All right, thank you, Amit, and thanks to the organizers for having me. Just like in real life, the complications happen at the very end of the day, when you're tired and you're waiting to go have a drink, and, you know, you've got probably your A-team tech and nurse are gone, you've got the late team, you know, that's annoyed that there's one more case to do, and that's when these things seem to happen, right? And so it's appropriate that I'm talking about it at the end here. So no relevant disclosures for this. And one of the things I, you know, was taught to me when I started training in endoscopy, someone said, you know, this quote, which actually I didn't know, it was from Harry Truman, but if you can't stand the heat, get out the kitchen, meaning, you know, we are going to be in situations in therapeutic endoscopy, it's guaranteed we're going to have to deal with adverse events, and so if you don't, you know, if you're not comfortable, you don't like that, then, you know, there's no way to get around in therapeutics without that. I didn't hear it from Harry Truman, I heard it from Jerry Way, who actually trained me in endoscopy when I was a fellow at Mount Sinai, and he, I thought he made this up, but it turns out it was not. So again, adverse events are common in therapeutic EUS. Now if you listen, you know, I was only listening to the adverse events part of all the presentations today because I knew I had to talk about it, and if you listen to it carefully, although, you know, we're trying to promote more people to do these things, if you looked at the details, you know, they ranged from anywhere from 0.2, 0.4 percent for FNA up to 25, 26 percent for some of the more therapeutic things, but nowhere was it zero, was one thing to note, and in some cases, it's actually quite high compared to routine endoscopy, so we have to be comfortable with it, so I sort of have the three A's of adverse events. One is anticipate, so when we're planning our day, so in the morning, I'll sit with our nurse and tech, and we'll review each case, you know, what do we need, and I'll not only plan for the procedure, but plan for how are we going to treat the complication of the procedure, right, and make sure we have those things ready and available. When I talk to patients, you know, sometimes it's not feasible, inpatient, it's acute, but if it's something more elective, like an edge for an outpatient workup, I will advise the patient on how we're going to do the procedure and how we're going to deal with the adverse event, so that I feel comfortable doing it rather than worrying about having to explain it afterwards, so I strongly encourage you, as you start to add more interventionally US to your practice, think and talk about the adverse event as if they're part of the procedure. Of course, avoid, and we'll talk about tips and techniques to do that, and then the third though is to act, you know, like I said, once you're in the kitchen, you've got to deal with the heat, and I think it's, you know, it's uncomfortable to have adverse events, they can be quite serious in what we're doing, but be prepared to act, you know, we are often looked at as the last line for, you know, endoscopic management of things, when you take on the role as the therapeutic endoscopist, and, you know, I think your personal expectation and those of your colleagues is, you're the guy or the girl who's going to fix it, and so be prepared to act. Now most adverse events, you know, we could, I'm not going to review everything we talked about today, but I think in routine practice, they're going to boil down to two things, one is risk from needle puncture, okay, and the other is largely going to be related to use of lambs or lumen-opposing metal stents, you know, I got a sense from everyone's reaction, I don't think there's a lot of cyst ablations happening out there, and some of these things that we discussed, so I'm not going to touch on those, but I think if you're introducing therapeutic EUS or mastering it, this is like 90% of what it boils down to, is you're using the needle puncture to do something different, and then you're usually going to, you know, involve one of the new lambs procedures. So here's the different things, and we'll go into detail one by one here, but needle puncture, of course, bleeding, perforation, unintentional organ, I think David already shared that, I'm going to steal his slide, and then embolization, which we commented on a little bit, and then with lambs, it gets a lot more complex and what can go wrong. Okay, so starting with EUS fine needle sampling, you know, if you started this, I think someone referenced this in the early 90s, right, you would read, fatal necrotizing pancreatitis following FNA of the pancreas, right? I mean, this was published, this was, you know, in, you can see, 1981, you know, who would want to, who would even approach this if this was the headline that we were reading in today's articles, but thankfully, this, you know, really is not the norm. So the reported incidence of pancreatitis is low, you know, anywhere from 0.2 to 2% incidence. The risk is greater, of course, in cystic lesions that communicate with the pancreatic duct, so IPMNs, I think we talked about that