So I titled this Building a Bridge because, and I think it was really wise to put this talk last. You guys are smart to have done that because this is not a super data-heavy talk. This is a very kind of fun endoscopy video kind of talk. And I do think EDGE, like Mahir was saying, EDGE is a great introductory procedure for when you're ready to use luminoposing metal stents to form an anastomosis. Especially pseudocyst drainage, big necrosis, those are great places to start using the stent. When you're ready to move into anastomosis, I think, and with my own fellows, we start doing EDGE first because it's a fairly, I think it's becoming a reasonably refined procedure, fairly safe, and we'll talk a bit more about it. It is a reason to celebrate an advanced endoscopy, right? I will admit openly, and I've told Tom Kowalski this, my first experience in the clinic as a medical student at Jefferson was watching a long-limb ERCP with Dr. Kowalski. It was four hours long. I had no idea what we were doing. And then I think it ultimately resulted in maybe a perforation or we didn't achieve the ultimate goal of placing a stent. And so I said, I will never go back to the endoscopy unit again. I can't stand this. Unfortunately, it came around to the light side, which is that there's a lot of great stuff happening in endoscopy. One of those great things is not single balloon or double balloon endoscopy for ERCP. And this procedure really enabled us all to have some other options. And I'm excited about that for all of us. So these are my disclosures. I will say, like all of my colleagues, as with 75% of what I do in a given day, a lot of it's off-label, technically not yet approved, the lumen opposing metal stent for this, but it works well. And I think we're going to see Boston Scientific companies working at getting us indications for some of these devices as well. The most important thing, so this is really important to me and for my fellows, is the most important thing is to know when not to do something. And that's really the important part, I think, of advanced endoscopy fellowship and something that's not to be missed. When should you not build this bridge? And that's an important lesson to learn. We'll talk a bit about that. And then also explore a couple of techniques for EDGE, like we've been talking about with everything. I mean, I don't only dilate my GJ, I over-dilate. I really want to see that stent open up to pull those two lumens together and make sure that we're forming a nice, tight connection, because we do do a lot of those procedures in patients with ascites. So we all have different ways of doing things. I think it's important to have a wide variety of ways of doing things. I saw things with Linda. I saw things with other docs in Boston. And then moving to Mayo, everyone there had a different way of doing things. Absorb all these different techniques and then adopt for yourself what makes the most sense, what makes sense for you and for your patients. And then examine some other EDGE-adjacent procedures. So just in this most recent issue of GIE, there's a really nice multicenter study describing the EDGE. So we're getting new alphabet soup acronyms in therapeutic endoscopy every week. So there's EDGE, which we'll talk about for ERCP. There's EDDI for making a similar connection to shortened root anatomy or altered surgical anatomy for ERCP. Then there's EDGI, which is for other interventions using connection of the gastric pouch or jejunum to the remnant stomach. So let's take a look at that article. I haven't read through it entirely myself, so I can't talk about it too much. But it looks like a nice paper, again, talking about other things. And that's one of the videos we'll show in a little bit after this talk. Other things you can do using an EDGE-like procedure. And then I'll talk about some of those controversies, things that all of us will disagree on within EDGE itself. So the obesity epidemic, and part of my job is doing bariatric endoscopy. The obesity epidemic, obviously on the rise, obviously of paramount importance no matter who you are. If you're a doctor, you're now an obesity doctor, right? If you don't have a bariatric bench out in your waiting room, then you're doing a disservice to your patients because you're going to have somebody with a BMI of 70 walk into your office. Roux-en-Y gastric bypass prevalence is growing by about 40,000 to 60,000 patients per year. We were talking this morning about how everyone seems to be moving towards sleeves. Well, now with the prevalence of Barrett's esophagus, maybe an increased risk of esophageal adenocarcinoma with sleeve patients, we're going to probably see sleeves drop off and mini gastric bypass, Roux-en-Y, other surgically altered anatomy procedures that complicate lives for an ERCP doctor rise in prevalence. But nonetheless, even now, we're still seeing another 60,000 patients with Roux-en-Y gastric bypass anatomy in the States. So every year, we're adding to that number of patients who are going to have to come for an ERCP potentially. We also know that obesity and rapid weight loss, which is associated with Roux-en-Y gastric bypass, are both independent risk factors for developing something that needs one of your help for an ERCP. So what other options do we have for ERCP and Roux-en-Y gastric bypass anatomy? Of course, enteroscopy-assisted. I already gave you my opinion on that procedure. We'll talk about also IR or a percutaneously placed wire rendezvous for ERCP. That's one of our favorites at Mayo. The EDGE procedure, obviously the topic of the talk. So really, case-by-case decision-making is key and should be really a case-by-case decision that you make with yourself and your team. So enteroscopy-assisted native papilla ERCP is expensive. You need special