All right, guys, so another neck resectomy, however, this time, you can see things very nicely. Axios deployed, pulling back, rotating a little, deploying, and this is me now. That was a different case, actually. I spliced in two different cases, but now I'm pulling back, rotating a little bit, deploying the proximal phalange in my scope, and then you'll see, in a second, the proximal phalange being deployed in that small little endo view right there. I'm just pushing that, and then similarly, a very satisfying experience as to what Wasif was talking about. One thing I did want to show here, and for the sake of time, I'm going to move this a little bit forward, is actually going in and doing some debridement here. This is just showing use of rat-toothed forceps, kind of picking at things, being careful, of course. You don't want to pick off a vessel or something, and can be time-consuming. For the sake of time, I'm going to move forward here to show you the endorotor device here. You see the device right there in the lower left, kind of mid-left. Now you see the interblade rotating. I've stepped on the pedal, and you see it rotating, and then you want to be in the center. You want to be near the wall, and then you position it, get it close to the necrotic, and then you step on another pedal, and you see all the stuff just being sucked in to the catheter. It's really cool how amazingly efficacious it can be. And again here, you step on one pedal to start the interblade, and then you step on another pedal for it to suck in, and you can adjust the pressure to low, medium, and high. You can start with kind of lower pressure. You obviously want to avoid the wall. You want to, you can rotate this catheter, and so you want to make sure that it's facing and kind of in the center. There's a case series. I think Kahala put together a case series recently showing the kind of efficacy and the safety of this. I will admit to you, though, I've had a perforation with this, and the patient ended up going to the OR. They didn't find an obvious site, so they just left like a couple of drains in, closed her back up, and she did fine. And so I wasn't quite sure why the perforation happened, but a couple of theories was we kept inflating this with CO2, so maybe it's better to perhaps use water, a fluid, instead of constantly inflating with CO2 to avoid potential microperforation. This is just the end, how nice and clean it looked. So Linda, what do you mean by perforation? What perforated? So don't know. Presumably, it was a microperf in the wall of the necrotic cavity because she had a lot of pain afterwards, this particular patient. And then when we did the CAT scan, there was a lot of free air, and so assuming... Like free air under the diaphragm? Yes. So basically, this went through the wall? Yes, exactly. So that's the assumption. But again, when they opened her up in the OR, they didn't find a large perforation site or anything, so just assuming it was a microperf. And then perhaps the other thing to do is, again, you got to stay in the middle of the cavity, not be near the edge of the cavity, and maybe do less, and don't be pulling the stuff off the wall and stuff, because perhaps the action of having it pulled off the wall might lead to a little tear or something. But it's a cool device, and as you can see, very easy to use, and does a really good job of sucking all the debris out. This is like a blender. Did you say it's like a blender? Yeah, like a vacuum. Yeah, I like that. It's like a vacuum. And then I did want to show this video of a left hepatical gastrostomy I did recently. So here you see a nice dilated left duct in this person, had metastatic colon cancer with hyaluronic acid. We had a plastic stent in the right side, but the bilirubin didn't budge. It was like staying at 18, 19. Brought him back, and you see here, 19-gauge needle I've accessed here, aspirating, confirm as vial, and then injecting some contrast here. And hopefully you'll see, you see a nice cholangiogram starting here, and this is our plastic stent here, stricture there. Unfortunately, actually, let me see if I could go back. Does it show? Well, they want to show here. Okay, so here, how do I, let me pause it, sorry. I just want to pause it right here for you guys, because what I want to show you is the problem. So here is my scope position, was trying to get a wire to go this way, of course, and the wire would not go that way. The wire kept going out that way to the right. I could not use an angled wire, torquing, changing, yada, yada, yada, could not get the wire to go this way. So at that point, I was like, I mean, there's nothing I can do, and it was hard to find a good spot. In retrospect though, I'm like, okay, I should not go at a spot with my scope position that way. I should make sure the scope position is oriented in a more favorable position that you'll see next to make sure that my wire will go towards the hilum. So anyways, I could not get it to go, pulled out, and was looking more and more and more, and then found this much smaller diameter duct. I think I measured it at like three millimeters in diameter, a little far, but at this point, this was the best that I could find in him. So then started all over again, 19-gauge needle in here, aspirate, inject contrast, and then got a wire down. You see the contrast injection there under EUS, and then let me see, there should be a fluoro, and actually now you see it kind of dilating more as I've injected contrast there. And now you see a very different fluoro position of my EUS scope, right? And so here, the wire went very nicely towards the hilum and was able to then subsequently dilate the tract. I think this is me just showing you the balloon, the hurricane balloon I'm advancing here. I dilated kind of all along here. And then after that, exchanged and deployed a fully covered viable stent, 10-10, which you will see in a moment was not quite long enough, and this is the stent coming in. I don't have a lot of fluoro, unfortunately, to demonstrate you the stent, but here we go. Here's a stent. You can see a little bit of stent right here, but that's certainly not sufficient. You need at least two to three centimeters of stent on the outside in the stomach. So always maintaining careful wire access, and then was able to deploy an overlapping viable that you see kind of coming out here. So again, the things that, and then the other thing I didn't mention to you is that I started out originally with just a 19-gauge FNA needle, and really what you should use is a 19-gauge access needle, the reason being that the 19-gauge access needles, they are sharp when the stylet is in, and then when you pull the stylet out, it's blunt. And that's what you want when you're doing this kind of procedure, because if you don't use that kind of needle, which is originally what I used, because I couldn't find the access needle, I mean, talking about getting supplies ready, did a very poor job of, you know, because we looked, and like, okay, we don't have an access needle, so okay, fine, we'll just use a 19-gauge FNA needle. But again, the problem with that is when you're trying to manipulate the wire, you could shear the wire, right, and then there's a little bit of wire just floating around in the patient's bile duct there. So anyways, you know, had people look a little more during the case, and in some cabinet somewhere, they found an access needle that one of my colleagues has squirreled away, and so then they switched to using that. So again, it's so important when you're doing these therapeutic procedures to have all the supplies ready. We actually have equipment lists for various different procedures so that, you know, our nurses and techs just kind of go down and say, okay, do we have this, this, this, this. And so being very prepared is super important, making sure you have all the equipment that you need. And then in this particular case, you know, I should not have just kind of given up when I had that less ideal EOS positioning on fluoro. I should have been like, oh, you know, let me just kind of keep looking until I get a better position so that I can ensure the wire would get towards the hilum.

neck resection

endorotor device

perforation risk

left hepatical gastrostomy

duct access challenges