Dr. Shayan Irani from Virginia Mason has a video ready. Dr. Irani, you can share your screen when you have the video ready. Morning, guys. Oh, morning. We can hear you. Perfect. Good afternoon. Oh, good afternoon and good evening, I guess. Linda, Ale, and Todd. Sorry, you guys. Flora just went down like literally 15 minutes before we walked in this morning, but I had some backup videos I thought I could share with you all. And this was an old video I had submitted to GIE a while ago called Dead End Ducks, Rendezvous Techniques for Reconnecting the Obstructed Pancreas. And this came about when I had bumped into a case, walked into a case that I was doing with Dick Kozarek, and I'm going to skip all the background slides and take you to his first case, which was a 80-odd-year-old female with pancreas divism. And he went in to do an ERCP, and he looks at the minor sphincter, and this is the MRCP image, and it's completely closed over. He probes, tries to get in with a wire, and nothing seems successful. So he asked me if I can help out with an EUS, and this was his pancreatic, her pancreatic duct on EUS, about two, three millimeters. And so he got in at that time with a 22-gauge needle, and I was able to pass a 0.018-inch guide wire, but it refused to pass through, and so I just left it coiled at the minor papilla. And I asked him if he would go in and do a little needle knife over that, which he did, and sure enough, the wire pops through, and he completed his sphincterotomy. So let me take you to the case that I did now, which was a Whipple patient. This was a 54-year-old lady who had undergone a Whipple for an inflammatory pseudotumor, and this is the opening to where the pancreatic or jejunostomy was, and she kept coming in with recurrent bouts of pancreatitis, and had a dilated pancreatic duct of about five to six millimeters, and that's what you see on the CT scan as I'm scrolling through that image over there. And so I took her for an EOS rendezvous because we couldn't get in through the pancreatic or jejunostomy, and there's a nice plump pancreatic duct, fairly easy to target with a 19-gauge needle, and then a nice pancreatogram, but the contrast is not pouring into the jejunum. And so I started probing with the wire. I said, okay, maybe I can't see a whole lot of flow going in, and although this video is attenuated, I tried for quite a while probing with that wire to see if that thing would find its way into the jejunum, and maybe it was just an imagination that that scar tissue had a little opening. So I gave up over here, coiled the wire, and I said, let me try the same thing I've done before, which is to try a needle knife over this wire. So left the wire in, and I go down with the colonoscope, but then I start dislodging this wire, and I said, okay, let me make some feeble attempts at trying to pass the wire back in with a forcep, and that just fails. This was a waste of time. And so I go back in with the colonoscope. I said, let me try a trick that Dick has tried before, which is use a sclerotherapy needle and see if I can just puncture that site, and maybe it's just a membranous stricture, and I can get some contrast to go into the pancreatic duct. And all I'm doing is creating a bleb over there, and I'm still away from that pancreatic duct. So I wasn't ready to give up yet, so I went back down with EOS, and now you can see that contrast sitting in that pancreatic duct, but still targetable. And I got another guide wire, and this time I used an angled wire, and I passed my needle all the way to the pancreatic or jejunostomy to see if I could really probe and get that wire to go through. Maybe it was just a bad, bad stricture and not a complete closure. But no matter how hard I tried, the wire refuses to go, and I said, okay, let's try one more trick. This time I went down, and I used a couple of endoclips, and I clipped that guide wire in place, so as I'm pushing my scope through this pylorus-preserving whipper, I didn't dislodge my guide wire. And now I came up to that point, and I used a needle knife, and this is really the key part of the procedure where under fluoroscopy, under magnification, try and figure out the right plane that that guide wire is in. I started probing, and you can see on fluoroscopy over there, I'm touching that wire and moving it. So this made me very comfortable. This is a good place to do a freehand needle knife. And so that's what I decided. I clenched my sphincter, and I started using a little bit of cut, and as I'm cutting, you'll see a nice gush of pancreatic juice come through. And so that told me, okay, this is not blood, this is not red pancreatic juice, that's good. So I got my needle knife in, and now passed a guide wire into the pancreatic duct. So with this technique of probing that guide wire that's sitting in the pancreatic duct, even if you don't get it fully through, you can recreate this anastomosis. And that's what I did over here, dilated with a six millimeter balloon. And then you see that guide wire that was meant to come through will hopefully pop out all the way. And then once that's done, now you've recreated your pancreatic or jejunostomy, and now it's just a typical rendezvous where you can go ahead and deploy your stents. And so that's what we did over here. A couple of seven French pancreatic duct stents go in, the wire that's no longer needed can come out, and those clips helped us prevent dislodging the stent. So you know there's another case I had over here in the same video, but I can stop here and take some questions if you guys want. Nice, nice case. That's not for the either the faint of heart or the people that aren't tremendously experienced. Another