Thank you so much, and it's my pleasure to be here. Thank you so much to the course directors for including me. I'm also really excited that I'm getting to talk about one of my favorite parts of therapeutic EOS, which is EOS-guided biliary and pancreatic access. These are my disclosures. So starting off first with EOS-guided biliary drainage. So we all know that conventional ERCP is the gold standard for biliary decompression, but studies have shown us that anywhere from 3% to 5% of biliary obstruction cannot be managed by conventional ERCP. And this can be from a variety of different things, including ampullary pathology, large diverticuli, patients with altered anatomy, patients with gastric outlet obstruction that precludes access to the ampulla. And in the past, really the option for these patients was to go for percutaneous drainage, which works and is efficacious, but comes at a price with significant complication risks and also the morbidity of walking around with an external drain. And I can tell you in my own practice, all the time I get patients that come hating walking around with these drains, asking for it to be internalized. And I think EOS biliary drainage is really an exciting alternative therapy for when conventional ERCP is unsuccessful. This concept has actually been around for some time. The first case of EOS BD was actually published in 2001 by Mark Giovannini. And since then, there's been numerous publications that have come out looking at efficacy and safety. This is a meta-analysis from a couple years ago that encompassed over 1,000 patients, showed pretty excellent technical and clinical success rates, and an adverse event rate that does look a little bit high, around 23%, but this study did include a lot of patients from when this technique was first being developed. And newer studies have definitely shown a decrease in that adverse event rate as operator experience and devices and industry has perfected the technique. When we talk about EOS-guided biliary drainage, there's really several different ways that this can be done, all with the same desired effect, which is to decompress the biliary tree. The two main ways to do it are to go through an intrahepatic approach, meaning you're accessing the intrahepatic bile ducts from the stomach through the liver into the intrahepatic ducts. And once you have accessed the ducts that way, your options for stent placement are hepaticogastrostomy, meaning you're putting a stent with one end in the intrahepatic duct going through the liver, draining into the stomach, or you can actually do a trans-papillary stent placement, but in an anterograde fashion, meaning pushing the stent from the top down instead of from the bottom up the way that we're used to with conventional ERCP. The other option is to do the extrahepatic approach, where you're accessing the extrahepatic biliary tree, usually from the duodenum at a place other than the ampulla. And here, again, putting either a coledocoenterostomy stent, meaning a stent going from the extrahepatic duct to the duodenum, or doing a rendezvous approach, where you're feeding a wire across the ampulla and then putting down a conventional therapeutic scope and doing ERCP using that wire access that you've obtained. And studies have really shown that both are effective, and there's not a huge difference between the two techniques. This is a meta-analysis over 400 patients a couple years ago, really showed no difference in technical success, clinical success, and adverse event rates between the two different techniques. And it's up to this point really sort of been a combination of operator comfort and experience, as well as patient anatomy. There are some smaller studies more recently that have suggested that coledocoduodenostomy may actually be associated with longer stent patency, but possibly higher adverse event rates. And I will say that the only thing to keep in mind is that a lot of this comparative data was done before the smaller size axioses that we have, which has actually made coledocoduodenostomy a much more straightforward and easier procedure to do. And so I think we may see some shift in this question in the future. But no matter what technique you use, the steps are pretty much the same. The first is that you're going to visualize a biliary tree on endoscopic ultrasound. You're going to access that biliary tree and inject contrast to obtain a cholangiogram. And generally, we're using 19-gauge FNA needles for this because that allows you to pass a 0.035 wire through that FNA needle. I put obtain wire access here in asterisks because nowadays with the introduction of hot axios into our arsenal, sometimes it's actually possible to go directly from obtaining a cholangiogram to actually using the cautery on the lumen-imposing metal stent without first obtaining a wire. For hepaticogastrostomy, a wire is always the part of the process. But for coledocoduodenostomy with a cautery-enhanced lumen-imposing metal stent, you can sometimes skip this step. You then are going to create your fistula tract, whether you're using cautery or balloon dilation or a combination of the two, and then ultimately deploy your decompressing stent. And when you talk about which stent to use, there's a lot of options out there. I just put a few examples here. You