Hi Dr. Sandeep you're live. Hi. Hi Shayan. Hi Todd and hi Amrita. Hi there. Can you have the first slide? This lady is a 66 year old lady with a recurrent vomiting and pain abdominal for one month and jaundice for last one week. She obviously has a high bilirubin and abnormal liver function test with very high CA99. Endoscopy showed a lot of food residue when we first scoped her and narrowing at the duodenal part, first and second part, suggestive outward obstruction. We did an EOS and a CT which showed pancreatic head mass with duodenal infiltration causing gastric outward obstruction. EOS showed the mass as you can see on the right panel. The FNA showed adenocarcinoma. So she has both obstructive jaundice as well as gastric outward obstruction. So the plan is to do a EOS guided gastrogynostomy followed by EOS guided hepatogastrostomy. So we're doing EOS-GJ first and the stent that we're using is Axios, hot Axios 20 millimeters and the device which is used to deploy this stent is a EPAS balloon. This is from Takahitoi and as you see the picture on the screen it has two balloons which the intervening segment is about 15 centimeters long which is filled with saline and contrast and a coloring agent. And once we trap that area of the balloon we then pass the endosonoscope and then drain it like a pseudocyst. So in order to save time what we have done in this case, there are several literatures now of EOS-GJ using several methods of doing this procedure. Freehand technique using balloon or other devices to fill the efferent limb and then you see it from the stomach and puncture it from the stomach and replace it. Firstly we have more experience with the EPAS balloon and we prefer this for the safety reasons because we want that loop to be fixed, not move around with the two balloons. And now one more slide please. And it has been shown that it is as effective as enteral stent and even with surgical GJ it has been found to be quite effective. So can we come to the live picture now of EOS and fluoroscopy? If you show the fluoroscopy first. Do you have the fluoroscopy there Todd? Can you see the fluoroscopy? You can see fluoroscopy in EOS and you as well. Okay, so you see this image is very, has a wire and a tube which is like a nasojejunal tube. The EPAS balloon with four or six pellets at the tip and this patient actually has a partial malrotation. So if I can ask the technician to just trace the wire from top here. This is how the wire goes. That's a stoma. That's a pylorus. And this is the D3 and it takes a turn from D3 only down below. So let's now start inflating the balloon. Can you show the two markers of the balloon? Fluoroscopy, this is the forward balloon marker. Can you just point at that? Not that one. Just go back five centimetres the other side. This is the first marker and the second marker is there, yes, on the spine. So we'll inflate both the markers now which has a balloon next to it with about 40cc of saline and contrast. Can you start doing that? So we did all this to save time. This whole process took about 10 to 15 minutes. Yes. Just to clarify, you placed a forward viewing scope and then a wire in the catheter and then withdrew and then placed the EOS scope inside. Is that right? Absolutely. We also use a short overtube. You please inject contrast. So we use a short overtube because this balloon, this EPAS system is very floppy and it can kind of buckle in the stomach and that's the reason we use an overtube. The tip of the overtube is placed across the pylorus so that the whole thing goes straight down. So that's the forward balloon being filled with contrast and also the second balloon, please. Both the flu and saline simultaneously almost. So this is an oro-gastric, oro-jejunal tube as of now. That's right, Shayan. That's the second balloon which is somewhere in the, from the third part of duodenum, the duodenum has taken an eccentric bend. This is a little adding to the degree of difficulty, I can say that. Let's see how the loop gets strapped in between. So Sandeep, we had a nice demonstration yesterday of these different challenges that you can encounter. And I think we'll see more on today's talk on gastrojejunostomy that the duodenum can take unpredictable turns. There's not just one pattern of a C loop, which is what you're demonstrating. That's right. That's right. How much has gone? So this is about 10 cc has gone now in each balloon. We'll wait for some time. There should not be any hurry because if you try to do it fast, like the contrast between the two balloons can slip down and then it adds to the confusion. So for people trying to order this balloon in the West, it's not available yet. This is something only available in Asia as of now. Yeah. So this is the courtesy Takao Itoi from Japan. And Takao is a good friend and that's where friends are for. Keep injecting, keep injecting. So one of the things that, you know, we see here is that we're focusing first on inflating and using fluoroscopy and then you will visualize by EUS and find the most ideal target. Other methods might require to identify what would be an ideal loop sort of, and then simultaneously infuse. Do you think that this is an advantage of this system? So we need the balloons to be in the right position. Unfortunately, we can't do in this altered anatomy, but that's why we're filling it up. It's always easy to pull back than to push forward. So we had gone as far as we can with the wire was, and then we're trying to pull, how much has gone in? 20? 20. Okay. 20 each. So maybe one or 10 more. 30? 