Thank you, and thanks to the directors again for inviting me. So I'm going to pick up where both Shyam and Ji left off, and they were great segues in. We're going to talk about the first case here, is a 42-year-old gentleman who had medication-related pancreatitis, developed nausea and vomiting and abdominal pain about five weeks after his initial episode, and had a CT that demonstrated extensive fluid collection throughout the abdomen. So a couple questions to think about as we watch the video, and then I'll pose to the panel. First of all, very important, is endoscopic drainage actually indicated at this time based on what we're seeing? If so, how should we approach it endoscopically, percutaneously, et cetera? When should we intervene, and are there any techniques to facilitate this drainage? So here is the collection, very extensive, you can see, Ji, Shyam, do we have your go-ahead to drain? I think so. It looks like we have a wall, right? We're about five weeks out, the patient has symptoms, I think, with a history of pancreatitis, it's a pretty good guess that this is a walled-off fluid necrosis or pseudocyst. So we are going to proceed with endoscopic drainage, is that okay? Or you think how extensive this is, is this need percutaneous? I mean, I would go back to the CT scan that you've shown me, but I think there's a good window from the stomach. I don't know what's happening down on the flanks, you'll have to play the video again for me to take a look at it. Everyone will agree that we are not going to surgery, correct? Yeah. Good. So we are going to proceed with endoscopic drainage. Here you can see the necrosis within, you've seen placement of the axial stent in several videos now, with deployment of the first flange, we then pull the entire stent up to oppose the wall of the collection to the stomach, and then deploy the second flange within the stomach. This is a 15 millimeter axios. It is good to know that we have 10, 15, 20 sizes available, and thinking about which one we should use is something that depends on the size of the collection, as well as the location. So here you see instant drainage of pus, and we're going to place a double pigtail at this time. We talked about early intervention versus waiting for next procedures, can we get some thoughts on that? Who would go ahead and... I mean, you need to tell me, was there gas on the cat skin? Was there... Not gas. And did your radiologist... This is the problem with the cat skin, we can't quantify the degree of necrosis. I can't say anything. So if there's an MRI, I can say, but since you're getting just clear fluid and there's no gas, I think we can wait on it. I think we can wait on it. Okay, good. So that is what we did. We sent the patient out, we brought them back about two weeks later, and after a CT to demonstrate whether there was some resolution, which there was some, but not... There's still an extensive collection. And the plan here is to go in now and do necrosectomy. You see we're removing the axios in order to allow for better manipulation of the scope, dividing the tract with a larger balloon so that we can get the therapeutic scope in. And now we're going to start to examine, look for vessels, and then start our debridement. Now when you talk about debridement, there's a number of tools that you can use. Interestingly, none of them are actually approved for necrosectomy, but it's what we've always traditionally used. And you can see here that using any of these tools does require movement in and out of the scope from the collection into the stomach to kind of drop off what you are debriding, which can take a lot of time. And you also lose a lot of material due to the consistency, and sort of it gets very sticky and it's just not very efficient. And you really have to judge for yourself with efficiency how long you're going to spend. You could spend hours doing this, or you could just decide, okay, I'm just going to do an hour, leave some double pigtail stents, and then come back. Again, all sorts of our common tools that we pull off our shelf. So in this case, we did several attempts. This is actually a compilation of a couple of different sessions. I think this patient went through a total of four sessions. This was earlier on before certain tools became available. In between each session, rather than replacing the Axios, because that's not necessary, we've already created our Axios. We placed multiple double pigtail stents. And then I'll just move ahead here a little bit. One of the sessions, we irrigated some hydrogen peroxide. Raman, how often do you use this, or when do you decide to use it? Yeah, I think there's some data showing that it can help reduce the number of sessions and increase your success rate. I think it's, as Cheyenne was saying initially, it can kind of mess up your view. So I kind of do it kind of at the end of one session, or I find it's particularly useful when you're getting close to the finish to kind of loosen some stuff up the wall. And it works, I think, much better if you do it in a power spray rather than a syringe. Good. Important that you suction out everything that you put in, because it can cause aspiration pneumonitis. And so finally, we brought the patient back after, for hopefully one of the last two sessions, and we're able to use another device, whoops, sorry about that. This is called the endorotor device. It actually allows us to stay stationary with the scope within the collection. And this device has a type of blade at the end of it that actually goes ahead and cuts out all of the material, and then, along with irrigation, and then suctions it all into a catheter. And it can be very effective now also with a new size catheter. And data has shown that this can kind of decrease the number of sessions required to even one to two sessions. And finally, at the end, we'll leave double pigtail stents, and also determine whether or not there's disconnected duct syndrome. So I think one thing, this case, again, this was done before Shyam's algorithm came out, as well as some of these newer tools became available. But you can see that there are a number of techniques that we can use now. And if we think a little bit about perhaps also multi-drain placement, that we can kind of cut down the number of sessions required, and get these collections resolved earlier going forward. And hopefully, we look forward to the data for the next, that we'll have coming out. So the next case is something we haven't talked about here, but gastric outlet obstruction, malignant gastric outlet obstruction. This is an 84-year-old woman with metastatic breast cancer. Symptoms of outlet obstruction, nausea, vomiting, her scans showed a large retropartinil mass causing duodenal obstruction. And the questions here are, how are we going to treat this? By stenting, by gastric bypass, from gastrojejunostomy, and should we do that endoscopically or surgically? And so a few questions just to think about is, what's her prognosis? Is there any evidence of more distal obstruction? And then, what's the long-term maintenance of the LAMs, which we won't talk about. But here is her scan. Here you can see the large mass, very distended, full stomach, there's no evidence of more distal disease. We go in endoscopically, obviously this video's about EUS guided, so we just chose an endoscopic option. We're placing a wire and a catheter into the more distal small bowel, and irrigating this these days with up to almost a liter of fluid with contrast and methylene blue in order to distend up the small bowel and find a good target from the stomach. Now we've placed the EUS scope into the stomach and located this loop of bowel where you can see the bubbles from the irrigation that we had performed. These days I actually place an irrigation catheter and do continuous irrigation throughout the procedure, but this was a little bit earlier. Here we're inserting an FNA needle just to confirm that we have a loop of small bowel as opposed to colon, and even injecting a little bit to make sure that our target is correct. And then we use a freehand LAMS technique, cautery LAMS, placing it into that loop of bowel, opening the flange into the small bowel, and then we'll open the second flange into the stomach. And then when we see endoscopically, you see the blue fluid come out, indicating or confirming that we have successfully placed this LAMS, and this patient now has a gastrojejunostomy and is relieved of her obstruction. And her prognosis was quite good because it was metastatic disease. Had we placed an enteral stent, most likely it would have occluded pretty quickly. And the guidelines, therefore, by multiple societies are that if the prognosis is less than three months, you should place enteral stent. However, if it is longer, you should consider a use-guided or surgical gastrojejunostomy. That's that.

endoscopic drainage

axial stent

double pigtail

malignant gastric outlet obstruction

endoscopic ultrasound-guided LAMS technique