Thanks, Linda, and thank you for all coming today. This is exciting. It's exciting to see everybody here. I do feel like the old person, but I want to clarify that Dave Deal has got to be older, because he was my attending at one point at UCLA. So I just want to clarify that. And this is, you know, it's fun to be here. I was involved in the building of this, the IT&T Center, when we were developing it, creating it, visioning it. I don't think we ever visioned that we were going to have two courses nearly overlapping at the same time. So this is, I think, only the second time it's ever happened in the history of the IT&T Center, where they had the advanced fellows course was yesterday and this morning, and then we're kind of coming through. So we're part of history as the IT&T Center expands. So thanks for coming here, and thanks for being part of it. And also thanks for those of you who are on the Zoom part on the hybrid. Just out of curiosity, how many people here did advanced, quote unquote, fourth year fellowships? OK, how many are pretty much kind of self-trained and have just picked it up over the years doing it? OK, so about half and half, and that's great. And so I think we're going to see that we have a little bit for both. The other thing that's kind of happened over the years with EUS, which kind of makes me feel old, is it now seems like EUS and interventional has now gone from your diagnostic EUS or your interventional EUS. And so it's an interesting transitional period, where actually when we hire people now, we're like hiring, OK, I need an interventional EUS who does these things. So it's really become sub-subspecialized, like metrib-GI. So I'm going to give you a little bit more. I'm more on the diagnostic side, but how things have changed now in terms of our diagnostic and using EUS for diagnosis. And so we've changed the name. It used to be, oh, we just do EUS FNA. Now we've changed the name to EUS Tissue Acquisition. And we can do it a couple ways now. There's actually more than just two, but there's a fine needle aspiration or a fine needle biopsy. And what is really do we want to do when we're trying to get samples? And what we're trying to do is figure out what's going on. We need diagnostic material. It has to be adequate. It has to have a high yield rate. And it has to have a low adverse event. And it needs to be fairly quick. So these are things that we do. This is kind of bread and butter EUS, things that we're doing all day long. When you look at, you know, Satyenwani and Mike Wallace came up with some quality indicators that the ASG and ACG used. And a couple of things, you know, you need to have high diagnostic rates, greater than 85%. And way back when, many of you in the room did a study with us in which we said, if you're biopsying pancreatic masses and you're pretty high suspicion it's cancer, 85% of the time, you should be getting cancer on those diagnosis. And if you're in a community hospital or someplace where somebody's biopsying a lot of masses that should be cancers and they're not, you have to start saying, you know, what's going on? There's something kind of an issue here. And so again, for malignancy, same thing, you know, 70 to 85% and the adverse events should be low for this, you know, should be less than 2%, you know, be a pancreatitis if it's a pancreas perforation bleeding. So, you know, at least the goals from 1992 when we first started this, at first it was get any cytologic diagnosis. Now it's we need to get a pathologic diagnosis. We have to have molecular profile and we have to have next-gen sequencing. So it's a very different change. We were concerned at first. When we started doing FNAs of pancreas, my surgeon flat out said, do not FNA the pancreas. They're going to get pancreatitis. They're going to die. And it's like, okay, we won't do it. So the people who started doing it was like a big deal. And then finally, now we do it all the time. So the complications we're realizing are actually pretty low. Way back when we had one needle, a 22-gauge needle, and then we said, well, maybe we can use a 25-gauge because the cytologists do it because they have less blood and more, you know, more cellularity. And then we evolved and someone said, well, maybe we need a bigger needle. We got a 19-gauge needle and now we have a variety of different needles and techniques. So knowing your adverse events, I think, is important. And again, this is from the, you know, just came out from the ASG standards of practice. This is mostly just so you know when you tell your patients. It's going to be a couple percent risk of getting complications. And I think we've, for those of us who do a lot of these, we see these, we see occasional bleeding, infections, perforations, and certainly pancreatitis. And so I think keeping these in mind when you can say your patients is important. Now, what are the different things that affect your diagnostic yield? Your target lesion, pancreas, you know, may be a little bit different if it's a hard fibrotic lesion than mediastinal lymph nodes. The skilled and the endoscopist, all of this as we do more of these, we get better. Again, there's maybe some differences with the needle size, maybe with the technique we use. We'll talk about that. How you prepare the cytologic material. Do you use rapid onsite cytologic evaluation and do you have