equipment, expertise. Dr. Diehl, you don't offer single balloon, right? So I mean, really top-notch advanced endoscopy programs in the States are just saying no. So that's what I say. Just say no to enteroscopy-assisted ERCP. Your administrators, this is one thing you guys will get along with, right? They don't want you spending four hours where you could be doing four ERCPs, doing a four-hour enteroscopy-assisted ERCP. Do something else. Make better use of your time. If anything, tools are contracting. So Olympus just announced that they're taking away the occlusion balloon for enteroscopes. They're taking away some of the stents that they've made for enteroscopes. So not only are we not growing the ability to do this procedure better, we're actually contracting our tools. Fairly low success rate, totally varies, depends on your experience. Is it a native papilla or not? That may play into your decision-making. High complication rate, perforations are not terribly uncommon. And so again, a lot of institutions and practices have just said no. I'd encourage you to do the same. That's a personal opinion, not of ASGE or Mayo. Laparoscopically-assisted ERCP is definitely the right decision for some patients. So when a patient comes and my fellow presents the patient and we're talking about this person needs an ERCP, they still have their gallbladder in situ, and we've got stone disease, well, they're going to need their gallbladder out, that admission. Maybe they have gallstone pancreatitis. When they go to the OR, I will come do the ERCP, and I just have to make myself available. This can be done often under a single anesthetic. You're in the room with the surgeon. I was talking with one of you this morning, and this is totally surgeon-dependent. If they don't do this for you often, so I, for example, have to go with my trauma surgeons, that means I'm with a, you know, if it's the middle of the night or whatever, because that's when they could get an OR for us, I'm often with a surgical chief. So this is like a resident or fellow. And they're always, invariably, going to put me right in the antrum at a very acute angle to make the turn into the duodenal bulb. I hate this procedure, but it's the right thing for the patient, you know, to keep that a single-session, fairly safe thing. And then if either of us has a perforation or issue, they can just close it there at the OR. But again, for some patients, this is the right thing. Definitely it's going to be a time investment on your end to meet the surgeon in the middle and find a time when you can go join them in the OR. And it really is, it's going to be dependent on your surgical team. I hate our portable OR fluoro, so I am spoiled. We have fixed fluoro in our units in our four ERCP rooms. And beautiful fluoroscopy, I feel for everybody who has C-arms for ERCP, when I go down to the OR, the tech has no idea what we're looking at. The scope's upside down, right? It's just a challenge. And then again, positioning in the stomach, you want to talk to your surgeons about bringing you up as proximal as they can find a window for you to place that trocar, and they'll place a large trocar that your duodenoscope can pass through. If you're not using the single-use duodenoscope, you're going to have to keep a sterile scope. Even though, again, we all know that these procedures are not sterile, you're entering the GI tract. When you do this, they like you to have a sterile duodenoscope. So that's something you'd have to maintain as well. IR rendezvous, I love this procedure. So this is another option, particularly for someone who I think had a really nice response to their gastric bypass. They're maintaining their weight loss. They're in a good place, and they just need a simple one-time ERCP to maybe clear some stones. They've already had a cholecystectomy, so this isn't the best diagram that we used for our paper. But if you anticipate a one-and-done ERCP, you can certainly have your interventional radiologist. They'll place just a small introductory catheter. They'll do a right duct puncture. They'll place a small catheter and then a guide wire. Usually a 450-centimeter jag wire is plenty. And they, again, they're wizards, right? They can work that wire down to the JJ. And at that jejuno-jejunostomy, we'll find with a colonoscope and then pull from both ends. So you have a wire coming out the patient's side, a wire that you've externalized. I use forceps. This diagram shows using a snare. You'll externalize that wire out of your scope, pull at both ends, and you can advance just like over a guardrail or like if you're going skiing up the lift. You're just going to advance right over up to the papilla, and you can do a really nice, even a long-distance sphincteroplasty and clear the stone and be done. So this is also the right procedure for some patients. The big challenge here, we like to do this also under a single anesthetic, and so coordinating our schedules can sometimes be a little bit of a difficulty. So that brings us to EDGE. This is the right procedure for patients who need multiple ERCPs, particularly if there's an indeterminate stricture, if there's malignancy, if you're worried about choledocal lithiasis where you're going to be doing multiple sessions of EHL, for example, and maybe a patient with cholangitis where you're going to leave a stent and want to come back to get that out. And I leave plus or minus there because same session ERCP at the time of EDGE is one of the debates we'll talk about in a bit. Very high success rate, so your chances of this working out are pretty high. Severe adverse events have been reported in the largest series to date in endoscopy 2021 of about 1% to 3%. Most of these are not surgical, fortunately. And then you certainly should consider an in-the-right