So, I'd like to introduce Dr. Swati Pawa, who's going to be presenting to us. She's coming to us from Wake Forest. A little change in the topic today, because I think we gave you a curveball on this one, but you're going to be presenting on adverse events associated with the EOS techniques and drainage. Thank you. Good morning, everyone. I wanted to thank the moderator, the course directors, and the ESG for inviting me for this talk today. It's quite an honor to give this talk to all of you as well. So, I'm going to be talking about reducing adverse events associated with EOS-guided transluminal drainage. And the objective is going to be to talk to you about pancreatic fluid collections, EOS-guided gallbladder drainage, EOS-guided bile duct drainage, as well as EOS-guided stomach drainage. So, we've got a lot to cover, and I'll try to do my best to be on time. But we're going to start off with the revised Atlanta classification. As you all are aware, it talks about acute pancreatitis either being necrotizing or interstitial. The majority of people will get, or patients will get, interstitial pancreatitis, which then develops into acute peripancreatic fluid collections, which if persist for more than four weeks will get encapsulated and will have fluid in them, and that's called a pseudocyst. On the other side, though, if this is bad necrotizing pancreatitis, that too will evolve into acute necrotic fluid collections. And if they persist for more than four weeks, they will develop also a wall around them, and they're called Waldorf necroses. So, we know that there's been a paradigm shift in the treatment of necrotizing pancreatitis over the last decade with three randomized controlled trials stating that the endoscopic step-up approach has led to less organ failure, pancreatitis, or pancreatic fistula, as well as less hospital stay and better quality of life. And then there is another trial that came out recently which stated that postponing intervention in infected necroses was better in terms of the number of procedures that were done as opposed to early intervention, where there was no difference in complications later on, just the folks who got, or the patients who got early intervention had more procedures. So with all that in mind, we kind of thought about what is this four-week rule of endoscopy, and if you look at the paper in Gut, which talks about people who had early intervention or patients who had early intervention actually had greater morbidity and mortality, but also bear in mind that all these patients were very sick. What really I want to draw your attention to is that as far as organ failure is concerned, they got better within one week of getting intervened. So there might be a subset of patients who are not responding to medical management and have multi-organ failure who might actually benefit from early drainage if they have endoscopic elections that one can drain. So keep that in mind, and that might be less than the three, less than the four-week rule. Then obviously there's always a debate, which stent is good, is it plastic versus metal? And there's an RCT that showed that if you used LAMS, which is the lumen-opposing metal stent which we generally use for all these, or which we're going towards for all these drainage purposes, that it led to more bleeding, more buried LAMS, as well as increased risk of biliary strictures if it was kept long enough. But it did decrease the procedure time significantly, and so they came up with the fact that we need to take it out within three weeks if the necrosis had resolved. So it's important if you are going to embark on these kind of procedures that you know your lumen-opposing metal stent. We only have one available in the U.S., there are more in Europe and other in Asia, but you should know that it's lumen-opposing, it's covered, and self-expanding to seal of a tract that you're going to create between two organs, and it serves as a port for transluminal interventions. What's key is that you should know what the saddle length of the lumen-opposing stent is, and it ranges from 10 millimeter and a 15 millimeter, and you should also know the longitudinal diameter, so if I'm going to put a lumen-opposing metal stent, I need to know the longitudinal diameter, which is going to be the trajectory that my stent is going to take, and how much that should be, that would be the runway that my stent's going to need to deploy safely. So if you're dealing with a smaller collection, you might not be, it might not be safe to put a larger stent in, but if you're dealing with a larger stent, for example, a 20 millimeters, you at least need 38 millimeters of a fluid collection minimum to be able to deploy the stent safely and not maldeploy it, so this is a very important concept that you should know if you're going to go and do these procedures. You also should know your cautery well, that we use pure cutting current, you want to advance your catheter slowly with steady pressure, stop when you see bubbles, which signifies target entry, and once you discontinue it, use your guide wire, which serves as a safety net to retain access, for you to actually lose access. You can always preload the guide wire before insertion and advance the guide wire after the puncture. So as far as our Waldorf necrosis is concerned, or pseudocyst is concerned, we'll do two procedures, one is drainage and the other is going to be necrosectomy. The drainage, again, you want to be sure that the cavity that you're draining is mature, you want to make sure that if you're dealing with a stomach, you are below the cardia and you're not going through the esophagus, and for duodenum, you're going beyond the pylorus, you don't want to drain a cystic neoplasm, you want to make sure that you know the cause of the pancreatitis and what you're draining well, and have a plan after deployment of the luminiposing metal stent, but more importantly, a multidisciplinary team of pancreatic