents, but I did not have to adjust my stents. I'm happy with my biliary stents where they are. And you can see there is some cystic duct patency, and his gallbladder fills. So if for any reason I cannot do what I was hoping to do today, which is an EUS gallbladder drainage, I have the option of going transpapillary in him. All right. Let's go to the endofeed. Endoscopy, Terry. Thank you. All right. So I'm in his stomach. And I'm going to push through his pylorus and get into his duodenum. And I would hope most of the times in the duodenal bulb is where I would be able to see his gallbladder. Can you guys see the EUS images okay? Yes, we can. Okay. So I'm rotating around in the bulb. This is Natalie. Can I ask why you're looking? Is your preference in these patients where you can do either transpapillary or transmural drainage to try for transmural first? So yes, if the goal is to provide him some better long-term drainage, my goal would be to try and go transmural. And especially if he has symptomatic cholelithiasis and I want those stones out, then I will try and go transmural instead of transpapillary so the stones can be addressed as well. Now granted we don't have long-term data what happens to these people five, seven, ten years out with regards to re-stone formation. But I still think at least clearing them for a period of time would be better than just transpapillary drainage. And the data on that I think bears out quite nicely. All right. So I have a view of the pancreas. I have a view of something with contrast in it. And that's Cheyenne's contrast with the bile ducts. And then you can see those stents going up into the liver. So his duodenum has always been a little bit distorted. And now finally, as I get towards D2, and let's get a fluoro shot so y'all can see what's happening to my scope, because this is just about at the neck of the gallbladder. So when you drain from the first portion of the duodenum, you'll hit the neck of the gallbladder. But sometimes we have to get to D2 to drain the gallbladder, which is really unusual. So I can stop and ask the panelists how often they drain the gallbladder from D2. It's rare that we have to drain from D2. I did one the other day, I agree with you, because I had one that went straight down like yours. In fact, mine was even closer to D3. But it's really uncommon, because most of the time, after the cystic duct comes off, it tends to go either straight laterally or upwards a little bit. So I have done it. And it's a little bit odd getting the scope to rotate over in that direction. Terry, switch me to Endo-EOS. There you go. Thank you. So yeah, so I am in that fluoroscopic scope position, and I'm still mostly seeing bile duct. Yeah, you're going to have to rotate. So when I did it, it was almost like a short ERCP scope position, and then looking a little bit laterally. So because when you do it the way you did it, when you track and follow the bile duct around, you're not in that position that you need to be in for this one, obviously. That's correct. And so that's exactly what I'm doing over here. So I'm showing you my Endo view. I'm trying to get into a short position, so that then I can slowly pull back and hopefully see the gallbladder. So there are my biliary stents, minding their own business. And let's switch you guys to an EOS feed now. And so slowly pulling back. And so there's the view of the bile duct with the stents in it. When you go back to your fluoro and see what that looks like, because sometimes that's helpful. Yeah, you fell back again. That's the problem. Yeah. So there in this intermediate position, I can see the gallbladder okay. That looks good. Thank you. It's nice. I was a little bit worried that the gallbladder would be contracted based on the fluoro and the imaging, but it looks nice and distended enough for... Hi, Amy. Hi. How are you? Good. Thanks. You're playing around too much, man. You should have stayed where you were. No, I was really in a... You should have seen my hands. They were really twisted. And then getting an axios down or a, sorry, a lumen opposing metals down and stent down in that position can be really tricky. So if I have a hard time in a long scope position, passing the stent down through the channel of the scope, then I will pull back, pass the stent down, get it out of the channel, and then switch back to my EOS view. Okay. So the next question, once I see the gallbladder and I show that to y'all, which hopefully happens before the end of this session, would be choosing the size of the stent. And so you guys want to talk about it or you want me to tell y'all what I do? Well, yeah, we can talk. I mean, I tend to use a smaller diameter stent unless I really think I'm going to eventually go back and try to drive through and do some sort of intervention in the gallbladder. So for me, because it's like anything else, it's like bile is liquid. It's not like you're draining necrosis. So I tend to put either the eight or the 10, but mostly the 10s, but I have used a couple eights. I mean, I've done all kinds of sizes, but I tend to go smaller. The other concern I have is if you put a really big one in, are you more likely to get food to go into the gallbladder through the stent? So I tend to go smaller. Yeah, I do the same thing. I agree. So I choose my stents, if possible, if there is enough landing space in the gallbladder, which this one seems to have, is based on the size of the stone so that I don't have to go in and do cholecystoscopy and get the stones out. So I'll try and size that based on the stones. And this actually, to me, is looking more like bigger sludge balls than really big stones. And so I will choose a stent that is adequate to drain the gallbladder instead of trying to chase a huge stent. And so I'm in this very unstable position, but I think I can have myself