have your plastic stents. You have your biliary self-expanding metal stents. They can be fully covered. Sometimes partially covered stents are used. And now you have as well your lumen-imposing metal stents as well. And when you're thinking about what stent to use, there's a lot of things that you need to take into account. One is the type of drainage, intra versus extrahepatic. Generally, if you're doing a hepaticogastrostomy to the intrahepatic ducts, you're going to be choosing your fully covered or partially covered biliary stents there, although there have been some recent studies looking at actually using lumen-imposing metal stents even for hepaticogastrostomy. You're going to be looking at the duct diameter. That's going to help you determine what size and what type of stent you're going to use, how far away the lumen is from the duct itself. We know that the lumen-imposing metal stents have a diameter, I mean, a length of one centimeter, some with 1.5, but only the larger ones. And so you need to make sure if you're going to choose that stent that your duct is very close to your lumen. And then, of course, if it's malignant versus benign, it's going to play a role as well in what stent you're going to use. I think one of the really exciting things about this procedure now is that we actually now have randomized trials looking at not even doing conventional ERCP first and going straight to EOS-guided biliary drainage. This is in malignant biliary obstruction, and these are three randomized trials that together encompass over 200 patients and really showed equal safety and efficacy when you look at these two procedures. And in one study, actually, the EOS-guided biliary drainage group had a lower adverse event rate, and that was mainly due to the avoidance of post-ERCP pancreatitis because you're not accessing the bile duct through the impula. Similarly, these are two meta-analyses that have also been recently published, basically, again, showing the same thing, that EOS-BD, even when you go to it as first-line therapy, without unsuccessful conventional ERCP first, there's comparable technical clinical success and maybe even a better safety profile with EOS-BD compared to conventional ERCP. So now the fun part. We'll do some videos. So this is an example of what intrahepatic biliary drainage looks like. Here you can see the first step of accessing the biliary tree and obtaining a cholangiogram. You can see, as contrast is injected, there's a very dilated intrahepatic bile ducts and a very tight distal extrahepatic stricture. You're not even seeing any filling of the small bowel across the stricture. So once you have your roadmap and your cholangiogram, the next step when you're in an intrahepatic approach is to obtain wire access. Here you can see the wire being advanced through the needle and down across the stricture. In this case, unfortunately, we weren't able to immediately cross ampulla into the small bowel. So this is actually a balloon catheter that's being used to give the wire a little bit of leverage. And then with that extra little stiffness, we can see here that the wire is successfully able to be passed into the small bowel. It's important when you're going to put your stent that you want to dilate the stricture and the tract so that it facilitates stent placement. So here you can see first the stricture being dilated and then the fistula as well. And then this is an example of anterograde stent placement where here is the fully covered stent being advanced. It's going to be transpapillary, but it's going to be placed from the top down instead of the bottom up. So you can see it. The distal end is going to be in the small bowel. The middle will be across the stricture, and the top is going to be just below the hilum here. And then the initial puncture site can just be closed with a regular hemoclip. And if you were to look at that patient not having known which procedure was done, I don't think anyone would really be able to know for sure that it wasn't put in by conventional ERCP versus USPD here. Okay. This is the other type where we're looking at an extrahepatic approach. I'll just let it play here for a second. So here you can see we're going, in this case, from the duodenum into the extrahepatic biliary tree. But again, this step's very similar. First step is to gain access with a needle, inject contrast, get a cholangiogram. Again, you can see very dilated biliary tree. This case was actually in the days before we had cautery-enhanced luminoposing metal stents. So we're creating the fistula tract with a dilating balloon. And then here is the luminoposing metal stent being deployed with the first end in the extrahepatic biliary tree and the other end in the duodenum. And the contrast immediately drains after that. When I am doing this procedure, I always put a double pigtail stent. After I've deployed my luminoposing metal stent, I think it helps to prevent the bile duct from collapsing against the metal. Just gives a little bit of buffering there, which facilitates drainage and also, I think, helps prevent trauma to the duct from the metal of the luminoposing metal stent. And as I mentioned, now, sometimes we don't even need wire access. You can just use the luminoposing metal stent directly without even going over a