Hey guys, I'm Andy Storm from the Mayo Clinic, and I'm here with my fellow for the day. Hi, I'm Shifaa, I'm the Ransom Doscopy Fellow at the University of Chicago. Thank you for joining us everyone. We're really excited you're here virtually. Wish you were here with us in person, but we're going to do our best to offer a training opportunity over this virtual experience. And specifically today, we're going to focus on fluid collection drainage. We're going to focus on basic FNA and FNB technique. Just to my left, you can't see it here on camera, but to my left is a screen that's going to pop up with any questions that you have to ask as much as possible, even though we can't be face to face and talking directly, hearing from you directly. If you ask a question, it's going to pop up on this screen and we're going to be intermittently stopping what we're doing to answer your questions. So I think this will be ideal if you ask questions as we go along, we'll try and again stop and address your questions so that this is as much a learning opportunity for you as possible. We have, again, a couple of plans for today. We're going to take a look. We're using the Fuji EUS equipment today. So both their processor and scopes, really nice system, high quality. This is brand new here at the ASGE IT&T Center. So we're excited to use those Fuji scopes today. And then we have a collection of different FNA and FNB needles that we'll be taking a look at today as well. I was thinking we would probably start with just a standard FNA, if that sounds fair. Yeah, sounds good. We're using a porcine model, explanted porcine tissue today. So you'll have to forgive us. The anatomy is not going to be exactly the same on the screen, but you'll notice some similar landmarks. We'll be looking at similar tissue depth. And again, the function of the devices are fairly similar in this explanted tissue as well. So the first tool we'll use is just a standard FNA needle. In my own practice, I'm using mostly 22-gauge FNA needles when I'm doing FNA and FNB. How about you guys at Chicago? Yeah, similarly. Yeah. Depending on if you're doing a cyst aspiration that's large cysts, we may go for 19-gauge. But yeah, usually 22. Good point. So earlier today, we heard during the lectures that 19-gauge needle can sometimes be helpful for that really thick mucinous fluid. I'll also use 19-gauge absolutely for bile duct access. So if you guys have questions that weren't answered during the earlier sessions, feel free to throw them up about bile duct access as well. We have a model that it'll look like fluid collection drainage. It looks like they also gave us a gallbladder today. So we may be able to show kind of a gallbladder drainage case later in the session as well. So this is just a standard 19-gauge FNA needle from Microtech. Again, it's a larger gauge needle than I would use for a standard FNA. I think data is relatively clear that 22, just as good as 19 when it comes to tissue acquisition and getting a diagnostic sample, 25 may actually even be superior. I don't use 25 in my practice, but the 22-gauge needle is great. Things that I really like about the Microtech needle, it's packaged fairly simply. So it just kind of pops out. So there's not a lot of steps to remove the tool like there are with some of the other devices. My favorite function about this is there's a very ergonomic kind of sliding handle on the needle itself. So if you can see here, rather than having the turn screw mechanism, which we'll show in another needle in just a little bit, speaking nothing about the needle itself, just the function of the handle that we have to interact with outside of the scope, I really like this about the Microtech needle. So it's just a push sliding function. You'll have to do a little bit of experimenting because, again, I really like this Fuji system, but I don't use it in my own practice. So at least with my Olympus scopes, I know that 1.7, about 1.7 millimeters is where I'll set the sheath, this lower part of the needle. And again, this is just a push button function that you can slide. You have to adjust this or you're going to potentially push your needle out into tissue as you're advancing it into the scope. Or if it's too far back, you risk pushing your needle out into your biopsy channel and actually perforating your scope liner itself, which is a real headache. It's a very expensive fix. So you're going to be sending your scopes out for repairs. If you find that your scope room or whoever's processing your scopes is having to send out a lot of your instruments because of leaks, especially in the distal channel, always make sure you ask to get feedback on why these leaks are happening and where they happen. If it's always in the distal channels, it's probably because of your FNA and FNB procedures. And so you may need to make some adjustments. What we'll do here is before we even go down with the scope into the model, into the PIG model, we're just going to put... I can help you as much as possible, sorry. We're just going to place the needle in the scope just to get a sense of where we want to set it. And this is what you're going to have to do. So if you use Pentax, Fuji, or Olympus EUS, you're going to have to check this. And it's going to be a little different between each scope, but I'm just going to guess that 1.7 is maybe the right measurement here. And we're going to go ahead and connect. It's just a simple lure lock mechanism to your scopes. You take off your biopsy channel cap, and then the needle fits on right there. And then we're going to look here at our distal channel. If you zoom in really close, I'll try and hold it still, but we're looking here just to see that there's a little bit of liner. You see that gray little cylindrical device right here sticking out of your biopsy channel or your therapeutic channel? That's the end of the needle. And if you give this an elevator, you can see it's going to bend perfectly. So it actually hides the end of the needle there. And then we relax. And then we'll practice here also just putting out the needle. So elevator. I'm always really careful, especially with the FNB needles, the shark core needle, any of them with a specially designed tip, the elevator of your EUS scope can actually damage the tip of the needle. And if you damage the tip, it's not going to take those nice cores that you were hoping for. So we'll go ahead and just practice here for the sake of showing you guys how the needle is going to come out. Again, you'll see when it stabs here, I already, sorry, I slid the thing down, as you can see, here comes our needle and there's that elevator function. So I'll turn it sideways and you can see when we elevate or don't elevate, this is, you know, I think it's helpful to see this outside of a patient just to see where your needle is going to be and in relation to your scope. And it looks like 1.7 millimeters for the Fuji system is probably an appropriate setting for the, this is for the Microtech FNA needle, specifically the 19 gauge. So we'll go ahead and pull the needle back. I just want to show you one other thing actually, before we come out entirely, you can maybe see that the tip of the needle here is very blunt. And it's blunt because of this stylet. So all FNA and FNB needles are going to come with a stylet. The stylet is meant to keep the needle clear. It's meant to help push out samples. Can you move the stylet back