studied enough that I can put in a 10, 10 lumen opposing stent over here. Amy, I interrupted you. What were you saying about the size? I was just going to agree with you. 10 is probably the most common size that I choose for the gallbladder. I don't really love to go bigger either. Right. Right. Yeah, I agree. I've had a lot of problem with food occlusion with larger sizes. Right. So to counter the food problem, I'll always put in a pigtail through opposing stent when I'm done. Yeah, I do that. I think I'm in a reasonably steady position. Can I get a 10, 10 lens? But I do the stint, of all the reasons to put the stint in, the food is the least for me. Like for me, it's preventing the opposite wall from hitting the edge of the lambs. It's preventing, which not only potentially could result in trauma or bleeding, but also you don't get good drainage if it's collapsed against the stint. So it gives you a little bit of a buffer right there. But the food is also an advantage, I think, if you put a stint through there, but that's obviously debatable. Some people don't put plastic stints through. Okay, what do y'all think about that vessel over there? Is that the GDA that I'm trying to hit? Probably. Okay, I try and avoid it. Yeah, because it's worrisome because you don't want to hit vessels that have names. Vessels that don't have names, you don't need to worry about. So I think this is a decent position if I can stay steady over here. I'm having to push my scope in a little bit to stay in that position. And as you can see, it wants to disappear, son of a gun. Yeah, it's a tough position. Once you're able to get the lambs in, is this something you'll leave in place indefinitely, or will you change it out for a plastic completely at some point, or does that really depend if it's a patient with benign disease or malignancy? Yeah, so with patients who are not great candidates to undergo anesthesia, I tend to leave them in permanently. And I've done that since I started doing this. And my experience is that they don't bleed unless they really, really need to get on anticoagulation and they get hypercoagulable. So I've had two bleeds in eight years and they both were super therapeutic on Coumadin. So this concern in the gallbladder is much less. It's very different beast than fluid collections with regards to risk of bleed. And I think that pigtail stent keeping the contralateral walls off, I think might play some role as well as at least my feeling. All right, I don't know if y'all want to see the lumen opposing stent going through. Yes, we do. I'm in a very happy, stable position right now. I like where I am. And I don't see the GDA in the way as well. So Terry, we can show the room set up if you want and turn the lights on. Perfect. So for those who aren't familiar with our only available lumen opposing stent, it's this one. There are four steps in deployment. Step one advances the catheter and this is gonna be a direct deployment with a coterie enhanced tip, which I'm gonna try and get out of the scope. And hopefully y'all can see. I'll show y'all on EOS when I'm ready. Then step two, we'll be opening the flange in the gallbladder. Step three, pulling it back snug against the gallbladder and then step four, releasing the duodenal flange. Lights off and back to EOS. Yeah, and I think the intrascope deployment is critical in these kinds of cases where you have very unstable. You don't wanna do the backing away to see the mark if in this kind of case that everything might fall back on you, as you know. So I can measure the wall over here, but having done enough EOS, most people would feel comfortable knowing that the gap between the gallbladder and the duodenum is well below a centimeter. So I've chosen a 10 by 10 lumen opposing stent and the landing spot, which is where my stent should poke into the gallbladder is also fairly adequate over here. We have in this trajectory of my stent, little over two centimeters, which should be fine for a 10 millimeter stent. And I had a better view of the gallbladder with more of a landing spot, but I was in a really unstable scope position and this stability makes me happy. I'd rather deal with a smaller landing spot than an unstable scope position. All right, so we're going ahead with the corduroy and then, and there's my stent in the gallbladder. Now, how much, when you have it all the way down, how much room do you have on the introducer, that little space there? I have about two centimeters, so I'm going to gradually deploy the stent and you'll see it open in the gallbladder and not pop out, hopefully. There you go. Now I'll pull it back. And so when I'm pulling it back to give enough tension, I'm trying to get my introducer to touch up against one of the sides of the stent. So it's kind of distorting a little bit, but not too much. So do you have a guide wire in ready to do your second stent or you do that? I already read my mind and she put the wire in while I was doing what I was doing. Okay. So I can advance the guide wire now or I can advance the guide wire after I deploy the stent. I'd like to pass the wire now because sometimes the catheter kinks. Yeah. Switch to a fluoro image so we can see them, the wire going in. Yeah, sometimes you have to hold the catheter. You don't need fluoroscopy at this point, but hey, this is pretty cute. It's going down the cystic duct. Fluoro. Yeah. Oh, so cute. Yeah. You did that on purpose, I think. Although, do you want it to go in that direction or not? No, I'm going to put a big tail. It's not going to go there. So it doesn't matter. Let's get back to EOS. So step three is deploying the duodenal flange. And as most people do nowadays, we deploy it within the scope. If it wants to threaten to go back in, it's because you forgot to lock yourself. Deploy it within the scope. You'll see that little bit