wire. So here, again, is another example of extrahepatic biliary drainage. In this case, again, first getting a cholangiogram, injecting some contrast. You can see here, again, this is the stent going in. This wire actually was preloaded. I know it doesn't look like that from the fluoro, but it was a freehand puncture. And then actually, the wire was preloaded into the luminoposing metal stent. And as soon as the first flange was deployed, the wire was advanced after that. And now, in a minute, you will see the first flange being deployed and then the second flange being deployed right in the GI lumen. And it's a very satisfying procedure. Sometimes, you get stones out right when you deploy the stent. Often, you'll see a flush of bile right away. So you can just feel the relief the patient's going to feel when you put that decompressing stent right in. And these are just some examples of what the fluoroscopy images and the endoscopic images can look like and the different techniques. One question that very frequently comes up when I'm talking about EOS guided biliary drainage is, what about the learning curve? How many cases do I need to do in order to be able to do this successfully and comfortably? There's been a couple of studies that have tried to answer this question. These are three different studies, all using different statistical techniques, but basically showing that, generally, the number in order to reach efficiency is somewhere either in the low 30s or maybe 40 in one study. Another question that frequently comes up is, what about patients that have malignant biliary obstruction, but may be surgical candidates? Can they have successful EOS guided biliary drainage and then go on to have surgical resection? And for a long time, this question has not been known. So this is actually a study that we just presented at DDW this past May, trying to answer this question. This was a multi-center international study of consecutive patients who had undergone hepatobiliary surgery after having EUSBD or ERCP. And it included 145 patients, 58 who had had EOS biliary drainage and 87 who had had conventional ERCP. And what we found when we looked at the groups was that in the EOS guided biliary drainage group, they actually had fewer repeat endoscopic interventions prior to their surgical resection after their drainage. There was a shorter duration between the time that they underwent EUSBD and their surgical intervention. There was higher surgical technical and clinical success rates in these patients, which we suspect is related to the absence of any pancreatitis in the patients that were in the EUSBD group, which can make the surgical field much more difficult. There was a shorter length of stay after surgery, and there was no difference in surgical adverse event rates between the groups. And there was, when we were collecting this data, we subjectively asked the question, was the surgical complexity increased compared to standard surgical techniques? And in both groups, there was no difference in increased surgical complexity. So the EUSBD group, at least subjectively, didn't seem to make the surgery more complicated for the surgeons. A lot of other exciting data coming out as well. These are just other ways that therapeutic EUS is being used to achieve biliary drainage. And I think we're going to hear about some of these later on in the course, so I'm not going to go into good detail. But these are some case reports of using EUS-guided gastrogynostomy to get closer to the ampula to allow, or to the anastomosis, to allow for biliary drainage. And, you know, there have been studies as well, draining the gallbladder to get sort of secondary biliary decompression of the biliary tree using EUS, as well as the EDGE procedure, both of which are going to be talked about later on in the course. I'm going to switch gears a little bit now and talk about EUS-guided pancreatic duct drainage, or abbreviated EUSPD. So relief of obstruction of the pancreatic duct with conventional ERCP in patients, generally this is patients with chronic pancreatitis, is not always feasible, similar to biliary drainage, there is technical failure rates, and in pancreatic duct drainage can be even a little bit higher, anywhere from three to ten percent, even in experienced hands. And really the alternative option has been surgical for these patients, which is effective, but again at a price with pretty significant morbidity and mortality rates when you're talking about pancreatic surgery. So EUS-guided pancreatic duct drainage, again, is an alternative option when conventional ERCP is not feasible or unsuccessful. The data here over the last couple years has been quite all over the place. Technical success rates anywhere from 25 to 100%, which is a huge variation. Clinical success, not great, 50 to 70%. And adverse event rates, again, very discrepant, anywhere from 15 to 50%. But newer studies have looked a little bit better, thankfully. And again, I think this is as endoscopists gain more experience with this technique and industry gives us the tools and techniques to do it more safely and efficiently. And this is a study we published a couple years ago, 80 patients. You can see much better technical clinical success rates and still a relatively high adverse event rate here. It was 