Thank you, Linda and Amit, and this is truly an honor to be here. And you know, as someone mentioned yesterday, but I have, when I started my, my fellowship many years ago, some of the faculty in the crowd were my teachers. So it's really an honor to be part of this faculty and this group today. So thank you so much. The middle one. Yeah. Yeah, got it. So these are my disclosures. And so I, I'm showing you this. This is actually our office building at the University of Colorado. And this building is right across from the hospital where I work. So I end up never going to the office building, but these windows or doors rather, I walk past every day. And every day I see them, it makes me think. And I think what it's telling us is that the endoscopic techniques that we have, have opened many doors and windows to do newer things that weren't there before. So every time I walk by, it makes me pause and think, what else can we do with the technology that we have right now? So what you're about to hear in the next 20, 30 minutes is basically an extension of basic EUS principles combined with some interventional endoscopy. So EUS gastroenterostomy for malignant gastric, so stenting for malignant gastric outlet obstruction is limited because of tissue ingrowth and overgrowth and the stent gets occluded. And so EUS gastroenterostomy can kind of go around, work around that problem and maybe offer a sustained patent conduit so that food can flow through and go around this problem with stenting. Multiple series have now shown the efficacy of gastroenterostomy by EUS over the last decade or so. And I'll walk you through some of that data. I'll also show you and walk through the steps of doing this procedure. This is a relatively high risk procedure. So again, thinking this through is very important. So even before we touch the EUS scope or touch our patient, I think planning for the procedure is extremely important, especially if you're starting out new in this field. So one is this requires fluoroscopy. And even though this can be done with propofol sedation, I would recommend using general endotracheal anesthesia for this. Things can go wrong, patient can move and so on. So I would strongly recommend talking to your anesthesia folks. Also remember, these patients have a gastric outlet obstruction and the stomach can be filled with food and fluid. And that can be a problem during anesthesia and during the procedure regarding aspiration. This is something that I discussed with my team when I first started doing this. And after some time, it becomes usual. You say you have a case, they have everything set up. But we still, every time, make sure we have this. And I'm going to say, you need to have glucagon, methylene blue. You need to have a backup plan in the case that the axial stent doesn't work well. You need long guide wires. You need to have dilation balloons, double pigtail stents, fully covered biliary stents, and then devices that can bail you out if there's bleeding or perforation. So you need to have some means for closure. And you might think that, oh, we do this all the time, so we have clips. But the one time when you need a certain thing, it won't be in the room because they didn't stock it or something. So just go through this list. Make sure that your nurses, your techs, your anesthesia folks, they're all aware of this, that this is not, you know, sometimes on the schedule, it'll show up as EUS. And the anesthesia folks don't really care or don't know what you're doing. And so it's your duty to tell them this is not a standard EUS, this is more than that, and talk to them about it. So now let's deconstruct the EUS-GJ procedure. So we're going to break it down into individual steps. So I've kind of simplified it. So first is identify and confirm the target, which is basically identifying the duodenum or jejunum distal to the obstruction. Next step is to distend or stabilize the target, make it a big target that you can access. The next step is to actually access that with different techniques that we'll talk about. And then finally, place a stent from the GI tract into the distal small bowel. Most important bullet is the last one, which is anticipate and plan for adverse events, because things will happen, even in the best of hands, even if you've done hundreds of these, something or the other will not happen the way you planned. So you should have a contingency plan. And I told you how to plan for some of the equipment that you might need. So let's look at techniques for EUS-GJ. There's a direct approach and an assisted approach. The direct is where you use a 19-gauge EUS needle, puncture the small bowel, and then do the next steps that we'll talk about. And in the assisted approach, you have to access the distal small bowel with either going through the stricture with a regular upper scope. Sometimes if the stricture is too tight, you might need to use an ultrathin scope, or sometimes just pass a guide wire beyond, and then advance a device, such as a biliary stone extraction balloon or a dilating balloon, maybe a nasobiliary drain, some means by which you can then distend and opacify the distal bowel, confirm