patient where you can delay that ERCP to allow tract maturation. That's going to lead to a lower adverse event rate, and you're going to encourage your surgeons to refer patients for this procedure. The downside there, of course, is that you're having multiple anesthetics to achieve that ERCP. So other times I think about avoiding EDGE, relative contraindications, I think about it kind of like a PEG tube placement. So this is a tract, a new tract you are making, just like with a PEG tube. So it's a lot of the same issues you have to think about before you place a PEG tube for someone. So this is general GI at its best. Someone who's at really high bleeding risk and on antithrombotic medications, think twice. Someone who has large ascites that you can't tap dry before the procedure, think twice. Definitely someone who you know to have unfavorable anatomy. I always look at the CT scan before doing these procedures to kind of map out where I think our best window is going to be. Patient preference. So sometimes this isn't the right thing to do because you just know that patient is not going to tolerate it if you have an adverse event or say your fistula doesn't close and they regain all their weight. So if you get to know your patient and you just get the sense that having an issue, a complication like regaining weight is not going to work for them, maybe go the IR route or send them elsewhere. If there's already a GG fistula, and this was a case, we describe it as kind of the triple sign for a GG fistula. So I'm always looking on that CT scan for a couple of things. We know that Roux-en-Y gastric bypass, especially those performed either greater than 20 years ago or by a surgeon who trained more than 20 years ago, is sometimes and often undivided. So they would staple, they'd fire their stapler, and now you can't. So I've needed to buy a stapler for our animal lab for a study that we're doing. I've needed to buy a stapler that does not also cut staple, two rows of staples, and then cut down the middle. You can't find them. You have to go to South America to find them. But back in the day, 20 plus years ago, they would fire staples and then walk away. And that was dividing your pouch and your remnant stomach. And what they found is a very high rate, greater than 50% risk of a gastrogastric fistula forming. And so that's what we're always looking for to see if we can help the patient avoid the need for an edge-type procedure. So what you're looking for here is a bubble. So here I can see in my remnant stomach, so this is my pouch closest to the aorta. This is where I've come down through the hiatus into a small pouch. There's a bubble there, but I also see a bubble in the remnant stomach just to the side. I also see that there's an undivided staple line. So my two rows of staples are not disrupted. And then this is also just looking at the adiposity of the patient's abdominal wall. I can see this is someone who didn't do awesome after their Roux-en-Y gastric bypass with their weight loss. So poor weight loss, surgery a while ago with an undivided staple line and a double bubble is a sign of a GG fistula. And this is someone where you can find the fistula, dilate it, maybe place an Axios through that tract if you need to, to keep it open. But in this case, we could just dilate our GG fistula, find our way through and perform the ERCP. This was a patient with cholangitis, again, able to spare them a more invasive procedure using their fistula. Supplies to have in the room. Everybody's talked about it. I think there, again, when you hear something that everyone agrees on, that's something to take seriously. So we all agree you should have supplies in the room. For EDGE in particular, you're gonna need a 19-gauge FNA needle. While I use the freehand technique, and I'll show that in a second, almost exclusively for EUS access procedures, this is a procedure where you're gonna need to juice up your target very often. If they don't have remnant gastric outlet obstruction, that remnant stomach's gonna be well decompressed and not a great target for EUS. So you'll need to juice up, infuse some fluid as a landing pad for your LAMs. You'll potentially use a contrast agent. Why not? So if, I'm trying to think of some cases. Early in your experience, you may find or describe, again, Dr. Diehl's group, I know this wasn't his case, but one of his partners published a nice report where they targeted what looked like the remnant stomach, and it was the colon. And so if you inject contrast at the time of doing that, all you've done, you've lost nothing. You inject through your 19-gauge needle, you really are trying to distend that remnant stomach. If you see, oh my goodness, that's taking the U-shape of the colon, stop, no problem. Come out, start looking again. So find your remnant stomach. I like to use anatomy. Again, I like to have a plan of what my scope's gonna look like on fluoro to meet that remnant stomach from the prior CT scan. I definitely use a guide wire, and I load that into my Axios so that I have access for my balloon dilation right after placing. So I don't do the stent placement over a guide wire, but I like to have one that I can advance to do secondary maneuvers like stenting and dilation. I really like an angled O2-5 wire. So the JAG Revolution or Busy Glide wires are great O2-5 wires. Because they're a little smaller and they're angled tip, you can steer and drive them. I think that's an important thing in therapeutic EUS, often overlooked. And then have a LAMS, ideally 15 or 20 millimeters. Remember here, the goal is not to drain anything. If this is for EDGE, you're trying to access with one of your biggest scopes in your cabinet, which is your duodenoscope. So it needs to be at least the 15 millimeter, maybe the 20 if you have