20%. This was mostly pancreatitis. And actually, the good news is only one of those patients ended up needing a surgical intervention and more than 50% ended up going on to achieve clinical success after the study. Again, the first thing to think about is the procedural steps, very similar when we're talking about pancreatic duct drainage versus biliary drainage, but a few subtle differences. The first step is to visualize the pancreatic duct on EUS. Most of the time, we're going to be draining the pancreatic duct from the body of the stomach, but it is certainly possible to have the best window from other areas. And so it's important to take a good look. And of course, the patient's anatomy will affect that as well. Next, to access the pancreatic duct and obtain a pancreatogram similar to biliary drainage, again, most are using a 19-gauge needle because it allows for bigger wire access. In pancreatic duct drainage, you're really always obtaining wire access here. This is a mandatory step of this procedure. And when you're creating your fistula tract, in this procedure, you're generally going to need cautery to create the fistula tract. Balloon dilation is not going to be adequate because the pancreas is often scarred. There may be calcifications. I would say 99% of the time, you're going to need cautery in addition to balloon dilation in order to successfully create your fistula tract, and then eventually deployment of a decompressing stent. There's some fewer options when we're talking about what stent to use when we're draining the pancreas. The majority of cases, you're going to be using plastic stents. My personal practice is to use a double pigtail stent in these patients. I like that that kind of anchors the stent in place and prevents migration. In rare cases, when the pancreatic duct is very dilated, you need at least 10-millimeter duct or bigger. Biliary self-extending metal stents have been utilized, but these can potentially cause quite a significant amount of pain unless the duct is big enough to really accommodate that stent. And really, when I'm choosing what stent to use, the one thing that I'm really looking at is the diameter of the duct. I like this cartoon. I created this when I was thinking about EOS-guided pancreatic duct drainage, and I was trying to explain it to patients and to to fellows as they were learning. There's many different ways that you can place the stents when you're talking about EOS-guided pancreatic duct drainage, and so I think this cartoon helps to illustrate some of the options. Basically, when you look at it, you can have the first breakdown is whether you're going anterograde or whether you're going retrograde, meaning anterograde drainage towards the ampulla or the anastomosis, retrograde drainage towards the tail of the pancreas. And oftentimes, this is going to be dependent on the anatomy of the patient. It's also going to be dependent on your access point, how your needle is angled, where in the duct sometimes you get lucky and it angles exactly perfectly and you can go straight towards the ampulla. Sometimes your best access point actually puts you pointing towards the tail. And either way is okay. It's just important to keep in mind the different ways this can be drained. My personal practice, I always try to cross the ampulla or the anastomosis if feasible. So whether I'm going anterograde or retrograde, I'm always going to try to cross and then either put my stent that goes from the stomach through the pancreatic duct into the small intestine or keep my wire there and do a rendezvous depending on the anatomy of the patient. But it's certainly not always feasible. And so here are the, you know, some of the other options. Okay. Oops. Okay. So this is my last video. Here you can see dilated pancreatic duct. In this case, this patient is post-surgical anatomy. First step, again, is to put a needle into the duct using both endoscopic ultrasound visualization as well as fluoroscopy. Here you can see on EUS the contrast being injected and you can see the pancreatogram on fluoroscopy. You have a very dilated pancreatic duct and no filling of the small bowel through the anastomosis. Wire access is the next step. You can see the wire here being pushed through the needle and coiled, and in this case, again, unable to be advanced across the anastomosis, so coiled in the duct. As I mentioned, cautery is generally required to create the fistula tract when we're talking about the pancreas. In this case, a needle knife is being used and that was able to successfully advance all the way and create the fistula tract. Sometimes a needle knife is not adequate, especially in very fibrotic and calcified pancreases. My next go-to is a cystotome, but it's a 10 French device. Unfortunately, we don't have the smaller cystotomes that they have in other parts of the world, and so, you know, I reserve that only for when really necessary because it does, it is quite a large device and a lot of cautery. I always will do a balloon dilation after after cautery just to help facilitate stent placement, and here you can see the stent being deployed. So one end is in the pancreatic duct and the other in the stomach. I think I've ended a few minutes early, so there'll be time for questions, but in summary, ERCP remains the standard