a cytologist expertise, which actually in many community places is important because they're not used to looking at these specimens when you're first starting a program. The needle placement is important. And so just remember the edge of the lesion always has most of the tissue. The center is gonna be viable tissue. The center is usually where necrotic tissue is. So that's why we'll do this fanning technique in which we'll go to the different parts of the lesion to try to get all these different ones. Usually these are quick jabbing ones and people debate how much time you do it. And you always wanna try to keep your needle in view. So sometimes you'll have an assistant hold the scope at least so that you're keeping, you can see the needle all the time so you're not going through the lesion or not missing the lesion. The type of needle, you know, we debate. You know, I'm just out of curiosity. For people who do routine pancreatic FNA of pancreatic masses, how many people routinely use a 19-gauge needle? Okay, so a couple people routinely use 19, 22-gauge needle as their go-to. Probably about half of the people. And for a 25-gauge needle. Okay, and so it's interesting. So again, there's no right or wrong here. It's just this is varied over time and people often get used to using a certain way and that's just what they use. So all of them are reasonable things. Again, the smaller needle, potentially you're gonna get more cytologic material and less blood. Maybe easier in fibrotic material. The 22-gauge is, you know, very standard. It works, you know, again, I'm saying use less, most of the time use less. I'm gonna change that slide because in this room it's used the most. So, you know, it just depends. In California, I think we do more, you know, the 25-gauge. And the 19s, we probably don't use quite as much just because it's a little bit bigger. It's hard to get if you're in the duodenal sweep. It's gonna be hard to get around that and there's be a potential, you know, damage to the scope if you're having those problems. But in a straight view, if you can get it through, it's not a problem. And then there's, you know, different kinds of, you know, needles, not just F and A. There's also F and B. And we'll kind of get into that in a second here. And so what about, you know, that question, you know, 25 versus 22? And again, there's been a couple of meta-analysis looking at this and actually showed that they're, you know, fairly similar between the 25, you know, and the 22. A little bit better sensitivity, similar specificity, you know, with the 22. So not necessarily a big difference between them. 19-gauge, again, most of the study's a little bit more difficult to use in the pancreatic head around the sweep. And so, again, both 25-22s I think are gonna be, for most people, your go-to needles. Stilette, no stilette. You know, when we first started doing it, they all came with stilette. So we said, you need to have a stilette. Why do we have a stilette? That was because the idea was you'd get some tissue plugging the needle tip, so you want to flush it through or keep the tissue from going in there. Then, you know, people said, well, it's kind of, it takes a lot of time worrying about the stilette. Let's do it without a stilette. And when you actually do with Satchin 1 and others, these randomized studies looking at this, there really doesn't seem to be a big difference between with or without stilette. So, you know, I'm just out of curiosity. How many people tend to do all, you know, most of their biopsies with the stilette in? And that's good. And so half the people, there's no problem one way or the other. And I would say for my practice personally, my first pass is always with the stilette, usually because it's in the needle. And then the second pass is I'm just getting, I want to rush and, you know, don't do it. They both work. You're not gonna be, there's not gonna be a problem. Part of this, going through this is to realize, you just want to be aware of all the different techniques because sometimes one technique's not gonna work and you're gonna want to try something else. So what about Satchin? How many people routinely use Satchin on their, when they're doing their aspirations? Okay, interesting, not that many people are using routine Satchin. I tend to use Satchin. I tend to use, since I don't know the answer, I use both. I use a little Satchin, a little no Satchin, just like hedge. And so the idea is that you're gonna pull material into the needle. Theoretically, it will increase your cellularity, but it also increases the bloodiness. And what I'll do is if I'm looking at, and sometimes you do, and you just see really bloody passes and you say, this is too much blood. And then I'll stop using Satchin, just switch to no Satchin. And so, but when you look at it, it's, you'll see a little bit more tissue with the Satchin. And so again, it's, I don't think it's strong, but some people would say do Satchin for these. And if you do Satchin, there's a couple of different ways to do it. So you have what we call dry Satchin, which is just, or syringe Satchin, where you use a 10cc syringe to trip the standard negative pressure. And that seems to work quite well. And compared to no Satchin, it will improve your diagnostic yield and improve the higher sensitivity, at least in some of the studies that have