access to the 20 millimeter LAMS. And then a 15 to 20 millimeter dilating balloon. You can over dilate. You can dilate the 15 millimeter LAMS to 18, or sometimes even 20 if you're having a little bit of trouble squeezing your scope through. That can be helpful. And then these are up for debate from the group, but OverStitch and potentially another stent fixation device, particularly for same session EDGE ERCP. And then also nice to have, and I think everybody who did an access talk has said, have a longer rescued covered metal stent, probably a biliary stent available, biliary or esophageal. So this is kind of a typical EDGE case. This is actually maybe not so typical in that this patient in particular had remnant gastric outlet obstructions. This was a case of mine two weeks ago. She'd had recurrent pyloric strictures in her remnant stomach and was just kind of felt miserable. So here's one, you probably could just go at this remnant stomach with a LAMS right away. This is someone who maybe doesn't need the injection, but I still just, I knew I had to give this talk and I wanted to have an example. You can inject contrast and really see how the stomach is filling out. This is clearly stomach and not colon. We're not seeing the hosta of the colon. And you just see this contrast swirling and go ahead and hook it up to your foot pedal. You can actually, you know, the little lure lock that locks onto your medivator to plug into your scope, take that off, put that on the lure lock of the 19 gauge FNA needle. You can stand on your foot pedal over your shoulder. They've changed out your water for a mixture of contrast. I like to use one or two bottles of the, I think it's a 50 CC bottle or 60 CC bottle of Omni-Pake. I'll pour one or two of those into a liter of fluid, maybe add a little bit of methylene blue, particularly when I'm teaching fellows. I like to have that reassurance of seeing the blue fluid come through like Mahir showed really nicely earlier. And then you'll fill up the stomach. We'll do a freehand technique puncture. You could see that we had a Jagwire or Busy Glide in this case preloaded in the Axios. You have to make sure you keep that back behind the tip because you want your tip to be sharp. Use a pure cutting current on your Irby, your electrosurgical generator, and you're just going to cut right through into the remnant stomach, place your stent like we practiced in the lab. And then here we can see this kind of blue tinged fluid coming back at us. This is a nice edge connection. The question then is, again, I will always dilate and have not had any issues with that, but we'll dilate this tract and then I want it to mature. When do you come back? I think it's up for debate, but again, I follow the paradigm of PEG tube placement. I'm not going to remove a PEG tube before four weeks. I'm happy to exchange a PEG tube if something terrible has happened with it over a wire in maybe one to two weeks. So that tract will be healed probably in about that timeframe. So I'm happy to come back and do the ERCP ideally if the patient can wait about a week later, two weeks later is better. Three weeks later, yet better. A month later, even better, but often patients can't wait that long. So we'll bring them back. But you're trying to avoid the separation of the tract that can occur when you push your scope through. I've become more and more intentional about picking a site where there's not going to be severe angulation of my duodenoscope as I enter the remnant stomach. So here again, you can see I've chosen a path where I can imagine my duodenoscope is going to come straight down and kind of make a nice S down into the distal stomach to make the turn for the duodenum. So this is just sort of a typical edge technique. Adjacent procedures like the EDI procedure. So this was a patient of mine who I saw for repeat ERCPs. I think Brett will allow me to say so. So the president of the ASGE couldn't get a long-limb ERCP done for this procedure. And so he and I talked and we met with her. She's from a rural town outside of Rochester. And she agreed that we would try a procedure to shorten the length of her root limb. So she'd had a coledocal cyst that was resected. She had root anatomy and very, very challenging single balloon anatomy to exchange stents. So she'd had percutaneous strains, bilateral percutaneous strains in place that were being exchanged. And she'd had this done for two years. I had met her when I was a fellow at Mayo. And then she came back and said, either I go to hospice or I get these drains out. So I'm either calling it quits or we do something to get these strains out. So we used the EDI procedure. This is EUS-directed transenteric ERCP. So you can see here we're using our percutaneous strains to inject fluid into the small intestine, again, to create a landing pad for our lambs. And then we're going to create a connection, an endoscopic gastrojejunostomy, a connection here between her stomach and her biliary limb here, which leads us up to be able to stent very simply. We were able to get internal stents. And she's in just an internal stenting exchange program now. Also consider other non-ERCP remnant or small bowel access procedures for bleeding, for tumors, for wall and off necrosis or pseudocyst drainage. There are other reasons why that EDGE technique is going to come into play in your practice. These are some of the controversies that I think we'll all agree exist around the EDGE procedure. So if you're a fellow in the audience, consider studying these issues so we can bring some to light. But where do you puncture? Do you go for the blind limb of the jejunum to the remnant stomach? Do you go from the pouch to the remnant stomach? I like gastric tissue. It's very forgiving. I think things close nicely when you're