of care for biliary decompression, but it's not feasible in all patients and there is a risk of post-ERCP pancreatitis. EUS biliary drainage is already an established alternative to ERCP and given the emerging literature may become, may become one day even the preferential treatment for malignant biliary obstruction, even in surgically resectable patients, and choice of technique is dependent both on accessibility to the duodenum, the ampulla, and whether the obstruction is intra-hepatic or extra-hepatic. When we talk about pancreatic duct drainage, it's an alternative option for pancreatic duct to decompress the pancreatic duct when conventionally ERCP is unsuccessful, but again not feasible in all patients. Although technically complex, recent studies have shown high clinical and technical success rates and stent placements can be done in a variety of different ways and I will say take what you can get in these cases. When you have your wire in a good position, put your stent, whether it's anterograde, retrograde, the the key is just getting a decompressing stent and I will stop there. Thank you for your time. Thank you so much for that wonderful talk and I'll start off, there's quite a few virtual online questions. One question that folks had was for EUS hepatico-gastrostomy, do you use electrocaudary to help create the fistulas tract or exclusively try with a balloon or other tools? Yeah, it's a great question and I think if you ask all of the panel, we'll all maybe have a different answer. My personal practice, I'll always start with a balloon first. I think a lot of the time with hepatico-gastrostomy, you can actually successfully get a balloon across and into the duct and create your fistula tract that way, so I'll always start there. If I can't pass the balloon, then I'll generally go to cautery and I'm usually going straight to a needle knife catheter first and then really necessary, then I'll use a cystotome, but that's very rare in hepatico-gastrostomy. I've also heard some people will use actually the cautery from women opposing metal fence to create the fistula tract, even though you're not going to actually deploy the stent, you can use the cautery to create the fistula tract and then take it out and then pass a different stent, but that's a $5,000 decision. Very expensive cystotome. Any specific balloon you use? I generally use a hurricane balloon. I find that it's nice and tapered, so it will oftentimes follow the tract of the needle and it does a nice job dilating, and I'll start with a four millimeter dilation. If that's not enough, which sometimes it's not, you know metal stents can be a little bit bulky and hard to push, then sometimes I'll dilate to six after that. Yeah, I love the hurricane balloon too for this indication. I think it has a stainless steel tip. It's really fantastic and for hepatico-gastrostomy usually works really well, so you don't need to do cautery. I get very jealous when I travel around the world and I see some of the other cautery enhanced cystotomes that they have, you know, six French, eight French, some of the dilating catheters, but unfortunately in the U.S. we don't have that. So another online question, for extra hepatic access of the bile duct, which wire and needle do you prefer? Do you, can you use a 22 gauge needle with an 025 wire? Then second part to the question is getting the wire to go in the direction of the amyloid can sometimes be difficult. Do you use straight or angled wire? Great question, and again I think a lot of personal preference here, and definitely there's no right and wrong. I tend to always use an 035 wire, so I'll always use a 19 gauge needle because I like to have a bigger wire. I think gives me a little more leverage. The one exception, if the duct is very small, not so much an extra hepatic biliary trees, but an intra-hepatic, occasionally I will use a smaller FNA needle, but instead of passing a small 015 wire, I'll actually try to inject a little bit of saline and dilate the duct in order to facilitate getting a bigger needle in and being able to pass a bigger wire. In terms of angled versus straight, I think you're gonna, you're gonna ask ten people and you're gonna get five and five one way or the other. I don't think there's a right or wrong. I tend to not use an angled wire. I like just a regular straight wire. I tend to use more hydrophilic wires for these procedures. I think if I do have to use cautery, they take, they take the cautery a little bit, a little bit better and shear less than my standard, you know, stiff wire that I use for conventional ERCP, but if anyone else has a different practice, I think it would be interesting to hear because I'm sure there's variation here and a lot of personal preference. I have a question for the smaller diameter Lumina posting stents, the eight millimeter, six millimeter, do you use it for duodenal, colico, duodenal stoma? Yeah, I mean, I think those have really revolutionized colico-duodenal stoma and made it a much easier procedure than it used to be. You know, I think the reason that there was maybe a trend towards higher complication rates when we talk about colico-duodenal stoma is because you have inevitably a little bit of leakage of bile from when you're creating the fistula tract to when you take that balloon out