and forth? So this also has a simple lure lock mechanism up at the top and we're just going to pull, so there's the needle back and forth. We're going to pull the needle out, push, we'll push the needle, push the needle out and then can you pull back the stylet? And let's just show, you're going to see that the needle becomes sharp here. So there you saw maybe it was very subtle, but the tip of the needle became sharp. So remember that that stylet is there to help you. It can definitely hurt you if you forget to pull back that stylet. You haven't sharpened your needle, you're going to have trouble puncturing things. I do find the Microtech needle is very sharp. I think most of our FNA and FNB needles are great in terms of getting through tissue, but specifically you have to pull back that stylet if you're going to leave it in at all. That's another debate to be had. Do you guys pull your stylet out before biopsies or do you leave them in? So we pull it out a little bit and then we biopsy and then we do a slow pull. Great. So I think that's a debate and one of the things about EUS that you have to love and hate is that there's 25 ways to do everything. I'll try and mention those different ways of doing things along the way. One of them is that, and this is what I do for simple FNA, I'll pull that stylet out completely. I don't use the stylet at all and I'll put my FNA needle down without the stylet and go ahead at whatever lesion I'm going to sample. It's not wrong to leave the stylet in. You do need to pull it back like Dr. Uma was saying. You'll pull that back just a little bit to sharpen your needle. So just that much is enough. Sharpens your needle, you'll puncture in. You may even, if you're in a cyst, push the stylet forward to expunge any tissue that you've pulled into that needle and then probably pull out your stylet and start sampling that cyst fluid, for example. Just seeing no questions, is that right guys? No questions so far from the audience? Great. So we'll go ahead and introduce the scope. Now that we know we've got a good setting on our needle, I'm going to reset this slider here and we'll go down. We'll show you our tissue model here. So we'll go to the EUS screen. And so our depth of insertion of the scope is going to be a little bit less because we have a shorter esophagus. I run our animal lab at Mayo Clinic in Rochester, Minnesota and when they harvest the animal tissue we lose quite a lot of the thoracic esophagus so the, the model is going to be a little bit shorter so we won't talk so much about insertion depths. But, but it's going to be a bit shorter so when we call out numbers maybe don't take those to heart when it comes to human stuff. A lot of us do not use balloons for therapeutic cases, it's a great question, something we can talk a little bit about are you using the latex balloon on the end of your. Yes, yes, and you can probably see it under my probe as well. So here we do have the balloon on the scope for this case. It's a fair question. It's not wrong to not use a balloon as long as you're getting good picture the balloon is there to create a fluid filled structure between your scope and whatever you're targeting. If you're in a air filled space, which is the GI tract, I actually do find I use the balloon in all cases even patients with latex allergies. It's a little bit controversial I have anesthesia coverage for my cases so if someone has an anaphylactic reaction, you know, we'd be able to treat that but I do use the balloon. Some of my colleagues, great endosynographers therapeutic endosynographers don't use the balloon so it's it's a fair question. I think if your patients intubated and you have the luxury of being able to put in a lot of fluid through your scope to really fill out and see see your picture well. If you're patients are going to penetrate well because you have fluid around you then you're right, the balloon is not necessary. Good question. So here we're down in the stomach. And we're just going to take a look around we're looking for some solid tissue so anteriorly, we have a bit of liver, we just passed kind of our pseudo gallbladder. We're looking here so we'll, we'll, we'll use our imagination that this is kind of a salt and pepper appearance, maybe of the pancreas. Looking at this picture I see maybe some hyperechoic strands and foci that would be indicative of chronic pancreatitis. So let's just imagine that about at the right in the center of the screen that we think we think there may be a small pancreatic cancer in the midst of this chronic pancreatitis these chronic pancreatitis changes. And we're going to show you just our technique for fine needle biopsy again, keeping in mind this is the 19 gauge needle so it's going to be a little bit, little bit more work to puncture. So first thing we'll do is find our target tissue. And we're just scanning around here again, kind of has the appearance of chronic pancreatitis, our pseudo pancreas here in the animal model. And that's a, maybe this is a great spot right here we'll pretend that this, you can kind of see there's maybe on the screen that there's sort of a hypoechoic circular structure here, we're going to pretend that that's about a maybe three centimeter mass we can try and measure that out. So if we freeze screen. And then we're going to take some measurements here. So again, use your imagination with me but it looks like yep right about three centimeters that's at 28 millimeters. My mentors who were instrumental in, in the early years of us, you know when it when it started in 1984, being used really for diagnostic purposes will point out that you really want to try to measure off of a linear plane from your ultrasound probe so you really do you want to imagine a burst of light or a straight line coming out of the center of your ultrasound probe there on this particular model of ultrasound it's up at the 12 o'clock position. So I have my first line just as a straight line out from the probe and then I'm drawing my other line perpendicular to that to get a measurement so we're going to say this is a 28 by 32 millimeter lesion. So maybe a typical size head of pancreas mass. When visualizing the mass do you ever use the frequency and depth function on the US. Say that again. When visualizing the mass. How do you use the frequency and depth function to help you. Yeah, so I think it's great. My least favorite thing about us is when I see someone doing an ultrasound associated rather than ultrasound guided procedure, and really by by by tuning your ultrasound as you go which absolutely includes changing your depth, you're going to have a higher amount of time that you're actually doing a procedure ultrasound guided in particular for therapeutic indications like bile duct access gallbladder drainage gastrogynectomy, a lot of these procedures edge that we'll talk about tomorrow, I'll zoom in quite a bit so that I can fine tune see what I'm dealing with it also makes that that little bile duct that you're targeting or little pancreatic duct that you're targeting for rendezvous it makes it look a lot bigger it looks makes it look a lot easier which can be helpful. So, in this particular model it's a little different you know they don't have an external processor with the Fuji system here. So I'm just getting used to it myself but you can see just by zooming in you can make structures look quite a bit bigger, bring them closer to you and you