come out. Wet Satchin is another to try to increase the pull. That's where you actually pre-flush your needle with saline or heparin. And then also a little bit of fluid in your syringe as well, then aspirate back. And the idea you're gonna get a bit of a stronger pull with this, higher, you know, there are some data suggesting, you know, maybe a higher quality of your specimens and similar accuracy versus air. So, you know, some people really like that. And then there's the slow stylet pull in which you're in there and you're just very slowly pulling it out. It can be anywhere from 15 to 30 seconds. This is often used, especially when you're doing fine needle biopsies using this. So again, all of these are things just to be aware of. And sometimes we'll use one or another and try different ones. And then how many passes do you do is always kind of a question because what this really is getting at is do you have rapid on-site evaluation or not? So just raise of hands, how many people for most of their cases do they have a cytologist in the room to give them rapid on-site evaluation? Okay, so fascinating. So probably only a third of people who are doing this have rapid on-site evaluation. And that's kind of changing things a little bit. It changes, and you'll see as we talk about this, it changes how you do. We know that for lymph nodes, you need fewer passes. And I can't get my mouse, yeah. For fewer passes, usually a couple, at least in our study, three passes, three to five for lymph nodes and maybe five to seven for pancreas. But that's with old FNA needles, not biopsies. And you just need to know pancreas tends to need a little bit more if you don't have somebody telling you that you have adequate tissue or not. For the ESGE, for their 2017 guidelines, they suggested if you're not doing rapid on-site evaluation, do three or four passes for FNA. This is gonna be for pancreas and two to three for FNB, just to be sure. You know, again, I think you'll know in your practice and you'll know for your cytologist, you know, what's getting your diagnostic yield. Okay, I'll use this one. And then expressing, you know, so when you push the material onto your slides, how many people use a stylet? Again, half the people. The other half are gonna be using air. And so it turns out that, you know, if you do it with air, you actually get less, turns out to be a little less bloody on the slide. Either one is gonna be fine. So again, these are, you know, again, you can use either one. Sometimes I'm finding it's actually faster if you just use air, and then you don't have to have the tech putting in the stylet. But if you can reuse the stylet the next time, then use the stylet. The rapid on-site, you know, evaluation, this is what we use in a lot of, when we first started doing it, we do it, we did, the nice thing about it is you do it, you get immediate feedback, you know, do I need to try a different area? Do I need to try a different site completely? Do I need to try a different technique? And then if it's, you know, if there's a thought, oh, it might be a lymphoma, you can put an RPMI. If you think it might be infection, you can send for culture. And this, you know, honestly, those questions don't come up that often, but they come up sometimes. And, you know, we had a case last week, you know, which we, it was a three-day week. And I just said, forget it, I'm gonna biopsy this person. You know, I just need to know if they have cancer or not. And then, of course, there was no cytologist. And then they say, no, we think it's infection or something else. And then the next day we had to do repeat FNA. But we, you know, we told them, we said, we're gonna, that may be the case. Most of the time, you probably don't need that person there, the cytologist. And especially, I'll show you the data suggesting, you know, that it is kind of expensive and it's time consuming. You know, a lot of times our cytologists just aren't available. You as an endoscopist can interpret your own slides. The ones up here on the right here, you can see a little granularity. You usually know that there's some sort of material there. And I encourage you, if you're able to, if you have a cytotec doing the smears, you know, look at the slides yourself. You can usually see, do this enough, you can tell when you have cancer diagnosis with the large, you know, blue, you know, cells, big nuclei molded together. So now we're switching over to USF and B. So how many people in the room predominantly use, is their go-to first needle an FNB needle? Okay, interesting. So probably about two-thirds of people are now using an FNB needle versus FNA. Now, about, and most of you then are using a 22-gauge FNB needle is what I'm gathering because you said you use the 22-gauge. And you can see we have a number of different needles and, you know, we'll go over kind of the different ways and the ways that they've been cut. And so, you know, there's a reverse type bevel, you know, BMI1, there's a Francine one which has three cutting tips. There's a Mangini type. And then there's a fork-tip type. And you'll, you know, you'll hear them, you often know them by their, the company names, but you can see they're a little different design for each of them. And the other thing as you're doing it is we talk about mohs, we talk about rows, we talk about mohs, that's macroscopic