with the needle biopsy as well. And here is, I think, a very key thing that we sometimes will overlook. When we go down in therapeutic EUS, we're often quite relieved to find the lesion and ready to go, and it's same with LAMs or anything else. My advice is once you find, let's say, a cystic lesion, and it looks like it's ready for puncture, take a minute to see if you can find a better way to puncture it, right? And here it's, you know, how much normal pancreas are you going to go through to get to that? And if you can limit the amount on normal pancreas, you're going to reduce your risk of pancreatitis. So, you know, it's, you know, while a lot of these things we can do fast, you can find the cyst and puncture it, take an extra minute or two. Is this the best possible route to do this? And that's true when you're deploying LAMs as well, and we'll talk about that. The risk actually is not different between FNA and FNB, and I know we discussed a little bit about rectal endomethysin and some good anecdotal tips about which lesions to use it in. But to date, there's no data to support that, but I do think that's a promising area of study. Now, we do have, you know, can we guide this? Or, you know, so if we want to use rectal endomethysin and you don't want to use it on everyone, you know, are there some risk factors? And this has been published. This was prospectively looked at, and it's important. I think David mentioned that prospective data is a lot more useful than retrospective data. And one thing where we've been bad at in endoscopy, it's a lot of retrospective data. It's a lot of, here's what I did, and, you know, I'll show you, and we're not as good with prospective data. So here they look prospectively at over 700 patients, and what they really commented on was they considered high risk more than five millimeters of normal pancreas and or traversing the main pancreatic duct, makes sense. And so notable difference, right? Pancreatitis rate was up to 9% if they had a high risk technical performance and quite low in the low risk group. And then, you know, this goes along with ERCP, female, young age, and of course prior pancreatitis. So I think the takeaway for me is it's less the lesion and more your technique, and are you minimizing that space, and are you being meticulous to avoid the main pancreatic duct? And that will help you with this topic. Next, something that I don't think we've talked about yet today and something we really don't talk about a lot in the United States, but is actually a topic that's getting more attention, which is needle track seeding. So the idea here is are you taking a tumor from the primary tumor and are you seeding it along the tract or somewhere else? Now, most of this data comes from the FNA era, and it's, depending on how you look for it, it can be exceedingly rare, 0.1%, or if you look for it very carefully, it can be as high as 3%. Now, with a caveat is, you know, thus far there's been no real difference noted in patient outcomes. They don't do worse from their cancer treatment and so on. However, as you can see here, there are some very real recurrences or new cancers that occur. This is at an FNA site, and here you can see on follow-up the tumor is not mucosal, but here located in the submucosal space right at the puncture site. And on the mucosal side, it looks more like a crater ulcer. So this was clearly attributed to needle tract seeding after a pancreas biopsy, and here was the histology that can be seen. And the way we know this is, when we look at under histology, again, you can see that it's distinct from the primary tumor, and here you can see a focus of tumor in the wall on a resected specimen. So this is where the idea came from, and where is it important though? And so where I think it's important primarily is in body tail lesions, right? Why? Because the stomach in those cases are not resected along with the primary tumor, as opposed to a head cancer where they're getting a whiffle and it's all coming out. So this is where I think if we need to be mindful, it's in those lesions. So what can you do, right? Well, one is, we alluded to earlier, stylet, no stylet, clearing the needle, right? So using the stylet after you take it out, expressing your specimen, and making sure you're flushed until it's clear. Some people even wipe the tip with an alcohol pad before going back in to do the next pass. Being meticulous about when the suction is on or off, so you're not in the wall of the stomach when you're turning it on. We're not sure, but we're hopeful that this is less common with fine needle biopsy, because the way the tissue is acquired into the needle is different than an aspirate, but we don't know. But I'll tell you, in Japan, this is a big deal. They talk about this, they look for this, and they're very concerned. And just like most things in endoscopy, Japan is about 20 years ahead of the United States usually, right? We're just doing ESDs now. They've been doing this for like 20, 50 years. So it's something to be mindful of. So I'll take a quick poll, and if you just saw this in the last presentation, you're cheating. But who can tell me what's seen in panel A, and then what's in panel B? Did you show this? Okay, what's in