really do want to use most of your field of view when you're doing procedures. We have a question from the audience. Do you use sauna view to assess pancreatic masses for targeting sampling any benefits. So we don't, I don't either so we, you know, a lot of lesions are not particularly subtle, and I find that we actually have in room cytology so getting positive samples, not particularly difficult. We don't use any kind of injectable or contrast agent to help with our procedures, it's a good question it's definitely available people, some people swear by it. I think it's unnecessary. Interestingly may be helpful for bile duct access not some of you particularly but there may be contrast agents in the future that are going to help us find bile duct for example. So here we are we're looking at the screen we're at a pretty good depth to sample our lesion here. So go ahead and we'll get the needle ready here to advance into the tissue and take a sample. So, not wrong at all what's happening here. She went ahead and sharpen the needle, I will often advance it out into the so I can see it on the screen but it's not wrong to do what you just did absolutely, absolutely fine. As you can see we had the push button. We've moved the slider down this is the protective stop gap and then we're going to look here on ultrasound, you can see on the top right side of the plane in Europe's European models sometimes you'll see the needle come from the left, but in most American scopes you're going to see the biopsy or therapeutic channel coming from the right side of the screen, and we're advancing forward here and you can see there, we're going to suction and we really want to get good opposition with our tissue. Anytime I see those waves coming off of the ultrasound I know there's there's probably air between us and the ultrasound probe tip. So here we're going to go ahead and advance the needle and I'm just looking there's our needle. I do like I think the microtech needle and all the companies are really working towards getting these needles. The tip of the needle as clear as possible for us on ultrasound so they they score the needle, the steel or night and all depending on the make of the needle is actually scored, so that it bounces sound waves back nicely and shows us the tip of the needle. tip of the needle coming out. And let's go ahead how do you how do you puncture, how do you think about puncturing. I mean do you set a limit on how far you can puncture or what are you doing. Yeah. You know, I'm just at the beginning of my fellowship and I do like you know measure the distance. And we mostly use the Boston scientific meals and similarly I would lock it to the depth like if the distances, as you know, a one centimeters or two centimeters I would lock the needle there so I can make. You know, when I'm sampling I can make like quick movement, like, particularly try to go like fast and into the tissue. And then the other thing I always do is try to Doppler before I go in. Yep, agree. I don't see any large vessels here right now but do you. So this is Dr. Storm actually a question for you that in what's your practice do you always keep the Doppler on when you're doing sampling or you just like initially target the tissue and then you switch it off. Yeah, I've seen it's a good question. You know when you turn on Doppler, you will actually reduce your frame rate so I think, particularly for therapeutic us since that's what this course is about. You're going to not use your Doppler often when you're advancing a needle into a bile duct into a collection into the small intestine wherever you're aiming into a remnant stomach if you're doing an edge type procedure. You'll turn that out that Doppler off because your frame rate the refresh rate and your image quality is actually going to be reduced by having the Doppler on. I always use Doppler like you said before I puncture anything I'm looking for vital structures big blood vessels. My goal always to send my patient home same day if possible, I went into GI like a lot of us, because we love surgery we like therapy but we didn't want people to have to stay in the hospital. We're trying to keep this as safe as possible so Doppler, great thing we can try and throw some Doppler on here. I think you had seen how to do that. We're obviously not going to see Doppler on our pig tissue here and I don't. There are some models where you can actually set up a pump to help with showing blood flow but this model is not going to show Doppler but we'll throw Doppler on. You can actually hear we even get a little bit of pseudo flow just from movement from subtle movements of the scope. So you'll put Doppler on and just make sure that there's no intervening vital structures definitely blood vessels. Another question, would you and could you sample a vein or an artery or the wall of a vein or artery if you were worried about malignancy maybe tracking up the celiac artery absolutely yes that's been reported on. And this kind of perivascular cuffing and and migration of metastasis up blood vessels is a well described phenomenon. No problem to sample those things, if and when that comes up. That's something to keep in the back of your head as well sometimes you'll intentionally sample the bile duct sometimes you'll intentionally sample a blood vessel. Usually we're aiming to avoid that. Great. So our needle sharp, and we're looking at our lesion of interest. We can see that our needle tip is just up there, and you can hear we're actuating the elevator function on the US scope. I agree, you know what you described in terms of, it's almost like throwing a dart, I like a good fast quick kind of flick of the wrist to move that needle down into a lesion, especially with a 2225 gauge needle, I'm not so worried about causing trauma on the far side and I want a good fairly long throw. So we're aiming to get to the other side of the lesion in this first puncture. If not, at least solidly into this lesion of interest so we'll go ahead and once we see our lesion. So try to target towards the center is that's great. Okay. So you can see the two finger grip that she has her thumb and forefinger up on the kind of grippy part of the needle. And there you can see it advanced into the tissue. And I'll try to avoid big swings of my body. So we want to keep the needles out in tissue, we want to cause the least amount of trauma as possible, but sometimes you will have to subtly adjust the angle of your scope and you'll just be looking for what what really keeps that needle tip, which is usually the brightest part of the needle again because of those scorings. What keeps that needle tip in view and here we can see it really nicely that linear echogenic line up at the top right of the screen leading down to the very hyperechoic tip of the needle. And then I'll start moving back and forth and this is where this is one of those things like the stylet where we're all a little different we all have different approaches, and every study that you read about this shows that someone's idea is better than someone else's. So, do you do the slow pull technique. Do you add suction, it's, it's going to be really up to you. And what do you guys do, we do the slow pull slow pull. So in with the slow pull method, while the needle is moving back and forth, you're going to have a tech or assistant who's really good at what they do, and they're giving you just a nice pool of the stylet