on-site. This is actually good as you're doing it, you're doing fine needle core biopsies, you wanna be seeing this white material that tells you you have your core. If it's just pure red, very likely that's just blood or blood clot. So, you know, and the more you start looking at it, you'll definitely start seeing that you'll see the white material, which just reinforces that you did get diagnostic material. And so what about USFNB versus USFNA? And it turns out when you do these, you know, randomized studies, you'll look at this and you'll end up seeing the FNB, the histologic yield and the cancer diagnosis, at least in this one fairly big study with over 600 people, better with the FNB needles. And so, you know, from this point of view, a 22 FNB probably better than a 25 FNA, which is a fairly typical, you know, things people do. Shyam and Peng and others, you know, looked at, let's look at the different needles for this. And so they looked at the Francine versus the fork tip needles, and actually looked at all four of the needles that we described, but found that really the Francine and the fork tip ones were the two that tended to have, you know, the best diagnostic yields in terms of regardless of if you use suction, no suction, stylet, whatever it was. The other needles are okay too. It's not to say they're not good, but probably you're getting a little bit more in terms of the Francine and the fork tip. And then, you know, we had another one, some network analysis looking at these when you start comparing them. And again, you start seeing that trend coming up a little bit better with the Francine and the fork tip needles. But I think an important theme that starts coming out is none of the needles were actually superior to each other or FNA needles if you're using rapid on-site evaluation. So you have someone in the room telling you, you'll be able to get, you know, you might take one more pass, you might change it. In the end, you'll get your tissue if you have the rapid on-site. Same thing here with subepithelial lesions. You know, we all come across, you know, little GISTs or big GISTs and things of that sort. And so again, with that, you know, there's probably a benefit if you're just using no rapid on-site evaluation between a core biopsy and a fine needle aspiration cytology. If you have rapid on-site evaluation for these, there's probably gonna be no difference at all. And I think most of us have probably switched over to core biopsies for these. And then what about for pancreatic masses? What if you have an EUS-FNB versus you just do an EUS-FNA and you have a rapid on-site? So Alan Barkin and his team looked at this and, you know, looked at people use either a 22 or 25-gauge fork tip one and used, you know, the same things, the fanning techniques. You know, suction was either way, wet or slow pull, two passes, and then did, or EUS with FNA with a 22 or 25 and found that they were the same at diagnostic accuracy, fewer passes for the fine needle biopsy, but not a lot, two versus three. And so in a sense, what they, and then at the end, it was a little bit longer for the FNA. So from a non-inferiority process, there was no difference just doing an FNB versus doing a cytology plus a rapid on-site with a cytologist in there. So again, pushing more towards you can do, having a, you know, not having a cytologist there. And then the other thing is, can you do rapid on-site with FNB? So curiosity for those of you who do rapid on-site, how many people do it on their FNB specimens have rapid on-site? And, you know, and so what we're finding is it's, you don't necessarily have to do a touch prep, you know, and we'll talk about that. A lot of times just even the bloody, the material you get that isn't the piece of tissue, you look at it and you'll actually see your cells off that. So you can get, if you do have rapid on-site, you can save the money of using two needles and you just use the one needle. And so, you know, what you find is you can do these touch imprints, but again, the blood itself should be the same, really no difference and you definitely can use this. And so what about doing USFNB then with or without, you know, rows with that? And it turns out that they're the same. So you're not necessarily in this case getting any extra benefit having rapid on-site in terms of diagnostic rates or diagnostic yields. There may be some other benefits, but your diagnosis will be the same with or without the cytologist if you're doing core biopsies. And then molecular profiling though, now everything's changing. And the question is, are these core biopsies really better for molecular profiling or not? And I think the answer is we're not sure. You know, there's some data which would say that there's no difference. There's some data that says there's maybe a little bit better for FNB for profiling. And then out of MD Anderson, you know, they're kind of coming up with some data suggesting that, you know, it actually, you know, the material you get with a cytology needle, an FNA needle may be better for next-gen sequencing than what you're getting with a core biopsy. I'm not sure that we, you know, I think at this point unclear and we'll just have to wait for more studies. You know, we send the material for however we get it. And it seems we never have anybody complaining about not being able to do