puncturing the stomach. So my opinion is take what looks best and safest for the patient, but I'll often have a preference. Some of my best friends and colleagues at my own institution disagree and will go for the blind jejunum as a site of access. So this is again, very much debated. Same day ERCP, again, I think for the best, for the best of the patient, you definitely have an increased risk of stent disruption, tract disruption, therefore perforation and a surgical emergency in a patient who gets a same day ERCP. So should you use suture or stent fixation device? My opinion is that I'll always do it for same day use and I'll over dilate the stent to really allow me to pass a scope through safely or I'll wait three to five days until the tract is matured a bit. And then finally closure. So when you go back to remove, you're done with all your ERCPs. Let's say it's someone who needed large stone EHL. Maybe they had five or six really big stones. They've had their three or four EHL sessions. All the stones are cleared and they're regaining weight. So they want you to close their fistula. I always close it. I don't just pull the stent and walk away. My own opinion is that I always offer closure when I pull a stent for edge. I think it's something that, everything you learned in kindergarten is all you needed to know. It's one of those things, like if you open the door, close it, that's my opinion. So here I'm showing you a gastrogastric fistula. Contrast filling the remnant stomach. So this is a patient where we removed the stent and they had non-healing. So we came back, did that procedure to show non-healing. I use really high wattage APC. This is at 60, 65 watts, just straight fire continuous to resurface the mucosal layer. I wanna get nice bridging fibrosis of this tract as it heals. This is the same general procedure that I do for peg tube closure. And here we're using a tack and suture device to just bring those edges together so that as they heal, they'll heal tightly. I do a kind of poor man's leak test during the procedure after the four tacks are placed and the cinch is placed. This is something you could do with a vesco. This is something you can do with overstitch. But here we're just gonna close that fistula up. I spray, I suction all the air out of the pouch. I fill the pouch then with contrast under pressure. And I wanna show that I'm no longer filling. You can see the air bubble of the remnant stomach, but I'm no longer getting contrast crossing over to that remnant stomach. Here you can actually see the tacks here in the middle of the screen. This is a two month follow-up, a esophagram and small bowel follow-through showing that that fistula is still closed at two months. And so I think that's probably the right thing to do having had some patients who've regained a lot of weight after an EDGE procedure. So in summary, I'd say EDGE is great when it's needed. Remember to consider patient by patient factors that are gonna dictate whether a patient goes to EDGE or IR or to the OR with you. Discuss that risk of weight regain and fistula with patients. Definitely have your protocol and equipment in your room and prepped. Consider EDGE particularly for non-ERCP and adjacent procedures with RUE and other surgically altered anatomy. I think it's really slick for accessing the remnant for other issues like necrosis. And then controversies do exist around the technique, the safety of same session ERCP and the need for closure of the fistula. Hopefully some of you can answer those questions over time. And then this is my favorite bridge in America. We were just talking, someone here is going to fellowship at West Virginia. This is over the New River Bridge. Actually in just a couple of weeks, they have Bridge Day where the people go and jump off this bridge. I've gone to this. They jump off the bridge and parachute. It's the longest steel span bridge in America in near Charleston, West Virginia. And MLK said it best, let's build bridges, not walls. Thank you so much for coming to the course. And I'll take any questions. Thank you so much, Andy. That was wonderful. People have questions in the audience. Technical question, do you usually find the gut, I mean, do you rotate? Because is it going to be posterior, the excluded stomach or not always? Yeah, I think most surgical technique will dictate that the remnant stomach is posterior and you're often going to see your probe looking over to the left. So it can be a little bit of an awkward position. Again, as you, and this is where I think the freehand technique for many reasons has some advantage. You can fill up that remnant stomach from anywhere. So I'll fill the remnant stomach and that might change what the best access point is going to be. That's why I don't love, you know, accessing with a needle, injecting with contrast, and then placing a wire through that same needle. The best point of access may now be a little different. And I think by filling the remnant stomach, you allow it to move, which it's going to do anyway. And you allow it to find a place where you're going to have maximal compression against your pouch and really find that best safest window. Another reason why I think that freehand technique, which you'll get comfortable with first in Pseudocyst and Necrosis works really well for this procedure. How about overtube use when you do the ERCP? Sometimes the angle is very acute. So overtube. That's interesting. So people have described using like the, you know, the overtubes that will actually lock. You can adjust and then lock the overtube into a certain position. People have described doing that to help try and prevent migration or movement. No, I don't. I've never used an overtube for one of these procedures, but maybe the group has a different, yeah, no. Good