the location. And then you can use that as a target. I have mentioned the EPASS method that Itoi described in Japan. This is a double balloon system that you can inflate two balloons. It's not available in the US. But two balloons are inflated in a segment of small bowel. That really secures that area. It becomes a nice target. You can instill saline in that space. And so you have a big target that you can then access with a needle or with a stent system. And once you've confirmed the target, stabilized the target, you can then place the stent in a single-step lumen-opposing metal stent system that you saw in the hands-on stations today and yesterday, or in a two-step procedure, which is the traditional method of needle puncture, dilating the tract, and then placing a stent over that. So that's basically how this procedure is done. I'm sorry I couldn't play that video. So I kind of just got these pictures to show. Here's a guide wire that's been placed through duodenal stents into the distal small bowel. I hope it's projecting well up there. I can try with this. And now a nasobiliary drain has been advanced. The contrast injection then shows the distal small bowel. That can be then seen on EUS. And then you've seen how the lumen-opposing stent can be placed into that bowel. We instill methylene blue in that segment of distal small bowel. This is just to tell you that you're in the right spot. As soon as the stent has been placed, you see that gush of blue, and you know you're in the right spot. That's seen on EUS as well. And then subsequently confirmed on fluoro. And this patient happened to have a CAT scan later that showed the stent from the stomach into the small bowel. This is a jejunal jejunostomy video that I can play for you. This patient had a complete obstruction of the jejunum. That dark spot is actually not a lumen. We injected contrast. There was nothing going through. And in that case, EUS was able to identify an adjacent loop of small bowel there that we've punctured and accessed with a 19-gauge needle. This is then distended to make some working space. Contrast injection confirms this to be in the small bowel. And then we use the conventional method, advancing a guide wire, dilating balloon across it. And this was done a while ago. I think that's when we had the cold lumen opposing stents. And once this tract was created, the distal flange was deployed. I'm not sure you can see that well on the fluoro. But here's the proximal flange being released. Most of you are now familiar with it, having gone through the hands-on station yesterday and today. So that's the stent placed. In six weeks, we took the stent out. And there's a nice connection between the jejunum to the distal jejunum. So what are the outcomes of this procedure? So this is a busy table. And I'll just draw your attention to the fact that there's really one prospective study. Others are mainly retrospective, multi-center, single-center studies. But what I'd like to highlight is that the technical and clinical success ranges from 80% to 90-plus percent in all of these. So this technology, this approach does work. Adverse events are still higher than what we quote for other procedures that we do. So I think patients should be counseled that bad things can happen and what that can lead to, not just saying there could be a perforation. But I think these patients often have a cancer diagnosis. And they're sick to begin with. And a perforation can be a serious problem. So just discussing all this, that they might require emergency surgery or they may not be candidates for even that emergency surgery. And that could mean this may be a life-threatening event for them. So now come two important questions. How does EUS gastroenterostomy compare with surgical gastrointestinaloscopy and with enteral stenting? Because that's the main thing we want to address. So I'll share with you this data on EUS approach versus surgical gastroenterostomy. This is a study of 54 patients, 25 patients in the EUS arm and 29 in the laparoscopic gastrointestinaloscopy. They define technical success as the ability to create the gastrogynostomy, clinical success as the ability to tolerate a diet post-intervention. There was no difference in technical success and in clinical success between the two groups. But adverse events were higher in the laparoscopic gastrogynostomy group at 41%. And I did highlight the adverse events. There was ileus, gastroparesis, bacteremia, pneumonia, urinary infection, and leak. And on the EUS side, the risk was the adverse event rate was 12%, mainly two patients who had bleeding. One had peritonitis. So the conclusion from this was that the EUS-GJ group, even though they contain more complex patients, efficacy was similar, but adverse events were significantly lower. This is another multicenter study. This was a retrospective comparison between the two modalities. And I'll draw your attention that the main significant difference was technical success was higher in the surgical group, but otherwise, clinical success was pretty much similar. And they said that the two groups had equivalent efficacy and safety, but EUS gastroenterostomy was