next-gen sequencing or anything else. But I think we'll probably hear more about this in the future. And so, you know, the future includes not just next-gen sequencing. It's looking for microRNA sequencing and, you know, in regular RNA sequencing, the whole exome sequencing. And we're doing a lot of organoid development. And so for organoids, you know, in which you actually get some material and then you send it to your investigator and they'll create organ or organoids out of the tumors in which you can actually do some sensitivity testing for chemos and whatnot. Those you need, bigger is better for those. So those I wouldn't be surprised if we start saying 19-gauge big cores are going to be important for organoids. But, you know, we'll see where this goes. And then, you know, switching over just for a minute, I know we're going to talk a lot about cysts and pancreatic cysts. You know, these are, you know, cysts are a challenge always. And again, you know, we realize that the vast majority of pancreatic cysts are never going to hurt anybody and depending on what study you use, up to 40% of people will have incidental cysts on imaging. And when you look at the SEER databases, the rates of pancreatic cancer are staying pretty similar, age-adjusted, and the number of cysts are going up as we do more imaging. So we're really just trying to figure out who needs to be concerned and who doesn't. I just want to say that from 2011, just a study looking at prospective studies looking at pancreatic cysts, and there it's a 5% risk when you do FNA of pancreatic cysts when you look at the prospective studies, not the retrospective. So again, that's pancreatitis, bleed, infection. So always being careful that cysts are a little bit different than pancreatic masses. So we have new techniques now in which you can do through the biopsy or through the needle biopsies. Is anybody doing this on a regular basis? Okay, so a couple people, but not a lot of people, and mostly on the faculty side, so maybe some of the universities. So again, being looked at, it's kind of a novel, interesting thing. You theoretically can get big pieces of tissue, send it for pathology, and you can see when it works, it works beautifully, and you see really nice pathologic, and you get architecture, and so definitely good. We'll put patients on antibiotics a few days afterwards, and you can target neural nodules. So potentially could be another adjunct that we have to improve diagnostic accuracy, especially in these cystic lesions. And when you look at this in terms of the outcomes, you actually get a fairly good diagnostic accuracy and sensitivity for diagnosing mucinous versus non-mucinous, and again, we can debate if that's important, rather than just assume everything's mucinous. In terms of doing a look at all the studies, in terms of your diagnostic accuracy, it's probably better for diagnostic accuracy. It looks like you'll probably really be able to say this is a serous cyst adenoma versus some sort of mucinous lesion. And then when you look at people who then went to surgery and look at that correspondence, it actually was very good concordance with the through-the-scope biopsies versus the cytology in terms of what you were coming up. So I think there's definitely some data suggesting you can increase your diagnostic accuracy of these cystic lesions. What are the limitations? Probably the biggest one are adverse events, and again, for those, I'll defer to others in the room who do a lot of these. But when you look at it, at least on the meta-analysis part, 7% to 9%, there's a risk of either pancreatitis or bleeding. And so we talked about that's higher than the 5% that I mentioned previously. And then at least on some of the prospective studies, you're seeing, in this case, 9 pancreatitises, four of them being severe and one of them bleeding to death. And so again, you have to start realizing for most cysts that may not actually be that worrisome, you don't want to start creating more problems that you didn't have. So I think that we still need to understand these a little bit better and how to use these safely. And I'll be interested to hear from other faculty, their experience with this. So I think it's an interesting one. It's here, and we're just learning where best and how best to use this. Liver biopsy, Dave Dio, I'm going to defer all of this to Dave Dio, but Dave's really kind of taken us to where we're doing a lot more US liver biopsies. So out of curiosity, how many people have now exclusively gone to US for liver biopsies in their institution? Wow, that's pretty good. That's like 20%. So thanks, Dave. That's you. We have definitely not. Our folks say, no, when we do our liver biopsies, just leave us alone. So we haven't quite got there yet, but we're doing more and more, and we're getting to the point where it can be done, it's easy, it's safe. And so the question is, which needle do you use, too, and how do you do it? And so this was interesting ones looking at using the Francine versus the fork tip. And again, you're seeing, in this case, the Francine being better diagnostic accuracy with these, and I think these were using both needles in the same patient, and more portal triads. So there may be some benefit if you're going to be doing liver biopsies using the Francine, although both seem to be fairly good, though. And so