and you advance your stent, you're gonna have a little bile leakage. You have a very high pressure system and you're leaking, you know, right, right out of the bile duct as opposed to the liver, which is a little more forgiving in that situation. But now that you can actually take the Lumina posing metal stent and create the fistula and immediately plug the hole as you're creating the tract, I think, I think it's really revolutionized. So yes, if I'm gonna do a colico-duodenal stoma, almost always I'll go for a small six or eight axios. The biggest I've put is a ten. And what about the drainage through the gallbladder, drainage of the bile duct through the gallbladder, do you use it for patients that are not surgical candidates with acute cholecystitis or only for malignancy? I think there's gonna be a whole talk on EOS gallbladder drainage, so you know, I won't steal the thunder from that talk, but yes, I think it's a wonderful procedure and actually even sometimes can be used for biliary or bile duct drainage of the cystic ductus patent in cases where other forms of US biliary drainage are not as feasible. Amy, wonderful talk. Just a practical question, like you suggested that, you know, a lot of investigators are suggesting we can just go to this as a primary access almost, it's become that refined. So if you're on at your hospital for the inpatient work, patient gets sent in for a failed ERCP, their dilated duct, how do you approach that? Do you try by ERCP but have them consented for US? Do you just go straight to US? What's been your practice now? It's a great question and so generally my practice, every patient actually that we bring for ERCP, we can send for US guided just in case we're not able to access. So it's become part of our sort of standard consent process, even if someone's coming ERCP for a stone disease, we'll consent them for US guided just in case we can't conventionally access the biliary tree. I think that although these randomized trials are exciting and they show that there's a benefit, I don't think we're quite there in clinical practice that we're ready to not even try conventionally ERCP. Certainly my surgeons at my hospital are not ready for that, so usually we'll at least look at the ampula and but I will say that if I think the more ERCP that you do, the quicker you know whether you're going to access the bile ducts that way or not. So I think that I have a much quicker turnaround to go to US guided approach, especially if the patient has had unsuccessful ERCP elsewhere and if I look at that ampula and I think there's a low chance that I'm going to be able to access it without a significant amount of needle knifing and difficulty getting in, then I'll switch to US guided very quickly. But I usually at least glance at it first before going straight. So there's an online question about in community practice where they do a lot of US FNA diagnostic US. How do we start US guided ERCP biliary drainage since the learning curve is 30 to 40 cases and there's another question that kind of you know goes along with this is the question about having surgical backup, IR backup if one fails? I think both are really great questions and there's again there's not a clear answer here. You know I think coming to a course like this is a great first start, especially if you have a lot of experience with the US ERCP. I think also you know being proctored in the first couple cases is helpful. Picking your patients wisely, you know the first US biliary drainage case you're going to do should be a patient with very dilated ducts so that you know that so that your chance of success is much higher and then as you know you get more comfortable and more skilled then you can go to some of the more difficult cases. I think a multidisciplinary approach is critical and it's very important to have both you know IR colleagues and surgical colleagues backup, especially in the beginning. You can have other complications like bleeding which may need to be embolized and you know I think it's a very important point and a critical part of this process, especially when when introducing into your practice. Can I just make a comment regarding this training? You know we get asked this question all the time as to how does one incorporate these newer more invasive techniques into practice and I just want to say a word of caution. When we look at these you know learning curves that you shared with us 30 to 40 cases, these are typically experts doing this and saying well I got to this point after doing 30 cases right and that does not apply to everyone doing EUS so I think we should take that with a grain of salt that many of these are not studies looking specifically at training but they're looking at you know personal experiences of experts who are at you know maybe doing thousands and thousands of FNAs FNBs and other kinds of interventional procedures and their starting point is very different from someone else who's doing it so I agree with everything you said we don't know how to to how to incorporate these but I wouldn't go by saying that I need to do 30 cases and start this. I think that's a very good point you make Ramir and I actually Amy what you said is the consent process is very important I think for folks who are going to start doing this start with the