less invasive. So let's look at EUS approach versus duodenal stenting or enteral stenting. And so this is, again, a retrospective multicenter study from the Hopkins group, 82 patients with 30 in the EUS group and 52 in the stenting group. And again, I'll show you that technical success, clinical success, adverse events were pretty much similar. But the main difference was that recurrent gastric outlet obstruction and re-intervention was higher in the stenting group compared to the EUS group. So now let's move on to the second part of this talk, which is EUS gallbladder drainage. This is on our campus in Colorado. And the reason I show this is that I don't think you guys can read this. But this thing here says a little trivia about Colorado is that the average American walks about 6,000 some steps in a day. The Coloradan takes about 7,500 steps. So just something that I found very interesting. So now let's get back to some EUS. So EUS guided gallbladder drainage was first described in 2007 by Todd Barron using plastic stents. And then the technique kind of evolved to the use of fully covered self-expanding biliary stents and then single-step lumen-opposing stent that most of you are familiar with. This is indicated for high-risk patients who are not candidates for surgical cholecystectomy. So here's a video. I think it'll play. Let's go back. There we go. There we go. So here's the gallbladder. I kind of measured it out just to see how much distance I have. I do have enough. There's the bile duct that's coming into view. And we had the Doppler there a second ago that showed nothing intervening. You're now familiar with this technique. We use the electrocautery enhanced method to drive the device into the gallbladder. The flange is then released on the gallbladder side. It's hitched up and then released on the proximal side. This can be done through the gastric antrum or through the duodenal bulb. There's pros and cons regarding both these approaches. The stomach tends to have more food go through it and can have food going into the gallbladder, the duodenum less so. The other thing is that the antrum does move with peristalsis, so there is a risk of having dislodgement of the stent. This is less with the duodenum. The counter to this is on the duodenal side. It's a smaller, tighter space and sometimes can get tricky to work in. But if I had to choose and if I could pick a window, I would go with the duodenal side. That's typically where we've been doing it. Later on, we can poll the audience and faculty and see what approach they prefer as well. How does EUS gallbladder drainage compare with percutaneous cholecystostomy and with ERCP-guided transpapillary cystic and gallbladder stenting? This is the main question here in these patients who are not surgical candidates. Gallbladder drainage versus percutaneous drought. This is a randomized controlled study. This is the one randomized controlled study that I'm sharing with you. As you can see, in the world of interventional endoscopy, we have a lot of case series and retrospective studies, not that many prospective randomized controlled studies. But this is one. This is by the Hong Kong group, 80 patients randomized to EUS gallbladder drainage versus percutaneous cholecystostomy. And what they showed was EUS gallbladder drainage significantly reduced adverse events at one year and at 30 days. Re-interventions also less in the EUS group versus the percutaneous cholecystostomy group. Unplanned readmissions and recurrent cholecystitis all less in the EUS group. Post-procedural pain scores and analgesic requirements also less in the EUS group. That's the blue line that you can see on the graph compared to the percutaneous drought. And technical success, clinical success, and 30-day mortality were similar in the two groups. Let's now look at the three modalities taken together, which is the EUS drainage, percutaneous drainage of the gallbladder, and endoscopic transpapillary drainage via ERCP. So this was a systematic review and meta-analysis published in GIE just last year comparing the three different groups, 10 studies, more than 1,200 patients, 400-plus in the EUS group. And what they found was that the percutaneous cholecystostomy and EUS group had the highest likelihood of technical and clinical success. Makes sense, cannulating the cystic duct and advancing wires and stents into the gallbladder is not always successful. Overall adverse event rates were highest in the ERCP drainage group, but overall similar in all the groups. And I think the ERCP risk is mainly from the risk of pancreatitis from ERCP than the procedure to drain the gallbladder itself. EUS gallbladder drainage had the lowest risk of recurrent cholecystitis, and the risk was highest in the ERCP transpapillary drainage group. The percutaneous group had the highest risk of reintervention and unplanned readmissions, and it was lowest in the ERCP group. So the conclusion was that the three modalities have their respective advantages and disadvantage, and the selection will depend on the available expertise and patient condition and so on. And I'll walk you through some of those nuances just in a couple