in conclusion for all this, so the fork tip or the Francine needles seem to be outperforming the other F&B needles when you do it. The F&B is probably superior to the US F&A, certainly if you don't have rapid onsite. If you do have rapid onsite, you can do either one. Both are going to be good. You can do touch prep, or you can actually just look at it from your F&A biopsy, so you actually don't have to do both cytology and F&B. And I think we're going to find out in the future, you know, a little bit better for the F&B for molecular profiling, and also for using through the scope forceps, or through the needle forceps. So that's it, and again, it always takes a big team. This is our endoscopy team at one of our fellows' graduations. So thanks again for everyone's attention. for that fantastic talk. So if anybody has any questions, feel free. But please do remember to push that button on that little black thing in front of you. Dave, you have a question? I was gonna ask you a question. I have a question for you, which I think would be useful for the audience. Very often after doing FNA, a predictor of the pancreatic head with cancer, there is an impressive amount of blood, sometimes in the stomach, sometimes in the duodenum. And I have to say, I tend to ignore it. Do you ever stop, look, make sure that there's no oozing, or do you also kind of let it go? Yeah, so that's a good question, Dave. Yes, there will be bleeding. There can be bleeding. It can be oozing. And sometimes, you know, we're going through collateral vessels. You know, if you worry about that, turn off your Doppler, then you don't have, then they're not there anymore. So it's like, it's really easy then. So, and you know, and even I go through, we go through a lot of collateral vessels, and we're not, generally not, we have not had any big bleeds. You will see bleeding. I think as we talk about some of the other interventional things that we do later on during this session, where you're burning holes through the stomach, getting things, I think, you know, talking about the bleeding, under what conditions, because sometimes those will impact you. But with the EOS, you won't have to worry about that. One thing I didn't say, and I don't know if I missed that slide, with the reason we do a lot of rapid onsite cytological evaluation, we get people sent tests from all over, and we know most of them are going to have cancers. I like to be able to tell them right there, and then you've got cancer. I tell them, you know, and that's what I do. I tell every single person, this is it, we did a rapid onsite, it shows cancer, and I'm gonna, you're gonna, I put in a metal stent, I probably put in an uncovered metal stent, because, you know, I know where we're going, if that's gonna be the case, and you're gonna see the oncologist in three days, and the surgeon, or whatever it is, and it just expedites things. So, at least in our practice, we tell everybody, you know, right there, and then they have cancer. We never, our cytologists will never change the diagnosis. There's never a misdiagnosis with that. But again, you have to, it's, there's local preferences in terms of that, and how people like to do it, but that's how we do it, and it helps us decide about stents, and our surgeons tend to like uncovered metal stents, even if they're gonna go to Whipple's, so we'll tend to do that, but again, everybody is different, but that's the reason, yeah. Any thoughts about the difference in the pancreatitis in the biopsy for the cyst versus the needle, FNA, FMB? I mean, there's a big difference there. 9% versus, like, 1%, 2%. Okay, and just so I can clarify, were you talking about just for the cysts in terms of? So, no, in general, pancreatitis is a complication for EUS with FNA or FMB versus the cyst when you biopsy the cyst. Why is there a higher percentage of pancreatitis when you do a biopsy? I'm gonna bring in John DeWitt or someone else who does a fair number of these, and yeah, any thoughts on the pancreatitis risk? Are you talking about with the moiré forceps? Yeah, I think he's talking about the moiré forceps. I mean, there is a significantly higher rate of pancreatitis when you use that because, you know, you're actually trying to biopsy the wall, right, of the cyst as opposed to just sticking a needle in and then aspirating some fluid out. And typically, you don't just do one biopsy, right? There are studies that have been done trying to quantify what number of passes is ideal to do using the mini forceps, and you wanna do more than one, ideally, two or three. So, you know, hence, you would imagine the more number of times you're going in and trying to grab a piece of the wall, that could be contributing as well. But there was a nice study, an Italian paper, that tried to develop an algorithm to help guide the safe use of these forceps. And they identified some risk factors that included older age. I believe the age was like maybe over 65. If it was an IPMN, that was also higher risk for pancreatitis and adverse events. And also, actually, the more passes you did, like if you did more than one. So it was a nice paper, I believe it was the Italian group that looked at this to try to help guide us in terms of when it, you know, is safer, hopefully, to use the forceps. And along the same lines, like, you know, the bleeding question, because a lot of