30. And I have my EUS scope there, which helps me to identify the loops which are there. So these are some of the jejunal loops on the screen, on the EUS screen, if you can see. That should be okay. I think that's fine. Looks to be quite well inflated now with 30 cc of saline. This lady is thin and frail. So now we'll fill the intervening segment, but I'll keep looking at that tube, which I see probably somewhere here. Let me see. Okay, I'll keep moving my scope around and while they are filling it, the intervening segment. So I see the tube there, which is somewhere here. Can you show the flora please? Okay. Inject, inject. So we'll fill the intervening segment with saline, contrast and coloring agent, which is indigo carmine. So I can see some movement here, but that's far away from me. So all these things take time, but it is worth the effort, we believe, because if one mishap occurs, then the patient goes for surgery invariably if you have perforated both the gastric and the jejunal side. There you see the contrast getting filled on the left side, which is far away from my scope tip. And what you see on EOS image is a balloon, which I'm seeing now, as you can see on the fluoroscopy also. So let me see if I can move around my scope. Maybe we can ask Shayan and Amrita, what are their techniques? What do they do normally? There's some contrast leaking forward. Yeah, obviously we don't have the EPOC balloon. I think the method of choice for us at least at our center is to go down and infuse with almost up to 500 cc of saline mixed with methylene blue. And then to come back with the EOS, a quick check with a needle to confirm that we're in the right space and then do a freehand technique with the Axios. We are heavily dependent on fluoro to help locate the best, you know, kind of get a sense of where we are going to be and make sure the angle is good. One of the things that I see here is that from where I'm wondering is how fluoro can be used there. That looks like a great, great approach there. Yeah, but you don't use the puncher balloon, the puncher technique? No, sorry, go ahead Amrita. I was going to say we use the free axis with the high Axios. That's how I started doing it Nadi, thinking that you could target the balloon, get the wire through. We put a little series of the different ways we tried to do it. And over the last 40 or 45 gastrojejunostomies I've done this puncher technique where I'll drop an orogastric tube if I haven't insufflated the duodenum and jejunum enough. And then I can use it hooked up to a foot pedal and a pump just to put in more fluid as needed. So essentially getting the same view you'll get, but not having the ability to trap a segment of bowel and then doing a direct puncture and deployment. That looks like a nice view right there. Yeah. So you see my scope position is terrible actually. But I'm seeing that the swirling movement, this is the intervening segment where my scope tip is. And I can also see the tube in between. That's the tube there. Keep injecting, keep it. So we inject about 150 to 200 cc of the whole solution. How much has gone in? 50 cc has gone in. Will it make it distended more? Keep injecting, keep injecting. But his point is important because the, while that, while we can see well here, we have to get the, the Axios catheter down. Very stiff catheter. Yeah. And this is a very angulated position. It's. So Sandeep in these situations, one of the things that you can tell the audience if you do is pull back, straighten your scope, get the Axios out of your sheath or the lumen opposing stent out of your sheath, and then go back into a funky, difficult, long position if need be and deploy it. Yeah. Thank you. Thank you, Shayan. That is a very important tip. And I was thinking of speaking it later when I pushed that stent in, but for the time being, my aim is just to create that pseudo pseudocyst. If I can use that word. Fake cyst, we like it. We talked about that yesterday, that one of the principles of using the Axios is really creating a lot of space in which to land the catheter and have, be able to visualize that the first flange when it's opening. And what position is the patient in? In prone or supine? She's in prone position. So under sedation without endotracheal tube. No, she's not intubated. She is under deep sedation with propofol and that's why I have my friend Dr. Pinder who's taking care of that. Okay. I think this is going decently well now. I want a dipping segment, which will make my, this is different. Okay. So what Sandeep just said over here was he would like a target which where when he punctures with his lumen-opposing stent, it stays in the lumen and doesn't abut the contralateral wall of the duodenum. That looks like a nice angle there. So you're happy with that, Amrita? I like that a lot. I think the scope is in a better angle for you to get. Yeah, now it looks a little better. Again, it's a little hockey stick, but let's try this. Make it wet, please. Sandeep, how much, what size of target do you want when you're doing this gastrojejunostomy? So ideally at least three to four centimeters, but if I found a dipping segment that makes my job a little bit easier, then I can pass my stent deeper in because that's what I want, but I can pull back the first line. So I'm now loading the stent. So this is where Cheyenne was saying the difficulty. Can you hold it, please? I'll fix that. So once it gets fixed, it should be okay. Now that's fixed. Can I have the position now seen on the fluoroscopy? That's okay. Now it's a little bit