as we go. And you'll see that this stylet comes out as we're taking the biopsy the process there is that you have a little bit of negative suction, essentially caused by the withdrawal of the stylet, and then this is leading to theoretically acquiring that tissue or cytology sample into the needle as we go. Just a few questions about you know how could I make my tissue acquisition better like any techniques that you particularly use for this. So I do like a bit of negative, negative pressure so you know this will this will come with the shark core with. I think all of the needles now come with something like this so there's a stopcock. The stopcock will actually close the device, and then pull back on the syringe, and then there's a locking mechanism where you'll turn the syringe, and this actually locks on a little shelf here at the bottom. And then so this has negative pressure right now, if you, you won't be able to hear this but if you know when I, when I turn the stopcock in line with the valve tubing. So it's, it had negative pressure within the syringe. So here we're going to reset that. So if you find that your yield is low if you have either you're putting your cytology directly onto slides if you have in room cytotech taking a look at things, or if you're just sending it off to histology and sending your, your, your FNAs as as histology exam. If you find that your yield is low this will help and I know, again, during the talks earlier today about novel ideas and and kind of the modern thinking around tissue acquisition, negative pressure will increase your blood in your sample, but I think it will increase probably your sample as well so this is what we use. Okay. Yeah. And do you focus your needle in one area of the mass or do you like to, you know, take it around. It's great. That's a great point. So, like we like was discussed a little bit today during the didactic session, moving your needle around the so called fanning technique so actually moving yourself through a lesion, particularly focusing on the edges of the lesion. And then you can see here on on the ultrasound view. A nice example of that so you're just, I'll actually even use the big wheel on the on the scope, so you can you can start at the high end, and then push the big wheel away and that'll actually fan you down some as well. Alternatively, just the elevator itself, so I'll start maximally elevated. I'm down low in the lesion and then as I release my elevator release my thumb, I can actually come up higher in the lesion. And then you're just aiming to try and sample as many different areas of the lesion as possible without causing trauma to our surrounding areas so this is, this is a good example here of kind of the fanning technique. So you can see the big wheel, big wheel moving some here she's pulling the big wheel back towards her which is going to pull everything down at six o'clock up towards nine o'clock, so it's going to snug her scope up against whatever we're looking at here and pull everything up so that she gets a nice fan of that of that area. So just to show as an example, you know, alternatively you could load this needle with the syringe loaded. And then once I'm in my lesion so I don't turn on the suction until I'm in the lesion but once we're in the lesion you can actually then turn the stopcock in line with your tubing at Mayo we actually do use external tubing we have about, it's probably two feet of just 10 French tubing that we connect to the needle and then I have a nurse that gives me variable pressure off of a 10 cc syringe depending on whether we're seeing blood in our sample or whether we're getting a good sample at any given suction so again, lots of different ways to do that, not any one way in particular. Quick question from the audience, can we review the danger areas and contraindications to FNA FNB with bile duct masses, particularly with possible cholangia carcinoma and tuber seeding dangers of sampling masses next to the bile duct and bile duct injury Great question. So, I think about this a couple of ways. Number one, I don't want to prevent anyone from getting a treatment that would help them more than all of the other treatments and the main one I'm thinking about since you brought up cholangia carcinoma is with the patient qualify. They go to Texas or California or come up to see us at Mayo to get a liver transplant and I don't want to exclude them from a liver transplant. One of the things that will exclude a higher cholangia carcinoma from liver transplant for example at our institution would be sampling, unfortunately direct sampling or FNA because there have been case reports it's a probably a low risk but there are case reports of tracked seeding from the IR literature, it's a very low risk. So that's why we're comfortable doing this for most lesions, but particularly for cholangia carcinoma there seems to be probably a little more, a little more risk and so at least for now our transplant surgeons have made that a no go criteria for liver transplant so if you think there's a chance that the patient will qualify for a liver transplant hold off on that bile duct biopsy hold off on that primary cholangio biopsy totally different for a distal bile duct cholangia carcinoma. There you'll see actually this year the ASGE's guideline will very clearly state that ERCP does not have to be the primary diagnostic modality anymore for cholangia carcinoma, EUS is awesome. It's going to diagnose those distal bile duct cholangia carcinoma is much faster and with higher sensitivity and specificity than, than ERCP. So, I would avoid the bile duct, if it's, if it's near the near the hyalum to answer your question. Some other other parts of the question that are really important sampling mass is next to the bile duct and causing bile duct injury. Just be careful. I'll do my best to avoid the bile duct do I do I stress if in ahead of pancreas lesion Have you done this, where you're sampling ahead of pancreas lesion and then you realize you've been like passing through the bile duct. The good news is you're about to do an ERCP probably in that case so if the bile duct particularly passes through your lesion. If it's passing through the head of pancreas, and that intra pancreatic portion of the bile duct is affected by your FNA or FNB. There's really no problem you're going to cannulate and you're going to place a stent, there's really not much risk or any risk for a leak, where I would worry about it is if we're sampling maybe a higher lymph node with a distal process so maybe we have a head of pancreas mass. We're sampling a higher lymph node that we're worried maybe a pancreatic metastasis, and we hit the bile duct there if you have an obstructed bile duct, and you hit it with a needle there's a chance you could cause a bile duct leak. That's the same pathophysiology that happens with an iatrogenic pancreatic duct leak. One of my main concerns about pancreatic rendezvous, I do it a couple times a year when we can't can't get pancreatic duct access for someone with chronic pancreatitis or a pancreatic duct stricture. One of my main concerns and what I always tell my fellows is we have to get a stent in place, we will not leave the patient once we've punctured that obstructed pancreatic duct or obstructed bile duct. We won't walk away until we have a plan for decompressing their biliary tree or they will get bile peritonitis or a pancreatic duct leak