times you'll do this and you'll go in cysts, and you can actually see the blood forming and seeing it. Do you worry about seeing bleeding when you're, you know, if you're using the biopsy forceps inside the cyst, did you just kind of, just like we did for the bleeding in the duodenum, not worry about that? Yeah, I mean, even when you're just doing normal FNA of a cyst, you might see a little swirling of blood. I mean, I ignore that. I mean, honestly, that's, you know, and there have been studies that looked at this as well, and thankfully, almost all the time, it's not clinically significant. So, you know, I don't usually worry too much about that. There are some questions, though, from online that I want to make sure we get to as well. One question is, conventionally, we give antibiotics for three days post-FNA of pancreatic cysts. Are you still doing this? We are, you know, generally speaking, but I don't know, what are other people doing? I feel, you know. Yeah, I mean, the- I think there was a good randomized control study showing that there was no real benefit, but the convention was that we used to do it, but I've kind of gotten away from it now. Okay, thank you. If I'm pushing this, oh, there was a really important randomized control trial published in Gastro, I guess about a year and a half ago, looking at this very question, and it showed no difference, and I think there was only one complication, and it was like a fever in one of the groups. So the best data says we should not be doing it. And how about, is there a role for any antibiotics during the procedure? I think this was a low-risk group. These were not people who had like endocarditis histories or maybe other problems. These were not high-risk patients, but no, these were, I think one was like either during or after, and then maybe three to four days of oral, and the other was nothing. And I think the answer was- No antibiotic at all. The answer is, there's no difference, and the rate is so low, it shouldn't be given. Okay, so good. I wanna add one thing about the pancreatitis and the through-the-needle biopsy. I think a couple of things I would say is, if there's a significant amount of pancreatic parenchyma you have to go through to get to the cyst, it is a 19-gauge needle that's required for that. So I would not go through, for instance, if the cyst is in the posterior part of the pancreas, I would not go through a large amount of normal pancreas where you might be risking injury in the duct to get to that. The second is, if you've done enough of these, you do get normal pancreatic parenchyma in your biopsies. So I think when we think we biopsy just the cyst wall, you actually probably are getting a chunk of pancreas as well. So that probably leads to some of these problems of pancreatitis as well. So there's another online question. Any role for NSAID prophylaxis against post-FNA or FNB pancreatitis? You know, I don't know, correct me if I'm wrong, I don't know of any data suggesting I've seen it done, and I just, you know, I think you could even argue, are we overusing it for all the ERCPs we do it on? But I have absolutely seen it done for people getting USFNAs. The only thing I would, I guess I would perhaps say is if you had a, you know, the kind of case where John's saying you're really going through a ton of pancreas and you're really worried, maybe you're gonna do everything you could like you would on a high-risk ERCP to reduce it. But I don't think, on a routine basis, I wouldn't, so. I'll say two things. Yeah, that's what I do. I mean, if I'm worried, I think I'm just treating myself, honestly, but if I'd gone through a fair amount of pancreatic parenchyma to get to whatever lesion, then yeah, then I'll be like, okay, let me just give some rectal indecine. Two cases I will do it in routinely is, I'm not doing it off protocol, is cyst ablation. Can you push the? Oh, I'm sorry. Can you hear me now? Oh, so two cases I will do it in off protocol would be cyst ablation with either chemotherapy injection or RFA. The European group who has the most experience with RFA do recommend now using it because they have gotten pancreatitis. So they do use it routinely in those patients. And Mihir, you had a question or a comment? Yes, can you hear me? Yeah, yeah. So about the Moray forceps, so we are doing a randomized control study looking at FNA alone versus FNA plus Moray. We are the primary site and it's a multi-center randomized study. We've been in it for about a year and a half now. We have not looked at our data as a whole, but we have not encountered any severe pancreatitis. We've had one case of pancreatitis, which was mild. The patient was in the hospital for one day. We have visibly seen bleeding inside the cyst, which has been of no consequence whatsoever, so we don't worry about the bleeding. But it's up to the endoscopist to decide whether to give indomethacin to these patients or not. But most people, because of a recent publication of one death, not in our study, but there's a publication of one death from pancreatitis after the Moray, we have now started giving indomethacin for the micro forceps biopsy. Interesting, okay, yeah, thanks. So there's another question online. What's the diagnostic yield of FNA or FNB of or in the main pancreatic duct to diagnose main duct IPMN? And what are the risks of pancreatitis in that