easiest of cases good patient selection and an aggressive consent process I mean you have to talk to the patient and give them the choice that okay if I am not able to do the ERCP this is another option versus always discuss the other option like PTC I mean obviously most of our patients don't like PTCs but you have to document that in your consent process that other options of failed ERCP were discussed with the patient which is PTC versus EUS guided drainage so that you have you know covered all your bases in case because we all will have complications and some of these complications will be the real terrible ones so so you're covered in from that point of view if you're going to do this in practice yeah I completely agree with that I just want to echo how important the consent process is and outlining the options because PTC has you know whether a percutaneous biliary drainage has been the standard of care for years right until therapy US came along so I think it's important to discuss that with your patients the pros and cons and then the potential for you know if you fail you still might end up in the IR suite or surgery so you know they need to be aware of that and I think that in terms of picking up these procedures you know I I personally feel I'm certainly interested to hear you know what other folks think that some of these higher-end procedures really need to be done at expert tertiary care centers you know some of these procedures there's not a large volume of them to be done in all honesty and you really based on the learning curve that we've seen you know here as well as you know other procedures like gallbladder drainage USGJ you need to you know do enough and have enough volume and access to be able to do these safely you know for your patient and I think also just because you can do something doesn't necessarily mean you should be doing it you know and and I think you always have to think about the patient first you know is this in the best interest of your patient if the patient was your mom or your you know son or daughter and go from there and at least have good backup I mean you I mean this ideally should not be done in places or smaller hospitals where you don't even have IR backup 24-7 because if you have a bi-leak at least if the patient can go to go to IR and get a PTC drain place that will save a lot of morbidity so I mean several hospitals that I know of where they don't have IR coverage or there's bleeding or a leak and you're in like doing it late and there's no IR dock and you're trying to ship the patient that is where you get into a lot of trouble in terms of complications. Picking up on that I would say if you're looking for a good first case maybe someone who already has a PTC and that's not uncommon patients may end up with a PTC from their oncologist or surgeon's office before they even see a gastroenterologist and you get referred you know to do an internal internalize the PTC you know especially if it's one where they were unable to traverse the ampula then you already have kind of your your backup in place and that may be a good you know initial type of case to tackle. I have just two comments one is you know Cheyenne published this article I think it was two or three years ago on you know his percentage of failed biliary access at ERCP and it was like 2% so I'm not saying everybody's gonna have a 98% selective bile duct cannulation rate but even in experts you know who are trying to achieve bile duct cannulation for stones or cancers it's going to be a very few percentage of patients who even need this if you're going the primary bile duct route so and the studies that were presented were randomized control trials where patients were put into one of two arms so the intent was to go for the biliary drainage so most of those patients who were going for EUSBD in those studies I'm assuming 95% or more could have gotten that procedure successfully done with the RCP anyway so if you're trying to do these for the first time you know it's going to be a very few patients because I'm assuming most of these patients who have you know pancreatic cancers and bile duct obstruction are going to get an EUS and ERCP together. The second is I want to emphasize that the pancreatic duct drainage stuff as she was describing with EUS is the highest risk procedure we do and please don't do this at your place if you don't do a lot of work. Hundreds of EUS is a year, hundreds of ERCP is a year. We published this early on an experience ten years ago we had about a 15% abscess rate you know and a lot of these were we're just rendezvous procedures and not direct duct drainages. We had a few pancreatic pancreatic gastroscopy so this was early in our experience obviously and as you get better you have less complications but if you're gonna pick one procedure not to do that's the one please don't do it because there's a very high rate of particularly if you're not doing rendezvous if you're trying to do direct direct duct drainage we just don't have the good tools to do this with. Needle knife access is extraordinarily difficult and you're gonna run into a complication that's where you're gonna have a problem so. Yeah I was just gonna say that you know when we come to courses like this all of us and Matt pointed this out we show our best