which can be pretty morbid. The patient ends up in the hospital for a while they're going to have to get either trans gastric drainage or IR drainage of that collection it's it's a kind of misery for the patient. So if you're going to commit to sampling near the bile duct be ready to drain it. If you hit it, and if you see bile leak. Nice thing about high fidelity ultrasound that we have nowadays is that you're going to see things that maybe you wish you didn't see, you're going to see bleeding. And have you seen that in cases yet this year, I've had one case with sampling of the pancreatic mass we went to through a small vessel, it was like hyper quick on the ultrasound. Yeah. And you'll see that you so you start with maybe a little neuro endocrine tumor in the body or tail of the pancreas and it's a little one and a half centimeter thing. And then you sample it and of course these neuro endocrine tumors are very well vascularized, you start sampling it and oh my goodness this hypo echoic little centimeter and a half thing starts growing to 234 centimeters. That's a hematoma, it's not the end of the world and I have to say I'm amazed by how well patients will do sometimes when that happens it doesn't guarantee them pancreatitis, but if and when I'm going to give someone a liter of lactated ringers like we do for ERCP prophylaxis, if and when I'm going to give someone with ultrasound rectal dichlofenac or endomethicin, that's the case. So if I see that intra pancreatic hematoma, I become worried that they may be at high risk for pancreatitis I'll go ahead and do those prophylactic measures, have the patient hang around in your recovery unit for a little bit longer than usual, just to make sure that they're doing okay, but again most bleeding particularly around pancreatic masses is going to stop it tamponades. It's usually small vessel bleeding that's no big deal. Have you done liver biopsy, where you've seen bleeding. I have not, this is this is something probably worth mentioning, you know, especially some of the other skills that I think we'll talk about tomorrow. When you're when you're doing the echo tip to measure portal pressure gradient, and you're intentionally puncturing vessels you can watch on Doppler and you can actually see bleeding in your tract and if and when that happens it's pretty nice you can just put your ultrasound. You'll just put that probe and push it up against the tract that's bleeding so you kind of find, you can see on Doppler that stripe of color, and you can find it and just provide tamponade so it's the same thing as holding groin pressure when you're doing vascular access in the groin for cardiac catheterization IR catheterization, you're just putting tamponade I'll hold sometimes if it's really bad bleeding just hold pressure for five or 10 minutes, let go and it's stopped. So I'm amazed by how bleeding doesn't come up as a major, major issue and most of our most of our procedures including liver biopsy. Great so we've shown FNA with the microtech needle. This is going to be more familiar to you so we'll move to the sorry the Boston scientific. This is the expect slimline needle. The subtle differences here. And again, just in terms of taking care of your in room staff. I'm always just careful to make sure that I've, I've moved this stopper all the way back up my needles all the way out. If you have suction on I'll actually turn that off just so that I'm not sucking up any GI contents from my scope on the way out of the biopsy channel. And then I'll hand this off, thank you so much. And Boston makes a whole series of really nice needles as well. There's a bit more stuff here to kind of unpackage. And they have a sheath for their needle here. This is a 25 gauge, so this might be something that I'd encourage you to start with if you're not already doing FNA. If you're just starting FNA in your practice, 25 gauge needle, it's often going to get you your sample. If you had to choose one, I like the 22 because I can get an 018 wire through it. So an angioplasty wire for therapeutics will fit through any 22, most 22 gauge needles. 25 is great. If you're doing celiac neurolysis, other injections, it's a nice small needle that's probably safer than others. Same mechanism here. So with the Boston Scientific device, you'll lock your lure lock, pull back, and then there's a little shelf there that's going to catch your plunger. And again, same thing when you release that, it's going to give you a nice 20 cc's of suction. So it's a lot of suction. And again, that's debated whether you need it. I think it's great. I do use suction for almost all of my cases. So for lining up the Boston needle, it's often about the same. So it's right now, I think it comes preloaded at about 1.5. So here on the bottom portion, this is going to adjust to your scope. I'm pretty sure 1.5 is going to do the magic because it seems like the Fuji system here is right in line with the Olympus system that I'm using currently. And we'll try this 1.5 and see how it looks. I do watch, if I'm using a new needle, because we often trial a new needle when it comes out, if I'm not confident about the measurements there, you can watch on your ultrasound screen and actually see if that needle comes just running out into your screen at whatever setting you have. Then don't hesitate to just stop, pull the whole thing out and readjust. Maybe pull out your scope too and take a look. Again, biggest goal is to not cause trauma. Doing a really nice job here of advancing the needle in a controlled fashion without using the elevator at first, because we don't want to crush the tip of that sharp needle. We don't want to damage the needle. So now that I can see the tip, I know the elevator can't possibly hurt it. And now we can do our sampling with this needle as well. And you'll have to describe to me, what's the difference when you do your puncture, when you do your stab here, what's the difference? I'm just going to come back on our stylet here. Tell me what you feel different between the 19 and 25. I feel like it went very easily. I personally felt that I was not using a lot of force. To me, the 25 feels like butter. It's like cutting soft butter, whereas the 19 gauge is really stiff. Again, the 19 is going to unfortunately, for better or worse, be your best friend for maybe liver biopsy. The 19 gauge shark core, although there's some evidence, Dr. Deal will talk about this some tomorrow. He's really a thought leader in liver biopsy, using biopsy needles. Maybe the 22 is just as good as anything, but the 19 will be your friend for therapeutic EUS. That's unfortunately all that will fit our classic 035 and 025 guide wires. What are you guys using? If you do a gallbladder drainage or bile duct access, what's your choice wire? Slip line 19. We've been using 0.035. 0.035. In my practice, which I acknowledge is kind of a weird, unique thing, we use only angled wires for ERCP, for therapeutic EUS, we really almost always, 99% of our cases, we use an angled wire. Are you guys using angled 035 or just the straight? I think it's endoscopists. One of the endoscopists prefers the straight 035 and the other one prefers the angle 025. For therapeutic EUS, I've seen 0.035 at our center. 