of movement. The stent's been deployed. And I can switch to endo view for you all now. And then that just involves slowly pushing the stent out from the scope. All right. Nice. We'll put in a pigtail stent, and then we'll pause and take questions. So when you go back, so let's say you do have a patient that has a reasonable life expectancy. They can undergo another procedure. At what point do you remove it? And do you replace it with pigtail stents? Or do you just take it out and you're done? No, I think that would be silly to take it out because the pathology hasn't changed. Right. Of stone formation. So then I leave them with two, seven, three centimeter pigtail stents for life. Yeah, that's what I do. And I don't change anything out. I say, call me if you have troubles. These are the symptoms. I hope by now you know what you're messing with. But you do it four weeks or more later after the initial- Four, six weeks, anytime they are willing to come back. Yeah. Yeah, I usually just use, we all think four weeks, you get a nice fistula forming there, but we don't know. But I wait, like you said, four weeks or longer. Yeah. Can I ask you in the panel, if it's a patient who is not currently a surgical candidate at the moment, but they might undergo cholecystectomy in the future, how do your surgeons feel about these transmural gallbladder drainages? Are they okay with it and they can manage it? If they do a cholecystectomy later, are they asking you to hold off and do trans-papillary? Well, surgeons don't have feelings. So, but no, sorry. Well, yeah, we haven't run into that too much. They either are or they aren't, but that issue I think will come up more and more. My thought is that, and I could be wrong, that, well, two things. One is I almost always go through the duodenum, but if I had a patient that I thought a surgeon might say you could use this for temporizing, which at this point they haven't, I might go through the stomach if I could, knowing that the gastric wall almost certainly will close when you take it out. And perhaps, you know, when they, and I would take out the axios and the plastic stents and let it close and have them undergo an interim cholecystectomy, but that hasn't really been studied. So I think for now- I think the Europeans just put together their experience, right, with doing LAMs and then letting them go to surgery. And at least in their experience that they're not seeing an increased conversion to open surgery or increased complications in their retrospective experience. They put together- Where was that published? Or is that abstract form? Should I? I don't know, Todd. Wait, actually, we presented it at DDW. Yeah, I remember. Yeah, you did, yeah. Last year. I do the same thing, which is if really the surgeons want to go later, I'm trying to convince our surgeons, let's go transgastric. That stomach is so robust, it will close. And they are now getting on board having seen the experience because some of these patients have ended up with cholecystectomy and they've all done fine. So- I think that we're going to get less, as data accumulate, I think we're going to be less worried. Although I think still duodenum, I'm a little more concerned than I am certainly stomach, but I always- I'm just deploying the pigtail while you're chatting, Todd. So you want to see floral image? Okay. Whatever you like, yeah. You're the one getting radiated. I'm getting radiated, it's true. Okay. The first pigtail, so it's going towards the neck of the gallbladder, which is fine. That's my black mark tells me my other pigtail is ready. Yep. Go ahead, deploy. And so that will hopefully keep some food out. There's no need to dilate these stents. They're going to expand. So there's no reason to do an extra balloon dilation, increase the risk of bleeding, dislodgement and all the other stuff that comes with it. Yeah. And then one other thing I didn't mention is most of the times when I'm about to deploy a lumen opposing stent, I'll try and look at my, no other stents. I'll try and look at my endo view to just make sure that I'm in the duodenum because sometimes you fall back in the pre-pyloric antrum. Yep. Just peeling off with your back wheel and making sure you're still in duodenum is a good idea. Yep. Placing stents all the way near the pylorus is I think a recipe for trouble. Yeah. I'm likely to have that stent migrate into the gallbladder and get food into that stent. So. Well, here's the other thing. Sometimes the probe is in the duodenum barely, but the working channel is on the pyloric side. Yeah. So the distance and everything looks great, but as it comes through, if you pierce through the antrum or the pylorus, the distance is going to be longer. And I've inadvertently done that, I think on one occasion. So that's a really good point that you make is that a lot of times, if you look at the fluoro, you can tell if you're well into the duodenum, but like you said, you should make sure that that, if you're close to the pylorus. Okay. I'm just showing you as, I don't know how much time we have left. Give me a five minute warning, you guys. Less than a minute, actually. Oh, less than a minute. Okay. Yeah. So are you guys showing a biliary rendezvous of sorts? I don't know. Why? Well, we could just show them how to line up the scope at least and try and line up for a hepatic gastrostomy. But we can just pause. You have a joke, Todd? Did you hear the termite walked into the pub and said, is this bartender? Okay. On that note, thank you for having us for this course. And wonderful rest of your day. Thank you, Shay. Thank you, Anna. Thank you, Marty. Thank you, Matt. Guys, nice to see y'all and speak to y'all. You too. Thank you, Dr. Ravi. Very nice to meet you.

EUS-guided gallbladder drainage

ERCP

biliary stenting

cholecystitis

lumen opposing stent

pigtail stents