A? Okay, and what's in B? Okay, we had to say the opposite if you said it in one. So point here is, on routine EUS, there are times where it can be difficult to distinguish major organs. And so this is a case, Dr. Diehl shared kindly, where a patient was scheduled for EUS-guided liver biopsy and resulted with a splenic biopsy. And this is particularly risky in patients with fatty liver, where the echogenicity of the two may be more similar. And so although a lot of things in therapeutic EUS, we get cocky and we can do things fast, but if you don't take that extra second to confirm what you're doing, you can run into this, as we heard from a very, very experienced center. Can I make clear? Please. This wasn't my partner's case. It wasn't my partner's. Harshit's not here to- No, not him, another. Oh, another partner. Okay, okay. I have a question. Can you tell by the vasculature, like the portal veins are, you know, the white light and- Usually, but sometimes the liver's very so hyper-echoic that the portal structures are. Yeah. So, you know, one takeaway for me after this was, you know, look for surrounding structures that you know, right? And so you should be able to tell whether in relation to your celiac or to your pancreas body, you should be comfortable that things are where you think they're supposed to be before you make that puncture, but something to keep in mind. Bleeding, and I'm sorry if you covered this already as well. So puncturing the liver, I think intuitively you worry, is there going to be bleeding after liver biopsy? And as we heard, the risk is not as bad as we think, but there is some technique to deal with it. So this is from one of Ken Chang's videos where you can look for it, right? So as you're withdrawing the needle, here you can see bleeding in the track. You see that? And notice he got the sample, but he didn't just pull out the needle, right? We're slowly withdrawing the needle now in that track, and we're watching for a little bit. And if you see persistent flow, what can you do, right? What are you going to do? Well, you're going to sacrifice a little bit of the tissue, and you're just going to gently advance a little bit of tissue in, and that's going to act as a little plug, okay? And so here I think is exactly what's going on here soon. And what you can do is just plug it with a little bit of the tissue you just took. You got a lot of tissue, right? Dr. Diehl told us we get tons of tissue, so you can sacrifice a little bit from the tip. Ah, here we go, yeah. And now you can see that track stopped flowing to the surface, right? So one thing, again, just take a little bit of time. It's easy to go in there. Not easy, but it's simple to go in there and get your biopsies, but if you rush out, you're going to miss this, and they will bleed. I had a 12-centimeter subcapsular hematoma after a liver biopsy, and probably if I just paid a little bit more attention, I would have known it was pending, okay? So one technique there. There are other techniques where if you've removed the needle, you can try to repuncture and, you know, put in some glue or so on, but I like this technique a little bit better because you know you're in the track where it's going to bleed. Coil embolization. So we heard nicely in the last talk, and one of the things we talked about is embolization of glue, which can happen. That risk has been minimized, but what about the coils themselves? And there is a scenario where you have to be mindful, and this was a publication where you can see here a nice, typical, large gastric varix. You can see here on endoscopy, and the endosinographer targeted that large varix. The next day, they get a call. A patient went for a CAT scan to stage their HCC, and they get a call saying, what are these metallic objects in the right ventricle? Okay, and these were the coils. So what happened? So here, the notable thing, and as Dr. Deal mentioned, this thing is humongous, right? And you can see the coils, and you saw in one of the videos, if the coil is not big enough to fill the space, right, it's just going to circulate, okay? And that is where the risk of these little coils flying off comes. So what you need to do is you need to account for the size of your varix. And so, and this is where we can do better. We don't have a clear algorithm for how to do this, but when you have a big varix, you need to use big coils, and the coils come in different diameters and different lengths. And so, you know, here, you wouldn't want to start with a small one, because you know it's just going to sit around. The other technique is anchoring. So what that means is you want to anchor one part of the coil outside the varix, okay? And there's two ways to do this. One is, and this way is a little bit, you know, a little more nerve-wracking, is when you puncture, you actually puncture through the back of the varix, start the coil out there, and then pull into the varix, and that becomes your anchor coil. And then everything else hooks onto it, and that'll keep it in place. Probably a little more palatable is doing that with your last coil and deploying part of it outside in the stomach, and that's, you know, typically what I'll do. And that way, you have something that's