of slides later in this talk. And so what they suggest is that in centers with expertise in endoscopic gallbladder drainage, these techniques are to be preferred over the percutaneous method of gallbladder drainage. This is one more study. This is a retrospective study. Six centers, 372 patients, and they compared the same three modalities of treatment. Clinical success and clinical success, significantly higher in the percutaneous and EUS group compared to the ERCP group. We saw that in the previous one as well. And the percutaneous group had a statistically significant higher number of complications as compared to EUS and transpapillary gallbladder drainage. This is, again, a busy slide. I just want to draw your attention to the fact that the difference was mainly the clinical success, much higher in the percutaneous and EUS group compared to ERCP. And long-term adverse events were highest in the percutaneous cholecystostomy group. And I'll draw your attention here to this. The main adverse events were related to the tube or catheter being dislodged or migrating and the post-procedure pain, which is from the percutaneous drain itself, which does cause more pain than any of the internal drainage methods in the other groups. Mean hospital stay was less in the EUS group compared to the others, and so they concluded that the EUS approach has a significantly lower overall adverse event rate, less hospital stay and unplanned admissions compared to the percutaneous drought. So this is the tailored approach that we have been following, and I mentioned earlier in one of my slides. So let's ask the audience here. So patients who are good surgical candidates and have cholecystitis, what's the recommended approach? Laparoscopic cholecystectomy. So that's pretty standard now, even though there is some data recently from the Hong Kong group proposing that the EUS method can be utilized in these patients. That's very debatable, so I'm not going to go into that, but this is the standard approach here. OK. High risk patients who are stable, they are not transplant candidates, liver transplant candidates, and a skilled endoscopist available. What's the method here that we think of? EUS. High risk patients, unstable, or EUS expertise, or EUS expertise is available but not higher EUS skills available. These patients should go for the percutaneous drought. They're unstable. They do need something to be done. And then high risk patients who are stable but may be potentially liver transplant candidates down the road, or if they have ascites, varices, or if the gallbladder is too far away from the GI wall, these patients may have an ERCP approach. So this is how I think about it in my mind. Of course, each patient is different, and it also depends on what the primary team and the surgery team have in mind as well. So it's a tailored approach. There's no one answer, and we can discuss this later as to whether other folks agree with this or they have something different that they do at their institution. So take-home points, EUS-guided interventional endoscopy requires high technical skills and should be performed by experienced endocrinographers. Again, very important, anticipate and plan for potential adverse event. I cannot overemphasize this. EUS gastroenterostomy has similar efficacy as surgical gastrointestinal and enteral stenting, but is less invasive and requires fewer reinterventions. EUS gallbladder drainage should be considered as a viable treatment option in high-risk patients, but management should be tailored based on the clinical scenario, patient status, and available resources. This is our upcoming course where we have a section on interventional EUS, so please join us in Vegas. And finally, I will end, and we can take questions. Thank you so much. Question here. You know, in all the studies you showed, the technical success rate was 86, 87. When you compared to surgery, there were only 20 patients in each arm. So is it truly equivalent in technical success or just not powered to find inferiority? So which procedure are you talking about? EUS gastroenterostomy. Right. So EUS gastroenterostomy, I think the success with surgery is definitely higher than its 100% technical success rate. As I said, there's not good prospective studies for that procedure. So your question is valid that we don't know whether the numbers are adequate. These are mainly retrospective reviews and so on. So we don't know. But the technical success is lower. We know that. But it is less invasive and less risky to the patient when you are successful in accessing the distal valve, which is why I think it should be done in a center that does these kinds of procedures. Because if it doesn't go well, you have a backup plan as to how you can bail yourself out or what else that can be done. I think the data in a lot of those studies was also done when the technique was first being developed and utilized. So there was a lot of variation in technique. And we were still kind of learning the best way to do the procedure. So now, I think if you were to sort of redo some of those studies only using the technique that most of us use now, which is the assisted