0.035. For therapeutics, I love an 025 wire. So number one, it's going to fit through that 19 gauge needle a little bit easier. There's a little more play in the needle. Whereas if you push a jag wire, a great wire, if you push an 035 jag wire and then pull it back through your 19 gauge needle, you will shear. You'll see that there are little bits of that beautiful gold and black coating that are missing when you pull your wire out. So I'm really careful if and when I'm using that 035, I'm careful about going in and out. That's why I like an 025. There's an 025 jag revolution. That's an angled tip. I really like the 025 VisiGlide wire. So that's another, that's really my go-to when it's available, the 025 VisiGlide. And it has a nice angled tip that you can spin and actually find your way up. So if you, if you puncture into a bile duct, you can spin it to find your way up. You can find your way down. Our cardiology colleagues who do interventional cardiology really only use angled wires as well. For that reason, it allows you to steer. Whereas if you have that straight wire, you're really at the mercy of wherever your needle is angled. I get a sense that that's why there are also some access needle devices. For the endoscopist who's not comfortable with an angled wire, you can actually use a device from Boston Scientific. Others are coming from other device companies to help you get that needle angled in the right direction by actually steering the needle rather than steering the wire. If you don't have that device and you're having issues with getting your wire where you want it to go, try an angled wire. Again, the 025 jag revolution, the 025 VisiGlide I can vouch for personally. I really like both of those tools. There are also angled glide wires, angled 018 wires, angioplasty wires that will fit through a 22-gauge needle, which can be helpful for some things like in the pancreas. Just like with our Microtec needle, the Boston needle has this preloaded stylet. We're going to just give traction here. It's just a gentle pull out. One of my colleagues also uses, will preload the scope, the wet technique, so you can actually preload the scope with sterile water or saline, and then give a little bit of negative pressure while you're doing your sampling. Again, all of these techniques have been shown to be effective. It's hard to say which one is the best. There's really not a lot of good prospective data on that. I think ultimately it doesn't matter. You have to find something that you're comfortable with. I liked the word today that some people will start with a stylet, they'll use it for their initial puncture, and then they'll move into something else. They'll maybe do their secondary tertiary sampling without a stylet in place. I think that's a fair thing to do. Good. Any other questions or thoughts about the FNA needle? I guess like you mentioned, sometimes when you're sampling a lesion in the pancreatic head and you have the bile duct around, is there a particular needle that you would prefer that you think will have more ability to navigate around the tissue or can bend more? Do you have a preference? We recently went through a trial of all the different FNA needles available. I have to say, what you'll need to decide is what's most important to you. Do you want to see the tip really well? Do you want a super flexible needle? Do you want a needle that's going to maintain its shape? Are you someone who's doing a lot of repeat sampling? Maybe you're someone, to go back to that cholangiocarcinoma case, maybe you're going to sample 12 different lymph nodes. I would encourage you to sample lymph nodes if you're worried about cholangiocarcinoma. That will help prevent that patient from going through all the work like a staging laparoscopy for either resection or for transplant. So go ahead and sample those lymph nodes. But if you're sampling a dozen different lymph nodes and your needle doesn't keep its shape, that's going to be a problem. So unfortunately, they all come with little things that some people like and some people don't. So for me personally, I like being able to see the tip because I want to know where the tip is, particularly for access. We're going to answer a question from the audience. Do you prefer 19 gauge access versus the 19 gauge needle from Cooke? And there are lots of 19 gauge needles, not just the Cooke one, although that is actually what I prefer to use for therapeutics. But that's because it's what I learned on. It's what I've always used. I think any 19 gauge needle is great. I love the access needle. I think it's a really cool concept. I just don't find it to be useful because I use angled wires. So I'd say if you're a straight wire person and your practice isn't going to let you have angled wires, the access needle might be worth getting your hands on. I think if you have access to an angled wire or can get access to an angled wire, probably acceptable. You may not need that access needle. It's expensive and it's another thing to learn how to use. And when you're doing an access procedure because you failed ERCP and you're a little flustered, you're a little worked up, and it's something that you only do maybe once a month or a couple times a year, that is not the time to mess with a brand new device that you don't know how to use. So my personal preference is that the access needle with a good angled wire may not be necessary all the time. Good. Perfect. So we're done with FNA. We'll pull this needle out. Again, she was careful to pull the needle out. I don't want to stab my tech in my room. We're all facing shortages of assistants in the endoscopy suite, so we don't need anybody out for hepatitis testing and whatnot. So be careful to sheath your needle, make sure that that's safe and not a sharp that's going to hurt anybody first and foremost. And then lock that sliding bit back. I'll hand this off. Thank you so much. So now we'll move into FNB. So FNB needles, generally speaking, same mechanics, same setup, everything is going to be the same except you're probably going to express your sample into a bottle of formalin and you're going to send it off for different processing. So at our own institution, it actually gets sent to histology rather than to our cytology group. And I think that'll be fairly uniform across institutions and practices. The nice thing about that FNB needle is that you can take the sample and as long as you're seeing a good core of tissue in your rinse bottle, it's fairly likely that you're going to get a diagnosis or at least know what that tissue was that you were sampling. So we're looking here. This is the BSC Acquire needle, same mechanism for the suction valve, do you suction for needle biopsy? No, we do slow-pull. Same thing, slow-pull. So again, just more evidence, they're doing great biopsies, we're doing great biopsies, you know, otherwise we wouldn't be doing it the way we're doing it. So everyone's having good success using different techniques. Here's another example of how standardizing everything in ultrasound probably isn't necessary. So again, this is the 22-gauge. This is what I use for 99% of my FNB procedures is a 22-gauge FNB needle. There are a lot of subtle differences between the different biopsy needles and you'll just have to decide which one's best for you. Again, same idea with a stylet. You could argue the stylet is more important for an FNB needle in that it'll preserve the architecture of the tip of the needle, which is important in some of the designs. So I'll give you this. Same thing with BSC. I load it to about 1.5. It looks like for both the Fuji and