surgeons, interventional radiologists, because this is all teamwork, this is not just one person doing it all by themselves. Starting direct endoscopic necrosectomy, this is laborious, tedious, needs to be planned well, you might have to do multiple sessions, and we borrow from our luminal side where we use caps, biopsy, SNES, there's not really much dedicated instruments for us there, except for the new one, which is Endorotor, which is powered endoscopic debridement system, which is currently the new kid on the block, which can suck, cut, and remove, but you still might need other accessories, be it a cap, where you can actually suction the necrotic tissue, but be mindful if you're using SNES, they're all pointed, and the walls are very thin and can bleed easy, so you have to be mindful of doing that, and you can also use hydrogen peroxide, which can loosen and dissolve necrotic debris. So how to avoid some complications, bleeding, you can try to, there's a paper that came out in GIE that for bleeding and for occlusion, maybe possible double-pick stents inside the lambs might be helpful in preventing those. Regarding perforation, choose your case wisely, and regarding maldeployment, we'll talk more, but maybe deploying in the channel as opposed to waiting for the black mark, especially with the smaller stents. This video here that I'm showing you is actually a Waldorf collection in D4, so a fairly tough case to begin with, this is the Waldorf collection that you're seeing over here, the lambs is being deployed nicely, there's enough runway for the lambs to be deployed. This is the distal phalange, and while in the U.S. you can see that it's being snugged, and there you see the deployment of the proximal phalange, but the bowel moves, the position is unstable, and in front of your eyes you can see that the lambs that we thought was going to open up over here get sucked into the cavity, because this was adherent to the duodenum, not much was lost, and the case was salvaged with two double-pick tail stents. So we will have holes, if you're going to undertake this, that's a reality, so you should not panic and you should know how to close these holes, right? So early recognition and early closure is key, you want to reduce the need for surgery and you want to reduce morbidity and hospital stay, you want to stay calm, encephalate with CO2, and you should have something called a perforation toolkit, which can include many different kinds of clips, as well as over-the-scope clips for which you might have to remove the endoscope as well as the endosuturing device. Quickly we're going to move on to EUS guided gallbladder drainage, so from one organ to the other, normally used in acute cholecystitis in poor surgical candidates, but can have other causes as well. Again that's time-tested PTC, which is easy to do, widely available, is there with 100% technical success rate, but the problem is the maintenance issues, the patients hate it, there are problems, it's unsightly, discomforting, can have permanent fistula, so there's where EUS gallbladder comes in, which gives you direct access, no maintenance, and preserves gallbladder physiology, but its role in future cholecystectomies is uncertain. You want to consider over-the-wire techniques when you are faced with clinically challenging situations, which could be a gallbladder packed with stones, or especially if your surgeon calls you to internalize a gallbladder, which has a PTC in it, which can be very contracted and difficult to do. You want to avoid the neck of the gallbladder, and you want to choose your stent size based on what you're doing, so if you're going to just drain the gallbladder, and there's nothing else you have to do with it, and you just have to put a stent in and maybe change it over to pigtails, you can use a smaller stent. If you're going after stones, then you can use a larger stent, even up to 15 millimeters. Again, if you put the stent in the stomach, remember that there is some occlusion with food, as well as invert stent migration because of high gastric contractile forces. And you can follow up in four to six weeks, you can change the stent out and put pigtail stents and leave it indefinitely. If you're going to go in, like you'll see in the video, you're trying to actually break stones and do a cholecystoscopy, you can actually do that, or you can leave it indefinitely in a frail patient who doesn't want to come back, and the three-year patency stent rate for that one would be about 88%. So here we are with an EHL probe, breaking the stone down, you need to be very careful. These have sharp edges, and so it shouldn't hurt the gallbladder wall, which is very thin as well, but you can take these out and use a snare to remove it and clean the gallbladder as well. Eva's guided biliary drainage, I'm going to touch very briefly. It's beyond the scope of this lecture, but you can actually do drainage of the bile duct and distal malignant obstruction, or you can actually do drainage through the hepatico-gastrostomy. These are probably the most challenging because we don't have dedicated accessories, and we are working with really small spaces. If you look at this particular video, this is actually a dilated CBD. You can see the puncture, and the reason why I kept this was that before LAMS came, we would actually put a guide wire in and then try to dilate this tract with a balloon, and you can almost see the tenting, and the tenting that's happening, we're trying to get this balloon in, and finally it doesn't happen, and so this was salvaged with the gallbladder drainage. But that's the difficulty, and that's what LAMS has overcome, especially with the cautery-enhanced LAMS. But again, with hepatico-gastrostomy, you are dealing with very small spaces. This is actually stones in the bile duct of an altered anatomy that we can't access by ERCP, and so you're going to notice that the first thing is you're dealing with very small radicals that you're