technique, where you distend the small bowel and you go freehand with a lumen-opposing mental stent, I think technical success would actually be higher than it was in a lot of those initial retrospective studies where people were still sort of learning and trying to figure out the best way to do the procedure. But agreed, technical success probably won't be as good, even with the newer procedures as that. Sir? Yes. Just, I know for the sake of time, you probably didn't include this, but take us through if you were to have an event with, there's different types of GJ problems, hasn't been classified for the gallbladder, but if you were to have the most common misdeployment in each procedure and you were to have everything available that you needed, how would you manage that? Right. So this is a good point. So what would we do if something went wrong? And the commonest thing that goes wrong is that you place the, you puncture through, you go with the electrocautery enhanced system. You don't see what you want to see, which is the device going into the target, which is either the gallbladder or the jejunum. What do you do next? If you are in doubt, I would say at that point, there is still time to bail yourself out. You have not actually deployed any flange of the standard. I think that is the safest thing. If you don't know, just abandon it at that time. Take it, take the device out and start again. All you've done is a tiny hole and hopefully you can, you know, deal with that with a clip or sometimes not even doing that. It's a small, small opening. The bigger problem is if you deploy one flange, which is the distal flange first, and if you find that that is not in the target, it's not in the small bowel, you still have the device, the system that is still exiting through the GI tract. And if you can, the step there would be to try to put a guide wire to access the distal site if you can. And I think if you can confirm that you're in the small bowel or gallbladder at that time, then you can, you know, deploy the stent. Even if it's in the wrong place, because you've partly deployed it, then bring the scope out and go in with a new stent or just do it through the same scope and put in a longer, fully covered biliary or esophageal stent to bridge that gap. You could have it the other way around where the stent is deployed appropriately, the distal flange is in the right spot, and then the proximal flange has been released and that slips out of the GI tract and now you don't have a space to go again. If you can get a wire through, that's the best way to bridge it. If you can't, you know, we saw a video yesterday, I have not done that, which has gone out into the peritoneum and tried to find the site. In that case, I've just tried to find a new site and try to at least get there and fix the problem. Many times if it's the gallbladder and you get another drain in, the first site may not be as much of a problem because you have an alternative way of draining the gallbladder with the jejunum, it's different and you probably will need some surgical help at that time. So question about patients with gastric outlet obstruction. Do you always do EUSGJ? Are there times where you might do an enteral stent, especially in somebody who is anticipated to have a very short life expectancy, so you're less concerned about, you know, tumor ingrowth into the enteral stent? So my opinion may be different from some others here and we'll see what they say. I still believe that if the patient has metastatic cancer, is not expected to have a long life expectancy, duodenal stenting is not a bad option at all. I think it's a much safer procedure. It might require more interventions in the long run because of occlusion and so on, but I think that is a safer option, especially thinking that if something were to go wrong in this patient, it's likely to be a sudden, you know, change in the patient's life expectancy to nothing more can be done. So I think doing a duodenal stent helps. Also, our site, our oncologists and surgeons are still very much focused on duodenal stenting and so we'll often get asked to do that first. And so we will do that as a first step unless there are reasons not to do it. I should point out that if you're doing a duodenal stent, you have to think about other things such as does this patient need a metal biliary stent before that because you're going to block off access and so on. But I would go the duodenal stenting first and I'm curious to see what others are doing at this. Amy has a smile, so she definitely has something interesting to contribute. No, I think you're right. There's going to be a lot of variation. I'll say our surgeons, for whatever reason, they love endoscopic GJ. Our surgical oncologists are a little bit hesitant to give up the gallbladder, but they are loving the endoscopic GJ and they actually will get consults specifically for this procedure. They don't want to operate on these patients. They much prefer the endoscopic approach. And for us, we do quite a lot of them. So at this point, we don't really place very many duodenal stents anymore unless the patient really has a limited life expectancy. So