Olympus. Dr. Strom, while doing like FNA, FNA? So I saw the needle hang up here. So if you're at this point and you're really having trouble, so let's say we're in the second portion of the duodenum, you're maximally torqued with your scope. You've got your big wheel all the way down, your little wheel all the way away. And you feel pressure here. Has anybody talked to you about like what to do in that situation? So a couple of things, like you could relax your wheels, try to get the needle down in the stomach, then go down again. The other is like you could try to increase this distance. These are two things that I've learned. That's great. So for me personally, so I'm in a position now at my institution where I learn, I hear about every scope puncture that we have. And so I've become more aware that it's happening a fair amount. So you have to be really careful with these needles, especially larger caliber needles. If you're in the second portion of the duodenum, look, you know, I'm a therapeutic and a sonographer. I need that 19 gauge needle in the second portion duodenum. I'm going to use it there. But I need to be careful I don't break all my scopes or I'm not going to be able to help patients or my costs are going to become prohibitive and eventually my chair is going to say no more therapeutic EUS. So if you feel hang up, particularly here in these last two inches of advancing the needle into the scope, I would say stop. You need to relax all your wheels and you don't need to leave the duodenum, but you need to at least unlock all of your wheels. So I would go ahead. Now they're unlocked. I'm going to let them go neutral and I'll back up probably about two inches and then try and advance again. And as long as it's advancing smoothly and I'm not feeling it hang up, that's fine. So you are actually almost retroflexed, which was a great example. So we're down in the stomach, but retroflexed in the stomach nearly. And that's why we were feeling this hang up and that that is something to be wary of. You don't want to damage your scopes. That's a great explanation. You were going to ask a question and it may be hard to remember now because I interrupted you. We'll come back to it. Yeah. Fair enough. Okay. Let's find our... Same process with the FNB needle. Again, this hasn't been studied. It's my own personal opinion. The tip of these needles matters as much or more than with the FNA needle. So I'm very careful to keep that stylet through the needle itself until I'm ready to use it on that first go. And then I'm definitely careful not to crush the tip of the needle, which can happen if you actuate your elevator before the needle is kind of out and invisible on the scope. So I've definitely had cases where I felt like we got a good core on the first pass and then the second pass, maybe I had my elevator closed because maybe I thought I was doing ERCP for a second. Had my elevator closed, I hit it with my needle coming out and then my needle just doesn't work well. And I'm not getting good cores after that. So I do think you can damage the tip, particularly if it's a trident type needle. If it has three tips like the Shark Core, like the Microtech FNB needle, if it has a fragile tip that's integral to its function, I think that's something to keep in mind. I think I was going to ask you one more question while we're talking about needle tips. You ever use your endoscopic view while you're doing FNA, FNBs for anything, like when you're passing the needles down, do you ever use it? I don't. Every once in a while, you'll get an endoscopic view. So I do, just like we have here live for the case, I do keep an endoscopic view down in the corner. It's currently not working. If there's a gap, that's one place where I might see the, if I haven't, if my team, maybe I have a new tech for the day and we just didn't communicate about loading the needle correctly, if that adjustment hasn't been made and the needle's too long, that's one place you might see suddenly there's tenting of whatever, the stomach or duodenum away as you're putting the needle out. So I do like to have that view somewhere just so that I can see it and be aware that some trouble may be happening. I know our endoscopic view is not working right now. Great question that would take several hours to answer from the audience. When is it better to use FNB than FNA? And this is really like, you know, what is the meaning of life to me? I don't know. FNB, you know, it gets great tissue samples. So if you need architecture, if you need a liver biopsy, you got to use the FNB needle in my mind. The FNA is often not going to cut it. If you're sampling a subepithelial lesion, so someone has a two centimeter, maybe a gist versus, you know, leiomyoma. So it matters, right? You know, do they have a totally benign lesion in the stomach wall or is it an early, you know, a small gist or something that could cause a problem in a young patient's lifetime discovered incidentally? You got to sample it. I don't know the answer here, but one option, you know, costs about 80 to, you know, less than $200 and then a core biopsy needle could cost $200 to $500 or more. That is something I do actually take into consideration. So if I can get the answer with an FNA needle, I will try to use the FNA needle when possible. That said, we also have to take into account, you know, I need to help a certain number of patients in a day and the FNB needle is going to be a lot quicker. I'm not waiting for cytotechnologists, I'm not waiting for slides to be prepared. So I think we still don't know. The economics need to be figured out. I am encouraged that we are seeing some less expensive FNB needles on the market. I don't like, you know, having to use a $300 or $500 FNB needle when I know that's going to result in probably a $1,500 charge to my patient. So that's a hard question to answer, but it will largely be practice driven. So what are you allowed to use? And then what makes the most sense for you and your practice? Do you really need to keep moving? At which case, you know, for a subepithelial lesion, the FNB needle makes sense. Or are you in a practice where you're mostly doing, you're trying to figure out, is this a cancer and do I want to use a bare metal stent in the bile duct? In those cases, I think the FNA needle is going to do the job for you. You're going to get your in-room cytology positive that day. You can place your uncovered metal stent and you're good to go. So it's going to be case by case. Can you think of other examples where, so liver biopsy for sure, I'll use the FNB. I was going to ask you, does the vascularity around the structure affects the choice of needle for you? Like, or doing a FNA versus FNB? Yeah, totally opinion based, no. Actually, if I'm doing an FNA, this is another example. If I'm doing an FNA and it's clearly failing, we're just not getting enough tissue on the slides, I'll move to an FNB needle and there I do often get diagnostic material. So maybe that's the other circumstance. This is, of course, surely my opinion, FNB for liver biopsy, and then I'll do FNB almost every time if the FNA isn't getting me my answer. And I have to admit, it often does get the answer. So give us a sense, do you feel a big difference? This is the 22. Unfortunately, we're comparing a 19, a 25 FNA, and now a 22 FNB through using, I assume you use a similar caliber needle, FNA and FNB in your practice. Do you notice a big