better. A lot of movement happening here, but... Do you give any glucagon or... Yeah, can I have a little buscopan, please? So we already have a little buscopan, or... Yeah, can I have a little buscopan, please? So we don't have glucagon. We use iosine. That's buscopan. So a couple of advantages using the EPAS do include the fact that you don't routinely have to give the buscopan because the balloons are keeping the segment inflated, and you also don't have to confirm that this is small bowel with a needle stick, as you do sometimes in the other technique to make sure that you're not in colon. Yeah, because in the freehand technique when you keep injecting, you don't know which loop is next to you, and you can actually sometimes end up doing a gastrocolostomy. And the longer it takes, the more chances of complications. Whereas here we have trapped that loop, which is here, and the swirling movement is happening in this one, and which I can cross-check. Yeah, here comes the tube. The tube is here. So this is where... Sorry, go ahead, Sandeep. This is where, if you're going to start taking your... doing this, take your time to make sure that loop of bowel is nice and steady before you get ready to puncture, because a lot of sphincters get tight when you do this. You can get palpitations as well. I think it looks... There's some, I think, balloon leak, because the contrast has now become more diluted. It's because of dilution, or just put pure contrast inside? That will help me. I'm taking my time. I'm sorry. I know time is a constraint, but this is a high reward, high risk procedure. One wrong move. Please do that. We really appreciate that, and your patient appreciates it. And it's important for everyone to see that this is not a quick automatic procedure. You really do have to stop and think, and sometimes abort if you can't, you know, find it. Absolutely. And then this should be okay. This is not descending well. This loop looks fine. I'll keep putting, keep put some more, put some more. Yeah, this is drawing some swirling of the contrast. Yes, yeah, put, put, put. I think this looks fine. What do you say, Shayan, Amrita? It looks much better. It's hard to see how magged out you are, or focused in you are. Do you want to measure your loop and see? Okay, this is one fold which is coming in between. I don't want to overshoot and go into the other side, because then it'll definitely cause some perforation. This is a fold, it's going like this. I think, I think you have a good view into lumen, so, in which to apply the cautery, and then if you can continue to push your catheter in without, that's right, it helped. Maybe I can bend a little bit on a different direction and go in. Okay, that's it. A little more, a little more. One more time. Take your time, Sandeep. And then the other important thing is to really have, have an idea in your mind of where your target is, because when you put the cautery on. Yeah, that looks good. That looks great. When you put the cautery on, you will lose your visualization for a quick second, and so you don't want to panic there, but rather have a visualization in your mind of where the target is. Yeah, screen. Okay. Yeah, that looks great. Okay, so I'm in now. I'll push a little bit more in for just a safety purpose, and then lock it. I think that's a very important step, I think, is to push in as far as, as possible without cautery, just to confirm that your plant will open. So now you've locked that catheter. I've locked. So Sandeep, maybe push a little bit more in. So can we get back to an EOS image? Yeah, that okay? I think, Shan, thank you very much. You're really a friend. You told me the right trick at the right time. Yeah, make sure you push it in a little bit more, just because the plant was threatening to come out. Yes, yes, yes, yes, yes. I am obliged. That's lovely. So what you'll see is this contrast in that duodenal flange, and that's very reassuring that he's in the right place right now. And I pull back a little bit, a little bit. That looks okay. Now I lock it again. Unlock the proximal flange. I can reason the scope, or I can, let me reason the scope itself. I've released it. That's always safe and nice with these gastrojejunostomies. All right, so he's reached over to an end of view. I've got endoscopy. I can see the stent now. I just have to push it out. Very nice. I'm hoping for a blue color to come out, apart from some red. It looks okay. That looks beautiful. It looks very nice. So, and what's your practice regarding dilation? Does anyone? I don't do dilatation. I just wait for it to naturally expand, which will take two, three days time. I want to play the waiting game. I do the same. I used to do the same thing with these stents, let them expand out, but sometimes if there is still some food material left and it's a very high-grade obstruction, I don't mind dilating, but I'll try not to dilate to the full size of the stent. So, if you've chosen a 15 millimeter stent, you can go up to 10, 12 millimeters. You let things pass through immediately. And you'll also still have the pressure of the stent to expand and give you the same benefit of preventing bleeding. So, you can thank you for that excellent demonstration. I think what we should do is go to another room where Mohan is getting ready with the case and then come back for the other. That was fantastic. Really difficult composition and really nicely done. Well done. Thank you. Thank you.

endoscopic ultrasound

gastrogynostomy

pancreatic head mass

stent placement

sedation

complications