approach obviously would have been to do a pancreatic gastrostomy and then come back on another day when the tract was formed and continued either to probe or to do something else. You know, because the concern is if you couldn't get back in, which you obviously could from the puncture, you'd have a fairly good size leak from the other side, or at least a reasonable leak because you have no place for that to go and then you'll leak out of the puncture site, right? Right. So pancreatic or gastrostomies, I've done a few of them, but they always make me nervous in case the pancreas is so scarred and stiff that no matter how hard you try sometimes that you may not be able to dilate the tract and get an adequate stent in. Have you guys had experience with failing like that? I've had some cases come over with really impressive fluid collections. Yeah, well, the only time I have is if it's really, really, really bad chronic pancreatitis. And the ones like you have here, they often have a little bit of atrophy after Whipple and I've found that they're not that difficult. But what I do is I don't go straight in with the balloon. I take an 025 Visiglide wire and then I use a 345 catheter, which although the package says 018 wire only, if you really lube that thing up, you can get it over an 025 wire and that almost always will pass through the parenchyma into the duct. And then you have a platform up to 5 French. You can either leave just a 5 French stent without doing any additional dilation or now you can balloon dilate because you're got a 5 French balloon. The balloon's mounted on a 5 French catheter, which then you can dilate. But there's always a risk of leak as well at the puncture site, even if you put a stent across the pancreatic gastroscopy. So yeah, nice case. Very nice. Thanks for doing that, Edge. I'm glad you had a backup case. I wanted to comment, everyone was asking about other ways of fixing, and I have used the over-the-scope clip and it works quite nicely. It really secures that stent nicely, especially if you... I think you get a nice grip on it. The challenge with an over-the-scope clip is trying to take that off if you don't have the over-the-scope clip cutting device. And so just be aware of that, taking off the over-the-scope clip may be a challenge if you don't have the over-the-scope cutting device. So your approach is the same as anything else. You have your visual with half of the gastric wall on one side and the other half with the edge of the stent. Is there any particular part of the stent that you target? In other words, is it the side that's opposite of where you're going to enter or does it really matter where you put the clip? I think it's more important to secure it to the robust part of the GI lumen rather than the portion of the stent. I think you'll end up always catching the lip of the stent itself. And then a portion of that clip tends to protrude into the lumen, which is why it was really hard when I did this with the 15mm lambs when we didn't have the 20mm stents. So it gave a lot of friction pushing that scope through. But to date, Touchwood have not dislodged a single one securing these in place with suture or with this. Once I figured out suturing worked just as nicely and was easy to cut, I've not gone back from suturing. Right. Okay. And I mean, that was a great demonstration of the needle knife technique, which I agree is certainly not for the faint of heart here. And I remember Chris Thompson, I think, described that in a case report years ago where he did that procedure with a needle knife. And one kind of bigger question I just want to ask in terms of doing this kind of EUS direct access approach to the pancreas, which is very different animal, I would say, from working in the bile duct, is what do you feel is the learning curve? When should somebody start to tackle doing this kind of work? And when should they perhaps not? You know, I think that's a really good question. I think the pancreas is a lot more forgiving than we feel, especially if there's a chronically obstructed duct. I think you will get into a lot more trouble if you have a naive pancreas with a smaller duct that hasn't gone through these bouts of chronic pancreatitis. And then even if you fail access, the worst you've done is a 19 gauge puncture, and you watch them overnight, and most of them do reasonably okay if you haven't dilated the tract and failed with the pancreatic gastrostomy. I think a good place to start is learning how to do fluid collections, going to the gallbladder, going to a big dilated bile duct, then going to smaller bile ducts, and then smaller pancreatic ducts. I think that would be a good learning curve approach to getting comfortable with EUS rendezvous. Yeah. Yeah, I completely agree. Yeah, it's definitely much more like you were implying, Linda, of an advanced, very advanced in terms of EUS advanced techniques. Right. If we're waiting to bounce between rooms, you guys, I have another video, which is a case series of patients with benign obstruction after a Whipple. What do you do with those patients that are sitting around in the hospital sometimes for a month to two months waiting for either their gastroparesis or the edema near the anastomosis to resolve? So let me know if y'all want me to show another video. Dr. Rani, I think that would be a good idea. Okay, why don't we switch over and get that going. And again, I'll show just one case with this. And just to wrap up the conversation about the EUS direct access approach to the pancreatic duct, the literature does, you know, suggest higher rates of failure and complications compared to the EUS approach into the bile duct. So just