question. Question about closing the fistula with X-Stack versus other full thickness suturing devices, please. So you're always weighing benefit, risk, cost. So the question was, you know, what's the best way to close these fistulas? We don't know. So it's under study. You know, it's something hopefully we'll be able to answer, but I don't have anything for you right now. I do think it's important to try and close it to show that you've tried to close it, but that's again, very opinion-based. But have you ever had X-Stack coming loose? I mean, we know it's not a full thickness. Well, yeah. So if you've ever done big wide field APC, like for gave or something like that, and you've had to re-scope the patient, there is a heck of an ulcer 24 hours after that procedure. So you've stripped the mucosa, and you're gonna start forming that bridging fibrosis within a week. So you just need a device that's gonna stay there for a week. I worry that TTS clips are not gonna do it, although TTS clips are getting bigger, better, and stronger. So that may come back into play. Historically would never use that for a fistula closure. But I want something that I know is gonna stay for probably about two weeks. I want something ideally, the theoretical benefit to X-Stack in this situation may be that you don't have suture running through the area that you've just ablated. So you're not gonna have that tissue ischemia or foreign body reaction. You're using something that's beyond the defect to bring it together so that those resurfaced areas are kissing and can form the fibrosis. I theorize why that has worked well for me in our practice, but it's a theory. An online question here. During EUS part of the edge, is the patient supine or prone? This is showing one of those weird things about Mayo. So when you glove, I still try and fight it. You have to put your left glove on first. The OR nurse won't hand you a glove unless you put out your left hand first. We do all of our ERCP supine. So not a single ERCP starts prone. So that's just a thing. So I don't think it matters is my personal opinion, but your anesthesia team loves you. They're very happy to do supine ERCP. Technically sometimes can be a little more challenging than prone, right? Although, you know what? I'll say, if you do it, give yourself like a month to do it. It's amazing how it grows on you. Because again, I learned at Brigham with ERCP, mostly prone position. When I moved to Mayo, everyone did supine and many other endoscopists who started in other institutions, Penn, Michigan, learning prone and then moved to supine. And they'll say that after a month or two, it just became like second nature. Yeah, there's studies that have shown similar, you know, success rate with supine versus prone. So it's all a matter of what you're used to. You hear that like cracking of their neck when they go into swimmer's position, and you're very happy to avoid that. Yeah, our patients do. It's like driving stick shift versus automatic. Yeah. He's got used to it. Andy, you showed us a great video of a follow-up where there was a fistula and you closed it. Is there any role for just doing it routinely, using APC and X-TAC routinely after you remove that stent? Because it doesn't take that long. That's what I do now. Yeah, so this was one that had failed, you know, spontaneous closure or de novo closure. But now I just, I do it as soon as we pull the edge, all of us at our group do, yeah. No, I was just gonna make a comment that I want to actually agree with what you said that the site for placing that stent is very important for many reasons, right? Not just to get it safely across to the remnant stomach, but also to facilitate the next ERCP that you're gonna go through. So sometimes the only place you can find the excluded stomach on EUS may be in the downstream jejunum. It's further distal from the GJ anastomosis, and you may stick it and distend it, and then you realize that, oh, you're too close to the antrum or you're pointing in a funny direction that the next ERCP will be tricky. So in that case, I'll do exactly what you were saying, as in you distend it, then come back, and now maybe you'll find it in a more appropriate position because it's a bigger target, and now you can get it from the blind limb, the pouch, or wherever you do it. So just think about that before you actually place the stent. You also haven't burned a bridge. You know, if you fill the stomach, the remnant stomach, and there's just no good window, go to IR, right? You know, it's not too late to change the path. Randy, any tips on recognizing the remnant stomach if it is decompressed? I know the sand dollar sign is there, but again, like David's group presented that, that there was a similar sand dollar sign, but- Yeah, colon, hostra look very much like this so-called sand dollar sign. So it's really, you know, if you keep a straight scope, you have your probe just beyond where you know the GE junction to be on fluoroscopy, you're rarely gonna find colon in that position, and you are often gonna find at least staples. That's your first indication, that staple line that's gonna lead you toward the remnant stomach. You're often, again, gonna be looking posteriorly. So just know your stations and where kind of, the more therapeutic EUS you do, the more you start thinking about, you know, that anatomy. And you'll be looking probably left and probably posteriorly. That contrast injection is gonna be your final test, right? Because all of us probably have found the remnant stomach and then discovered it was, you know, something different. Yeah, I completely agree. I mean, with you guys in terms of using the freehand technique, just inject first and then find your good spot. And I'm curious, because you were talking about this, I just want to