anchored to, you know, the stomach, and everything else is tied to it, and that can help reduce the risk as well. But when you have these large ones, you do have to be mindful of this, okay? Oh, I stole my own thunder. Okay, anyway, we'll go through it. I meant to talk on that slide. Okay, so moving forward to LAMs, or lumen-opposing metal stents. These, of course, have been revolutionary. I was in the hands-on, you know, and it seems like mostly everyone has gotten their hands on these, has used them, and is using them. So, you know, what do we know about this? So it's important to look at it based on indication. So if you look at pancreatic fluid collections, this is where we have, you know, this is what they're indicated for. First of all, it's a very important thing to remember. There is only a single indication in the United States for lumen-opposing metal stents currently, and that is for the drainage of pancreatic fluid collections. We, today and tomorrow, will talk a lot about other uses, but when you're in practice and planning these procedures, it is important to note that with your patient in order to, you know, just to be thorough and transparent about your consent. So most of the information we have is on drainage of pancreatic fluid collections. A lot of studies have looked at this. This was a multi-center international prospectively collected data where they looked at it, and this is not, you know, not little. 24% total adverse event rate. When you break it down, you can see the different types. So bleeding, and this can be either early or late, and you can see, you know, most of them, actually the minority were mild. Most were moderate or some were severe. Many managed endoscopically, but you can see IR had to get involved in a fair number. Two, stent migration. We don't think of that as an adverse event, but it is, right? Because it may have, it may create a new problem or the original problems left untreated. So stent migration up to 25%. This tends to happen a little bit later, and we'll talk about how to avoid that. Infection, especially, you know, in these days. I feel like ever since these stents came out, I no longer see pseudosis. I only see Waldorf necrosis, right? And so mostly we're draining these complex, nasty collections. And so, you know, may not have been infected until you got in there, right? And so, you know, we consider infection an adverse event in everything else we do. So we need to consider that adverse event here, and then related to that is stent occlusion. But point being, it's not uncommon. I'm going to pass on that. Oops. Okay. So techniques to reduce adverse events. And a lot of this comes down to one technique, actually, that you've heard, and that is the use, or at least this is what we have now, maybe is how I should put it. And so bleeding, the number one thing to avoid is to avoid leaving the stent in for a long period of time. And that has been shown to be clearly the highest risk factor. You get erosion of nearby arteries or arterioles from the stent as the cavity collapses. And these can be severe, life-threatening bleeds. I'm sure most of us have seen this by now. So one way to avoid that is the use of a plastic pigtail stent placed through the lambs. And the idea is simple. You're just preventing a complete collapse onto the flanges and give a little bit of breathing room. Number two, stent migration. So here, obviously makes sense. Use the largest stent you can. And again, another use for the pigtail stent, which hooks, kind of creates this external hook to prevent complete migration. It may still migrate, but it may not go distant or get away. And then stent occlusion. This is especially true when you're dealing with Waldorf necrosis. So one, I always dilate the stent after placing it in those cases. And often we'll use, now if we're planning early debridement, you know, there's a ton of necrosis, you're planning to go in and do necrosectomy, like within two to three days, there I don't typically put the pigtail up front. But after I've done, let's say, 50% necrosectomy, and now you just wanna let it ride for a bit, then definitely put in a pigtail stent to prevent that occlusion while the cavity is healing. Evidence, there is some for this. Retrospective, 40 Waldorf necrosis, 20 head lambs without pigtail, and 21 with. And here you can see, kind of interesting way they presented this on this table, but here is number of adverse events on the bottom, and then time since placement. And if you can't make it out, all these four here were lambs alone without double pigtail stent. And so you can see more adverse events, especially at a later stage. So although retrospective, I think a lot of us think intuitively this makes sense, and it'll be nice to see if we get prospective data to confirm this. This I'm gonna skip. Primarily, okay, I'm gonna tell you why I'm gonna skip it. I really had nothing to say. So this is the scenario where you're in the cavity, and it starts bleeding, right? And I wanted to be able to tell you guys some specific way to deal with this, but I don't know if Amit or David, if you guys have any tips, but it's basically do what it takes at this point. We do use things like COAG, Grasper can be useful. If you can