I agree if they're only going to live three or six months with their cancer, it makes sense to put a duodenal stent. But patients are living a lot longer with pancreatic cancers, with metastatic cancers. The oncologists are coming up with treatment regimens that palliate the disease a lot longer and so we're finding more and more people are outliving their duodenal stents when we were putting them in because at six months, 50% are already occluded and then you have to put another one. So we will actually go straight to GJ in a lot of patients that come to us with gastrointestinal obstruction unless they have a very limited life expectancy or if they're really high risk for getting anesthesia, then we may opt for the quicker duodenal stent. We've had a similar experience. Our surgical oncologists love GJ. So we get a referral a couple of times a week specifically from surgical oncology. It's not an absolute contraindication in our practice, but I personally don't love GJ with ascites. So I consider that like another relative contraindication. I tell patients they're likely to get secondary bacterial peritonitis and they're going to be on either lifelong antibiotics or intermittent antibiotics if they do get infected. That's my other concern for healing of the tract and seeding the ascites. I'm also concerned in that case that you might have the separation of the two lumens if there's ascites. Right. Also, when there's ascites, many times these patients have peritoneal carcinomatosis. So there's often not one site of obstruction, even though everyone comes after the duodenum saying that, oh, the stomach is so big and the patient's throwing up, but there's often other sites of obstruction distally. So just doing something there may not, even a duodenal stent may not be the best option in these patients. I'm glad you say that your surgeons like one thing, other surgeons like something else. And so this is not, I don't think this should be done as a, you see a patient and you say, well, instead of duodenal stenting, let's just do this. I think there should be a discussion with your local subspecialties and then decide which avenue is best for you. So there's an online question about US gallbladder drainage asking about, would you favor doing the first case in the OR with surgical backup? But I think this also leads to a larger question of how to learn and what the learning curve is for these two procedures, which I feel are very, very high end interventional US procedures. So we'd love to hear your thoughts. So I personally have not done a US drainage of any kind in the OR. I don't think it is required if you have the skills and the team in your room to help you do that. And if you're doing these kinds of high end procedures, I don't think it's required to do it in the OR. But what is more important is, I guess the question is saying that, should I do it in the OR in case something happens? And which means I have my surgeon and everyone. I think you could have the same kind of setup with making the surgeon aware and talking through with them saying that, look, I'm planning on doing this. It's going to be done on this day. I just wanted to let you know so that you could have. I don't think this is never an emergency when you need to be in the OR at that minute. If something were to happen, yes, if something does happen, you probably might need surgery, but doesn't need to be done that minute. So you could do it as needed. Also in terms of just the, I mean, I'd love to hear everybody's thoughts too in terms of the learning curve for picking up these procedures, the USGJ as well as the US gallbladder drainage. So I would say USGJ does, I mean, in my mind, it is one of the hardest procedures and probably more unpredictable. I think, you know, technically difficult is different from unpredictable, right? I think if something is technically difficult, you can keep doing it and, you know, get better at it. But some things are just unpredictable. And, you know, the small bowel can move things, you know, the stent sometimes is in a very awkward position that it doesn't release as smoothly as you think. And then suddenly it gives and opens. And now you've released it where you didn't want to. And so all of these things will happen. So I would say that, you know, once you're comfortable with EUS, FNA, FNB, pseudocyst drainage, then maybe gallbladder drainage might be the next step. Because it's still safer than EUSGJ. Maybe EDGE after that. And, you know, Dr. Storm's going to talk about that in the next lecture. So we'll see that. But I do think that, you know, even EDGE, I think, is a little safer than EUSGJ. You're working on the stomach, which is a little more forgiving. You have more options available if something were to happen. And then probably EUSGJ would be even beyond that. There's another online question asking about the size of LAMs that you prefer when you're doing EUS gallbladder drainage. I guess commenting on how you decide to choose what size. So I think it depends on, so there's two main sizes, 10 and 15 now that we use. I tend to go with the 10 or 15. But if there are stones in the gallbladder that