hear from the faculty, their thoughts on same day ERCP versus waiting for the tract to mature and bringing the patients back, in a non-emergent case, of course. I'm not talking about cholangitis, someone's dying of it. I'm talking about a non-emergent situation. Yeah, we'll typically wait, you know, three to five days. Often these are patients who can't go home necessarily, but we'll give them the weekend or something and then repeat it. Well, you were saying, Amy's hand was itching, that I need to do it right away and just get it over with. I actually do it same day almost always. So I will fixate pretty much every stent that I put in. So you'll suture it? I'll suture it right away, immediately after. I'll dilate just to 20. Routinely, I will only put 20 millimeter LAMs for edges. I won't put a 15 and I'll dilate it up to 20 and then I'll do it same day session. The one time that I delayed was when I had a jejunal gastric and it was actually the angulation that the ERCP scope had to take to get through the LAMs was putting too much pressure on the jejunal limb and I was worried about an opposite wall perforation from the knuckle of the scope there. And in that case, I decided I would wait and bring the patient back. And I waited actually a good 14 days so that if I thought I would probably have to remove the lumen opposing metal stent to facilitate getting across the fistula tract. But otherwise, we do it same day routinely. And then when you suture, how many sutures do you put in? Two, usually two. To just right across diametrically? And you want to make sure that your sutures are pretty close to the stent because you don't want to have too far of a distance between where you bite and the stent because then when you singe, you can actually dislodge the stent. So you have to be sort of targeted where you put your sutures. I mean, if needed, for sure, but I think not many things make me nervous, but this makes me nervous, doing it on the same day and dislodging it. I'm like, I don't want to even dilate it. I just want to see the little bit of methylene blue coming and I'm like, happy, let it go, bring them back in three days and then do it. We haven't had a single. Yeah, I know, I know, this is how we learn, right? So now it's an economic decision. So if they can wait, I'll do it. But safety and economics, I'll have them wait. Most of them can, yeah. But otherwise the two suture technique works nicely and we'll show that in a video in a little bit. I think people in New Jersey are just more impatient. Yeah, I'll just add to the diversity of opinions here, but it's interesting. When we first started doing EDGE, I think we were just so relieved to get out of the world a double balloon that we started getting very enthusiastic and doing the same day approach. And after a couple of mishaps, we realized we really need to be a little more thoughtful about who needs it the same day. And so now I think much like Andy's suggesting, most patients can really wait and come back and do it in a safe way, unless you're gonna take the time to suture it. And now you've really added a lot to it in our opinion. So we tend to delay if we can. If somebody's so sick that they really need it that day, maybe you needed a percutaneous destabilization and whatnot, but be thoughtful and stay out of trouble, I think is rule number one. Although there's nothing wrong with suturing at first, that certainly works. I think the first few cases you do actually a very relief, at least you got it in the right place. You just want to pull the scope out and quickly go home. That's what I felt initially. No, I would say that very few patients needed the same day, right? So we've sutured our stent and one of my partners did this case. The stent was sutured and it still migrated during the same session and there was a big mess. And that case was actually presented at the ASG video forum by one of our fellows. It was called an edge from hell and it won the first prize for that presentation. So I would say that, you know, so we've really thought about when we need to do it same session, even with suturing. So I would say if it can wait even a couple of days, I think it adds to a layer of safety. And I think it all depends on the intensity of the suturing that you've done. And have you gotten good, like deep into the wall? I mean, if you're just scraping, yeah, exactly. Yeah. So, I mean, I certainly know there are studies that show the safety of doing same day ERCP with the fixation. And certainly I know different, you know, like you guys in New Jersey do same day. I know other folks do same day. We don't do same day at the Brigham. Even though Chris Thompson's there, like world's expert on suturing. I mean, he still doesn't do same day. And yeah, so I personally don't do that. I just put it in, don't mess around with it and then let it mature and bring the patients back. Because also the thing is that they need that second procedure anyway. I mean, even if you've done a same day ERCP, you're not gonna be, you know, pulling that lambs out that same day. I mean, you're gonna have to bring them back later on to remove it and maybe close the fistula or not, depending on what your practice is. So, but again, as you can see, practices differ, you know, and we're still not sure exactly what the right thing is to do, but. You know, we found one workaround that we do. We often do same day, but we have this old, it's a JF 140 duodenoscope. We do the same thing. You can use a 20 millimeter axios and that small scope. If you don't have that scope, you absolutely have to fixate it. Yeah, Olympus doesn't make those scopes anymore. No, they don't. Yeah. I was actually just gonna say that and they just told us two weeks ago, they're not gonna service those anymore. Yeah, no, they're done. So