difference in the feel between the two needles? You know, not, I wouldn't say that I felt like a big difference in my limited experience. I agree. So, you know, when I'm using a Boston, an Acquire needle, the FNB needle, I think it feels very much like their FNA needle, which is good. You know, it's consistent. The function is the same in terms of adjusting things. And same thing with suction. It sounds like you guys do slow pull. So do you do slow pull every time? Yeah, slow pull every time, unless it's like a cystic lesion, then, you know, and we're aspirating. Absolutely. Yep. So there are needle options where you can actually remove the needle altogether, put in a new angle with, yep. I'd like you to try the Microtech Trident then too. So give that a feel. Yeah, again, like, like we discussed going through, there's no big difference for me at least. So you can see there's good needle action. I will say, this is important. There's a slight difference between FNB technique and FNA technique. I'd say for most people, again, this is opinion based, but I think most, most docs would agree with me. When you're doing an FNB, you're going for, you're trying to get tissue and you really want to go, I think from one side of the lesion to the other confidently the whole way through. This is not the little collect a few cells here and there. Like I do with FNA. I have a fairly short throw where I'm trying to sample the edges of a lesion with FNA. With FNB, I'm going for a fairly long pass. I'm trying to get a true core. So particularly if we're pretending now that we're looking at the left lobe of the liver, maybe we're in the duodenum, looking up at the right lobe. When I'm doing a pass, I start right at the edge of whatever I'm going for. I'll often ride the suction. So Dr. Lee, one of the course directors here taught me a diagnostic EUS years ago. And that's, you know, she would always say suction, suction. You really need to keep the tissue opposed. This is true in therapeutic EUS as well. You want to keep yourself opposed to what you're trying to sample and what you're trying to get at. So I'll ride the suction and I'll do long throws with the FNB needle, starting from the edge of whatever I'm sampling through down deep. And again, everyone has a different technique. For me, I do maximal suction with an FNB needle for a liver biopsy. So if I have a 10 cc syringe hooked up to a little bit of tubing, I'll have my nurse give me 10 cc's of negative suction on the count of three, one, two, three, and I'll actuate three using my elevator to change the trajectory of the needle, three different punctures in three different places, long throws, again, avoiding vasculature and other vital structures. So that's right. And then again, you'll see some differences. The Boston needle, it does have these little kind of hash marks in the metal to help with the echogenicity of the tip. You can see we're still losing the tip here every once in a while, which I don't love. So I try to find my angle where I'm seeing the needle in plane. But it can be challenging sometimes, and particularly when you're in a challenging location, particularly when you've used that needle a couple of times, it'll start to get bent. We're seeing more nitinol needles now, which theoretically should have less of that memory. It should have less of the kind of bending like we see with the steel needles. Happy with that? Yep. Great. So we would have done, obviously, slow pull for you there. So needle's locked, needle's back in its safe place. Should we push the send just to be safe? Thank you. Coming out with this tool. Thank you very much. So this is one of the core biopsy needles that I do use in my practice. So again, this one, the Boston needle comes loaded to most scopes at 1.5 centimeter down at the lower marking. This one you'll need to adjust like with the cook needles. So here I'm going to go down to about what I think is 1.7. That should work well with the Fujiscope. The Fujiscope has a very nice 3.8 millimeter therapeutic channel. So here we're going to sharpen our needle, so she's pulling back, unscrewing the lure lock there on the stylet. We're just, I like this very simple, you know, push button sliding technique of the Microtec needle. I find that easier than having to turn the valve. I wish that everybody would move towards that kind of sliding button. Here we can see our needle beautifully on ultrasound, and I can see she's using ultrasound suction intermittently just to oppose the tissue. That's why we have such a nice view here. And then we're just going to go for our stabs, and so it's, yep, it's a nice long throw, just like that. And then again, I'll use both the big wheel and the elevator to change my trajectory to get those different, different passes. We have a question from the audience. In patients with suspected advanced pancreatic adenocarcinoma and severe pain, do you ever consent for celiac block to be done at the same session as EUS FNA, FNB with ROSE? And yes, is the short answer. Actually, I've started doing a lot more celiac block at the time of gastrojejunostomy as well. So anytime I think I can help, and I can help the patient avoid an extra charge, I don't want that patient to have to go try like a, you know, through the back, a trans lumbar block with our anesthesia group. They're wonderful. They're really good at what they do. Don't get me wrong. If our technique, doing it endoscopically while we're already there for something will work for a patient, absolutely. We do, as you had mentioned, we'll do a block rather than a neuralysis initially. Most of the time, I like to, I like to see patients succeed with a block and then maybe come back for the neuralysis at a later date. That is very contested and you'll hear more about it, I think tomorrow when Dr. DeWitt talks about that, that in particular. Neuralysis, you know, just like everything in EUS, again, EUS is not much older probably even than you. Right? I mean, in 1984, we were doing, it was the, we're early diagnostic EUS procedures. So it's still, there's still a lot of questions. We're still figuring out. This is like five, six years older than me. Yeah, that's right. So it's, you know, it's, it's not, it's not that old. It's a fairly new technology, particularly therapeutic EUS. It's all fairly new stuff. So that's a great question. Yeah, I would offer it. FNA, FNB with ROSE. Yeah, same session. I think, I think as much as possible where we can offer patients same session procedures, I think it's great. Potentially even like an ERCP with a metal stand, if it's a PET mass. Yeah, I'll book myself for just a little bit more time, but you can definitely do Neurolysis, FNB or FNA, and then metal stent placement, ERCP all in the same session. That can be really, really nice for the patient to get all three done. I will caution you, you want, you want to let your pre-post team know with Neurolysis plus the other things that they may have some escalation of their pain and that doesn't necessarily mean it's, it's pancreatitis. So just keep that in the back of your head. You may shoot yourself in the foot with a few post-procedure admissions for just that typical Neurolysis associated pain that you think is pancreatitis, but in fact is not.

fluid collection drainage

FNA

fine-needle aspiration

FNB

fine-needle biopsy

needle tip visualization

suction techniques

needle advancement

Doppler ultrasound

patient comfort