see it and coagulate the vessel, that's probably the most useful thing if you're able to visualize it. Otherwise, there's a lot of blood. So often, we'll make sure we do our necrosectomies with therapeutic EGD scope. So at least we have a larger channel for suctioning blood when we come upon it. I personally have not used hemo spray in this situation. You can consider it. I've not yet done that. Along those lines, something I wanted to share is not really an adverse event, but in cases where you're doing necrosectomy and the stent dislodges, and you're not done with it yet. So what are you gonna do? Are you gonna open up a new $5,000 stent? Are you not gonna put it back in? So there's a technique, and I think some of you are familiar with this, and this is one way, is you can reuse the same stent. So you remove it out of the patient, bring it out, and here's how it's gonna work, and here's just a short video. Couple different ways to do this. You can take a biopsy forcep, put it through your EGD scope. You kind of make the stent real small and grab it with the forcep and pull it in. In this case, they're just pushing it in as well. It helps to use a forcep to pull it in, and now basically you have it, and so load it into your scope. So you're gonna deploy it with your scope. Now you take the EGD scope back down into your cavity. You enter the cavity. Here, let's see. This is why I use a forcep, but you just pull it in, and it's a lot easier. I didn't have time to video myself doing it. Now you go back into the cavity. You push that forcep out, and you're gonna see the proximal, or I'm sorry, the distal flange. Well, just as it comes out of the scope, you're just gonna open back up, and these stents are designed to keep their shape. Looks like they have a lot of work left in this cavity, by the way, but here you go. As you're pushing it out, you're gonna see it open up. You're gonna pull your EGD scope back a little bit into the track, and then you're gonna push out the proximal end you'll see here, and at the end, boom. You've got it back in, and nobody knows the difference, right? So one little trick to salvage or reuse your stent in between, and actually, I often will remove it on purpose because it makes necrosectomy a lot easier. You can use slightly bigger tools, snares, and you don't have to worry about it getting caught. You can just start hosing things out of there a lot faster, and then put it in at the end. So if you've used the biopsy forcep to pull it in, you just leave that. You go in, and then you just push the biopsy forcep out. Another adverse event of limbs is the opposite problem. It doesn't come out. It gets buried, and so this is typically seen if they've been left in beyond our usual four to six week range, and what happens is they migrate into the cavity, not all the way in, which may be easier, but they get stuck in the wall. It's like buried bumper, but for our limbs. So this can be tricky, actually, because you don't see it. So the whole point here is you don't see it, right? So these guys, they knew kind of where to go, so they found it on EUS, and then through EUS, they targeted it with a needle, and you're gonna see that here in a second, and this is why EUS is so helpful. So I don't know if it was clear, but they targeted it with the FNA needle, advanced a wire through that to get through the stent, took the needle out, put a dilating balloon to now dilate the track, but at least you know you're dilating where the stent is, and here you can see the balloon dilating through the axios right there. Once you've done that, now you're kind of more or less back to normal, and then you can use a grasper of some sort to grasp the stent. They're really committed to EUS. They're watching the whole thing on EUS here and grabbing it and pulling it out. So in here, you can see using the grasper to do it. So the idea here is the EUS can help you find the stent and then kind of recannulate it almost and use different tools. You can also sometimes just use the balloon, and if it's really inflated, just pull it out with the balloon as well works sometimes also. So again, plan for the complication, right? It's easy to put these things in, but have some tricks up your sleeve for what to do when you can't get it out. And so here they successfully took it out and the cavity looks good. Gallbladder drainage. So overall, you know, a fun case. You know, these are fun to do. They're very satisfying. The number one problem with IC is stent migration because it's not like there's a thick pseudocyst capsule or so on, there's a higher risk. And there's two things to consider here. Before you do the procedure. One is, are you doing this as a bridge to cholecystectomy, or is this sort of final treatment, you know, palliative or never gonna go to surgery? So the reason for this is, if you're doing it for bridge to surgery, your surgeon's gonna be a lot happier if all they have to fix when they remove it is a gastrostomy defect, right? That's very easy for them to fix compared to fixing a duodenostomy defect. If you've done it from the duodenum. So if they're planning cholecystectomy, try to find your window from the stomach, usually the antrum, and drain it from there. If they're