if you have them and they break, you're gone, so. No, it's a great scope, you know. Yeah, I think companies will still service, we've learned, which is nice, but. It's smaller, it's a pediatric diameter. Yeah, it's a feather duodenoscope. So, I mean, a fantastic scope. I absolutely loved it, but they don't make it and apparently don't service anymore. One common I'll make, I think the Brigham's a little different because we call it the GATE procedure instead of EDGE, gastric access temporary for endoscopy. So that kind of, instead of all this alphabet soup, just kind of covers all of endoscopy, so. Now, I think there's a few, I'm sorry, a few more online questions, if you don't mind. What's the mixture of agent you use? Contrast, saline, methylene blue, and where you puncture? Oh, I think they're just asking, I'm assuming with the FNA puncture, where do you puncture? Which I think is just wherever. Antrum of body of the, like, like the initial puncture is it in the antrum of the body. So it's, there's a Goldilocks situation where you, you know, you want, you want just enough to get a nice gastrogram, but you don't want it to be so dark that you won't be able to see your stent deploy. So I'll usually go with one liter of pick your poison, you know, saline, lactated ringers, whatever you've got in the room, water, whatever. And then two bottles, you, they're actually, you know, national shortage. If you have some, hang on to it, but two bottles of the, it's either 50 or 60 CC. It fills up, you know, not quite, I think it's 60 CCs of the Omni-Pake 300. Two of those poured into your one liter of, choose your, your saline. And then plus or minus on the blue. If I'm driving, I don't usually use blue because my argument is you've already made the hole. So let me hear, I know you, you, you use blue. So maybe you feel differently. You've already made the hole. So it's, you know, you've, you've either done a good job or not. The blue doesn't help you make that decision. But when I'm, when I'm with a fellow, I like them to have that confirmation. And so we'll sometimes put blue in. And again, that's a choose your own adventure. It depends how much, how, how blue you want that to be. But usually a nice dark blue stain is fine. And the amount of fluid is just dependent on what you're seeing. You just want to distend it enough, right? Yeah, you want distension. You ideally get that, that remnant stomach to oppose so that it's almost like a pseudocyst or, or necroma. Get that to oppose the remnant or, or blind limb of jejunum wherever you're puncturing. So you have a nice, nice, nice window. Yeah, a couple of two or three centimeters at least of fluid is nice. Have you ever had a situation where the sutures, suture line, staple line is coming in the way of your puncture? Yeah, I've had patients where it can, it's never in, it's never hindered the puncture, but I have, I did have a case where the staple line came into play. And that was that the staple line is often a little ischemic. There's not great dual blood supply to that area. And so I've seen what was my two centimeter axios fistula. When we came back, it had extended to like a eight centimeter fistula along that staple line. So if you can, you're going to have trouble avoiding the staple line sometimes. But I would say that, again, even if I know I'm going to close, I still tell the patient, look, you underwent a $125,000 gastric bypass surgery that your insurance company decided to pay for. And in five minutes, I'm going to reverse it. There's a chance it stays reversed. There's a chance it comes undone. So even though I'm closing fistulas, we all need to respect the fact that we are reversing a big surgery. You know, this was not a small thing. And doing a revision surgery is definitely possible. You know, doing a fistulotomy, surgically possible, but it comes at a cost and a fairly high morbidity rate. Yeah. There's one more online question. Somebody's asking about, can you perform EOS guided biliary drainage through the gastric pouch in a bypass patient? And this is in the setting of, if you need to establish urgent biliary drainage, but don't want to, I guess, you know, use a LAMS to go into the pouch, yeah. Yeah, no, I've done that. So you can do an EOS rendezvous. So much like with the IR approach, it's probably going to have a lower success rate. It's definitely going to require a time commitment on your end, but you can often from the pouch, or again, from the blind limb, if they have a dilated left intra-hepatic, you can absolutely do a hepatogastrostomy or place a wire. And if you can navigate, the problem is we don't have cystotomes. That's one problem I see as a big problem in therapeutic EOS in the US. We don't have cystotomes, which hopefully will be coming soon. And we don't have guide wires, steerable guide wires and steerable catheters. And so if I had a catheter, I could place over my wire puncture into the left liver to then direct my wire and help support my wire down to the JJ, I'd feel very confident. But we've had cases where we successfully, for malignancy, and we had some free time, we were able to achieve an EOS rendezvous, getting that wire from the left liver down through the common duct into the duodenum, down into the jejunum, found it with a colonoscope, and we're able to place a metal stent. So it's feasible. I don't know why you'd put yourself through that though. All right. So maybe we'll take just a quick five minute or less break, and then we'll finish up with some cool videos. So you guys can obviously ask us all sorts of questions during the videos. Thank you. Thank you, Wendy.

Building a Bridge

Dr. Andy Orlov

advanced endoscopist

edge procedure

endoscopic gastro-gastric anastomosis

gastric bypass surgery

remnant stomach

endoscopic interventions