to be mindful of that. All right. So this was a case for a series of what do you do when you have a gastric outlet obstruction that's benign and you can treat these with temporary fully covered metal stents. The problem with fully covered metal stents is they're going to migrate and slip on you. So let me just dive straight into the case that I want to show y'all, which is this one. So this was a lady that underwent a complex Whipple operation. And actually it was an Applebee's and she developed a fluid collection which required a drain. And this is what showed at endoscopy two weeks after the Whipple. A complete necrotic breakdown of the anastomosis. But you can still go through that and find the afferent and efferent jejunal limbs. And this is pulling through that necrotic mess over there. So this was not a time to drain or put in stents. And so what I did was put in a feeding jejunostamine to the efferent limb. And then she had ongoing symptoms. And then two weeks later I came back and what I see is there's some healing with some granulation over here. But the percutaneous drain has migrated into the stomach over here. But you can see now the anastomosis is a lot more healthy looking than it is over here. And so this is me driving up to the biliary anastomosis and this is down to the efferent limb where my jejunostamine is. Now what I wanted to do was to place a gastrostomy so that I can secure these stents to the feeding tube and also use it to provide nutrition if need be. So what I did was I just placed a peg into the stomach right near the anastomosis and I took out some of this necrotic stuff. Now she continues to have a really high output from this peg and is unable to advance her diet. And this is what you see on upper GI at about six weeks. There's a really horrendous stricture that's developed. And what you're seeing here is a buried bumper right near the gastrojejunostomy. So I pulled that out of the way and I want to try and find where on earth the gastrojejunostomy into afferent and efferent limbs are. And here it is. It's this little five millimeter stricture. And so I injected contrast and I can now demonstrate both the afferent and efferent limbs. And I dilated it and I said okay let's try and stent both these limbs with covered metal stents going down both sides so she can drain her biliary tree as well as drain and feed into the efferent limb. And so guide wire access I got into both sides. And now it's time to deploy a stent. So I chose a fully covered biliary stent for the afferent limb and that's being deployed under fluoroscopy over there and you see it endoscopically. And then for the efferent limb I chose an 18 millimeter fully covered stent. Now if you leave these stents in as all of you know most of them will migrate downstream or upstream. Downstream is not a good idea. Upstream is tolerable. So I decided to suture them and secure them to the gastric wall. But we also know that suturing stents to tissue these stents can still break. The sutures can break and migrate. So I've stitched both stents to the gastric wall but I decided I'm going to stitch them together as well. And so that's kind of what I'm going to start calling now whipple pants. That's what one of my fellows came up with. Let's call these whipple pants. And so I've stitched these two stents together so they don't migrate now downstream because there's a waste to that pant. And now before I was still securing them externally to the peg. So this is a biopsy forcep with a suture going down the peg. And then I'm going to pass it through that stent and then grab it with another forcep endoscopically and now loop this suture all the way back out through the peg so that it's secured externally. So there's no way on earth these stents are now going to migrate downstream. So that's the forcep pushing it back out through the peg. And when all is said and done these stents have now been stitched to the gastric wall, stitched to each other and externally to the peg. So there's no way now these stents are going to migrate. And so I can stop here and take questions now. I'll tell you what I've started doing is I found that none of these stents migrated down and I've no longer needed this external peg securing. And once you create this kind of pant device where the stents are stitched to each other they will not migrate downstream. They may migrate back into the stomach when their job is done but they at least won't migrate downstream. So I'll stop there and take questions if you guys want. Well we call that a tour de France case. So yeah this is just then contrast going down both limbs. That was a joke by the way, tour de force. But what I, here's something. If you go back to one of your earlier images what I probably would have done since I'm not as clever and skillful is would have done a new endoscopic gastrogygenostomy and bypassed their bypass. Because I think you could have gotten into the efferent limb with an Axios and then just put double pigtail stents in the afferent limb and it'll just go back through and down through the Axios. Yeah I think that's totally an option. Todd this was a video from about 10 years ago so we didn't have access to that. So this is when I chose this option back then. But for people who don't do limbs and are comfortable with stents this certainly is an option as well to then just. Yeah they have to be comfortable with stents and then they have to be comfortable with suturing too right. You have to be comfortable with a lot of things. So no I think it's a great case. Yeah I love suturing everything to each other. That was awesome.

pancreatic duct obstructions

ERCP

pancreas divisum

EUS

sphincterotomy