situation? Gosh, I mean, generally, we wouldn't be using FNA or FNB to diagnose the main duct IPMN. We're gonna do it by imaging, by dilated pancreatic duct, by seeing mucin within there, by seeing a fish, you know, gaping kind of fish eye kind of thing on the ampulla. So I don't know, you know, again, we're generally speaking, we're only doing targeted biopsies of mass lesions or nodules and things of that sort. So I'm not sure there's any definite answer to that. You know, one way or the other, I think if you had a nodule or a mass lesion, you know, probably either one is gonna be potentially fine. Depending on where it is, I might use a smaller needle if it's a real small thing, just to minimize risk. But I don't know, there's no data that I know of. I guess the question is, sometimes you're presented with a patient who has a somewhat dilated main pancreatic duct and you're not sure if it's main duct IPMN or is it older age, is it chronic pancreatitis? You know, what's causing the main duct to be dilated? So I wonder, you know, do people biopsy the main duct in that situation to try to help them make a diagnosis? I mean, I think without a visible lesion, the yield would be pretty low. I think if anything, you might want to do a pancreatoscopy if that. Yeah, direct visualization with pancreatoscopy is would probably, if you're gonna do that, I'm sure I would do that, but. There's been some cases where I'll put a catheter up the main PD and just aspirate the pancreatic juice. And if it's a main duct IPMN, often I'll get a positive cytology. So I consider that very safe to do. You know, I'll tell you, this is a great question because it sounds like everybody's gonna be all over on this one, but I think what probably makes people nervous is you put a needle through a normal duct and that puts people at a high risk of pancreatitis. At the same time, the question here is, is that big dilated duct chronic pancreatitis or is it a main duct? Obviously those are treated so much differently that you can imagine a scenario where that information is important. So I think it's a case-by-case basis, but assuming you're thoughtful about it and you take those precautions, like Tom said, I think there are scenarios, but I think they're pretty selective. I'd say most of the time that can be made on clinical criteria. That would be my take on it. Sorry, I think sticking a 25-gauge needle in a six-millimeter pancreatic duct just to aspirate a CC of juice for whatever fluid analysis you want to do is extraordinarily safe. I can't, I mean, I don't have data. I've never had a case of pancreatitis with this that I know of. And if the fluid is thin and non-viscous, it might take you five or 10 minutes, but you'll get a CC of fluid eventually with a 25-gauge needle. And that to me, if a patient has, is this the IPMN versus chronic pain question? I do that all the time and find it to be very safe and that's the way I do it. Yeah, I do that too. And the only time I don't, I mean, I look carefully to see if there's a stricture somewhere because I don't want to stick a needle into an obstructed pancreatic duct, but if I'm sure there's no stricture and there is that question, I do that. And using, again, the smaller, thin needle, 25-gauge needle, that's definitely a time where you just want to minimize your risk to the pancreas. And there's- Oh, we have a question, oh. Yeah. Any comment on the number of passes for a proper collection of the liver biopsy to make sure you have the number of portal triads for diagnosis and the wet versus the non-wet technique for the liver biopsies? Most of my reading is usually, David and the others, Craig Brown, two passes. I think one is actually can be very, very good. And sometimes you do the right lobe and the left lobe and that's often what we'll try to do. But I don't know, for those of you, Dave, you've published the most- Yeah, I'm gonna cover it in detail. Dave is doing a whole talk on the liver. We'll hear about that here. You can get it in one pass, though. Stay tuned. There is another question from the online folks. Any tips on how to communicate findings, quote, the phone call with patients and family? I'm assuming they're alluding to cancer, maybe cancer diagnosis here. Yeah, probably, yeah. I mean, again, in every single one of my reports, I will write down pulmonary cytology reveals adenocarcinoma and await final pathology. But the people who come to me, they already know, I mean, they've got a mask, they know it's gonna be cancer. They just wanna put this to closure and move on. But if it's on a phone call, if it's something, sometimes what I will do is if it was sent by the oncologist or somebody else, and it's kind of a complicated case, I will defer, I'll say our preliminary shows this, but you need to discuss with your oncologist or your surgeon if that's the person who has that, who spent a lot of time talking to the patient. And that's probably just, you know, in general, if you spend time talking to the patient and family before you do the FNA, you'll probably feel more comfortable. If you didn't spend much time at all, you may have to be with whoever referred them, the oncologist or surgeon. Great. Thank you so much, Tom. Thank you.

endoscopic ultrasound

tissue acquisition

fine needle aspiration

fine needle biopsy

diagnostic accuracy

EUS-guided biopsies

pancreatitis