videos right so I think it would be wrong to leave from here saying like oh I can do this because it looks straightforward and I've done thousands of FNAs. I think this these procedures require not just skill in EUS but a lot of skill in guide wires and so on and it's not just you it's the team that you work with. As part of the university system that I work in I spend 99% of my time at the main hospital and once a month I go to our satellite hospital to do EUS and ERCP there and it's so painful doing EUS and ERCPs there just because they do it once a month right and to do these kinds of procedures in a setup like that is an absolute no-no so I would just say be careful and you might have the skill but you may not have the team to back you up and it's not IR and surgery it's your own team that I'm talking about so I think all of this needs to to be put in place before you start doing this. You also need to make sure you have your proper equipment you know not as much for this but you know we have through the scope fully covered stents when we're placing lambs we call those our emergency stents and you know I won't do any USGJ or a gallbladder if I don't have in the unit you know my my bridging stents just in case there's a problem so for every procedure you need to make sure that you have the equipment that you need ahead of time for both doing the procedure successfully and also managing any complication that might happen. I also want to be encouraging to the group that you can pick up these skills right some of the skill sessions that we'll have today and tomorrow includes like fluid collection drainage so there are chip shot procedures for EUS and therapeutic EUS that are great ways to introduce you know accessing things into your practice and then you build on that so that's I mean I don't know if you guys do this Amy too but we have our fellows start with again that chip shot 12 centimeter fluid collection drainage and then they can move into rendezvous when we have a failed ERCP they'll move into GJ kind of last a nice progression right you have to master each step of the way and then eventually you can get to the most complicated ones at the top so just the same idea a couple of quick online kind of technique questions and then I think we'll have to break do you change so this is EUS pancreatic duct drainage do you change plastic stents periodically to avoid a clue the stents which time interval do you choose if you do that again great question and a lot of variation I think in people that do this procedure so it depends so for me if I if I'm able to cross the ampulla in the first round then I'll leave that stent in place a little bit longer if I'm not I'll bring them back a little bit sooner because once you have the fistula tracked I think you then are more likely to be able to cross the anastomosis or the ampulla so I'll I'll bring those back for stent revisions faster I definitely you know the animal studies have showed that the the fistula tract itself is mature you need a minimum of 14 days so I certainly you know wouldn't do anything earlier than that and I you know in terms of long-term management I think I think again we're gonna get lots of different answers there are people who put those stents and they leave them in indefinitely and never change them out you know some people change them every six months there is even if the stents get occluded there is drainage that happens through the wicking effect along the stent so you can get away with leaving them longer than biliary stents for instance but I'm curious what other people's practice is because I think there's gonna be a lot of difference of opinion in pancreatic gastrostomy stents and when to revise them so I think for the sake of time we can circle back to that maybe tomorrow during our panel discussion but for the sake of time one last question in US guided biliary drainage do you remove lambs after a few weeks to prevent known complications like bleeding I think that question it really depends on the etiology you know of of the biliary obstruction I as I said to prevent bleeding for me I always put a double pigtail through my lambs when I put it into the bile duct so I don't see much I don't have much worry about bleeding per se when I put that in because that stent acts as a buffer so you know as the bile duct gets decompressed that's gonna get smaller and I think there is potential for trauma to the wall and bleeding if it rubs against the metal of the stent but if you have a plastic stent in there it kind of acts as a buffer so you know in patients that you're decompressing before they go to surgery for instance I may not revise the stent unless it becomes occluded or there's a problem you know in in more benign diseases and yes I'll bring them back and try to try to restore their natural anatomy try to cross the ampulla or resolve the stricture and ultimately take the stent out so I think it's very dependent on the indication and the etiology of the obstruction great well thank you so much Amy really appreciate it

EOS-guided biliary and pancreatic access

conventional endoscopic retrograde cholangiopancreatography

biliary obstruction

EOS-guided biliary drainage

intrahepatic approach

choice of stents

malignant biliary obstruction

EOS-guided pancreatic duct drainage