either you think should drain on their own or if you need to go in and take the stones out, I would go with the 15. Otherwise, a 10 would be enough just to drain the gallbladder. Otherwise, I have not used the smaller sizes. I typically use the 10 or 15. This is an audience question. I think someone had it. Just for benign gallbladder drainage, how do you manage them afterwards? Are you exchanging the Axios at some point for some plastic stents? And how do you decide when you want to go after those stones? So our practice is to leave the Axios in for two months and then go back and change that into double pigtail stents. And most of these are non-surgical candidates, so we just leave it indefinitely. If the patient is doing fine, I typically don't go in the gallbladder and take the stones out. Just let it drain, and the tract is formed, and it'll keep draining alongside the plastic stents. Can you press the button? In both gastroenterostomy and vodunocortisostomy, do you have to dilate? Is that a mandatory? So I try not to mess with the stent once it's been appropriately placed at the same time. Just because, you know, I think we saw a video yesterday. Someone showed that they were dilating a stent, and that dilation caused the stent to dislodge. So unless it hasn't opened and there's pus in the gallbladder that really you think is not draining, I've typically let the stent open on its own, and most often that should do the trick. I don't know if others are routinely dilating. For EDGE, it's a little different. I mean, if you want to go through it, you do need to dilate for EDGE. But for these, I don't routinely dilate them. For Waldorf necrosis, I will dilate it at the same time, but I wouldn't do it for GJs and these procedures. I don't know what Amy and John. I actually agree. We dilate every time. I always dilate every time. Yeah. I think it actually anchors it a little bit. It's funny. This is the U.S., right? Yeah. And everybody's different. So we dilate every time, every gallbladder, every GJ right away. Me too. And the thinking behind it, at least in my mind, is that, you know, you create the fistula tract that's, you know, this size, and then if you dilate, you're making a much bigger diameter than the fistula you created. So I think it helps a little bit with migrations less likely to move. I usually don't dilate, but the one advantage of dilating is it brings the two flanges closer, right? But I am a little concerned of that very phenomenon. This is like the Chinese finger trap, right? I mean, when things stretch wider, they become shorter. And I am concerned that you might have the stent coming. This is, I don't think there's any data to back this, but that's the reason I don't mess with it. I'm glad to hear that you have been doing this and without any issues. Yeah. I mean, when we're dilating, you know, we make sure that we're very still and not moving because I think the other concern is that if you dilate and then you move that balloon, you can also dislodge the stent. So, you know, I talked to my anesthesiologist, like, this is not a good time for the patient to buck on the vent or move or, you know, when I'm teaching this procedure and make sure that, you know, you need to make sure you're in a stable position with your scope so that as the balloon is being inflated, you don't get, you know, sucked in or pushed away and accidentally dislodge the stent. But I agree. We don't know. Yeah. Yeah. I mean, I think this, again, points out how much we don't know about these procedures and all the kind of variation in technique. And presumably, despite all the variations in technique, you know, most patients are still doing well. So, you know, still a lot to learn. The thing is, two things about dilation. One is that if you're using an EUS scope, you're going to be at an alternative angle to where that stent's going to be out. You're going to be going at a 45-degree angle. So switching to an upper scope for that is not unreasonable if it gives you a better angle. The other is for something like the gallbladder or the jejunum, your distance that your stent, your balloon needs to be inside that lumen is very limited. So 80% of your balloon or more is going to be outside into the stomach or duodenum when you're doing a dilation. Because if you push that balloon way away from that, and you start stretching that up, you probably are going to increase your risk of that dislodging from where you need to be. So I put most of my balloon, I try to see that catheter going against the other wall. But then when the dilation goes, I actually pull back a little bit because I'd rather have it come back in the stomach than go forward into the other area. And I under dilate for my stent. So if I'm using a 15, I don't use a 15 dilator. I might use up to a 10 or a 12 just to make sure it's kind of on its way to open rather than trying to be a hero and going right to 20. So. All right. Fantastic. Thank you so much.

endoscopic techniques

EUS principles

EUS gastroenterostomy

malignant gastric outlet obstruction

EUS gallbladder drainage

surgical gastroenterostomy

transpapillary cystic gallbladder stenting

technical skills