going to have to puncture in the liver. Then there's the guide wire problem of trying to manipulate this guide wire and avoiding a share of the guide wire, which happens often. Once your guide wire is in, you're trying to now manipulate the scope and the wire to get it into the duodenum, and then you are going to try to put a stent because there's a landing site in the liver, and then there's a landing site in the stomach, and you have to be very careful because these are very sick patients, and the complications can be pretty severe, especially if you lose the stent or you're going to cause biliary peritonitis in already a very sick population. So can you imagine a hole in the liver and a hole in the stomach in a very sick patient who's not a surgical candidate, and you see that we almost lost it here but salvaged it with another stent, in a stent, and that might be the way to do it. So always your guide wire is helpful. We're going to move to the last organ that we're going to target from one mobile organ to the other, and that's going to be EOS-guided gastroenterostomy. This has emerged as a comparable alternative to surgical bypass. The technical and clinical success is about greater than 90 percent. It has an acceptable 10 percent reintervention rate, and adverse events occur in about 10 percent. Five percent of those can be serious, leading to peritonitis, perforation, or bleeding. And again, this used to be the gold, probably is the gold standard with excellent long-term durability, but it is invasive and may delay systemic therapy, which is where the endoscopic GJ is, or gastroenterostomy is coming into play. There is a time-tested endoscopic stenting for patients who have life expectancy of less than three months, maybe, but it has limited long-term patency. When you look at the EOS-guided intervention, it has a high technical and clinical success rate, but only in expert hands and is being done in expert centers, faster resumption of chemotherapy, and ideal for patients who are going to live longer. Again, little data on this right now, but there's been a lot of publications recently. In this particular case, you are actually going to take a cystic catheter, put it in the small bowel past the gastric outlet obstruction, fill it with the small bowel with dye. You want to put saline, some dye, some contrast in it so you can see what you're dilating. You're going to keep your EOS scope handy, and then you're ready in the stomach, and once you see a dilated loop of bowel, such as this, you're going to make sure there's enough access to deploy the stent, and you're going to go ahead and put your Axios in and go ahead and deploy it, just the same way, with enough runway to deploy the distal phalange, holding it snug, and then deploying it either under endoscopic guidance or looking for the black mark, and once you see the black mark, endoscopically releasing the proximal phalange, like so. You want to give glucagon sometimes to slow down the mobility of the bowel as well. But there are complications related to this, and they are divided into four types. These are maldeployments, which are the first one, which is type one, is when you actually deploy the stent, but it never reached the target. It just hangs from the stomach, in this case, into the peritoneum. The second one is you actually nick the bowel as well, but then it didn't really enter the bowel, so now you've created a greater problem because there's stuff oozing out from the bowel contents, and you've got a hole in the stomach. The third one's probably the most severe, where you've actually lost the proximal phalange as it's now in the peritoneum, and a permanent hole in the small bowel, which is now draining into the peritoneum, and this one is a gastrocolic, where you actually then went inside the colon. And so if you have a type one, this is a maldeployment, and I'm going to be wrapping it up. These are the last few minutes. This is a maldeployment. You can see the guide wire is beyond the bowel. It's not in the bowel, and so in this case, they decided to go into the peritoneum to try to salvage this case, so they're dilating the maldeployed stent. They've got a balloon. You can see the waste that's going to be obliterated, and once the waste is obliterated, you're going to actually see that they're peeking into the peritoneum and actually looking at the loop of bowel that was intended to be punctured, which is right over here. They look at that, and they go ahead with the EOS scope and actually puncture it, put a stent with an ascent, and salvage this case. So in conclusion, you, I think I, let me just touch briefly on what you can do with these types of techniques. For type one, you can remove the lambs and close the stomach site, easy, because it didn't really touch the contralateral bowel wall. For type one, two, three, you could also do what was done, which is salvage with either a fully covered metal stent or another lambs, or dig deep in your soul, and if you really want to do notes, then you want to go ahead and then go into the peritoneum and do a site salvage. And then for the last one, you want to let the fistula mature and then remove the lambs and close the site. So really, we all have adverse events. We know that, but you should know your patient, just back to the basics. You should know that you're doing this for the right indication. You want to set expectations, and you want an informed consent. You also want to know your limits. Select patient based on your expertise. This is not a one-person effort. You should have a competent endo team who's going to back you up. You also want to seek multidisciplinary input when you embark on these procedures. Have adequate backup should you need help. And a stepwise approach can salvage most maldeployments without serious adverse events. I thank you for your attention. »» Thank you.

adverse events

eos techniques

drainage

revised Atlanta classification

endoscopic step-up approach