not, then we prefer the duodenum. Why? There's less peristaltic force in the duodenum compared to the stomach, especially in the antrum. And so it migrates more from the antrum than from the duodenum. So again, if it's up to you, you wanna try to target the duodenum. If you have a surgeon who's gonna get mad because they're gonna take the patient to surgery, then go from the stomach, all right? And then using, again, double pigtail stent may be helpful to prevent migration. Bleeding and infection are actually uncommon. And then of course, bile peritonitis. And this is one where you gotta be committed to this, right? There's no poking it and then coming out and not fixing the problem because that patient, by definition, is gonna have a bad bile leak. So here's one where when you're using the LAMs, I recommend you have it loaded with a guide wire. And I don't recommend, or I don't do that for pseudocyst or even for gastrogynosomy, maybe. But here, have it loaded. Once you make your puncture, advance that guide wire, okay? And then, now you can do whatever you need to do. And if it migrates or something happens, at least you still have a window to take care of the problem. And here's why this is important. This is iPhone footage. I'll go ahead and tell you that off the bat. And this was a gallbladder drainage case we were doing last year. And I'll show you, and I didn't do what I just told you. That's why, of course, that's how I know this. So here's a nice gallbladder. You can see two big stones sitting there. And not a lot of space in that gallbladder. So what did we do? We said, we're gonna use one of these smaller LAMs, right? I think this was maybe the six millimeter one. Because that's all the space we had. But the gallbladder's a little different beast than a pancreatic fluid collection. You know, when you start retracting, you don't have that big, thick kind of space, right? The gallbladder's pretty thin. So the other thing is, you don't have the same tactile feedback retracting the six millimeter axios that you do with the 15 and 20. So as, and I'm gonna throw her under the bus, as my fellow was retracting here, she didn't recognize sort of where the stent was. And you're gonna see what happens. Direct your attention right here, okay? So she's deployed it, we've deployed it in the gallbladder. We've pulled back, but you can see this sort of has gone forward quite a bit now. Okay, oh, sorry, I jumped ahead. So now she's deployed, we've deployed it. So now typically we pull back, right? This would be the step we learn, right? So we're pulling, but it's six millimeters, and you don't get that same feedback. And I'm just here like videotaping it like a fool, not paying attention. And you're gonna see what happens here as the proximal flange is deployed. A lot of space here, right? And when we were nervous, like we don't wanna pull it out because we can't quite tell. And now we're deploying, deploying. Sounds like it's going good. But what happened here, right? Our technique is normally what? We deploy in the stent, in the scope, right? And then we push it out, right? But we've already just deployed it without pushing it out, and now where is it? It's outside, right? It's actually within the stomach wall, unfortunately. I don't know what I would have preferred. Fully outside or within? Within is better. Within is better. Yeah, well, it's safer. So that's what happened there, right? In no wire. So now what? So now what are you gonna do? What? Okay, so you can try to puncture through that. Make a bad situation worse. Okay, so that's one option. Okay, look, chef is here to save the day, of course. So what we ended up doing, I'm saving this for the later session. You'll see is, now you're committed, right? Who are you gonna tell that you just did this? Now they have probably a little bile leak, a hole in their stomach, and a stent sticking there, right? So you gotta fix this, right? So yes, so what we ended up doing is we went to a completely different location. We went to the antrum, located the gallbladder, put in a regular-sized LAMs, and then took an EGD scope through that into the gallbladder and removed this from the gallbladder side, and went on our way. Gastrogynostomy, main concern here is misdeployment. And the number one reason is the jejunum is not fixed, right, it's moving. The window, you fill it with solution, but the solution goes down by the time you're ready to puncture it. And so that's the main issue with this procedure. Free perforation or stomach or jejunum is what you end up with. And this is not uncommon, 10 to 25% in published series. And think about what's not published, right? Okay, so here's one example from our friend Amy. And one thing I wanna note and really shout out to our co-faculty, it's really helpful when you publish your complications. That's the only way we all learn from these things is when people are brave enough to publish them. So Amy's out there somewhere, you can thank her for this. So here she is, she has the EOS scope, has advanced the guidewire into the jejunum. And I believe this was maybe with cold Axios, so they're dilating a track. Here comes the Axios deployment. It looks a little, oh, okay. That's not what you wanna see. So here it deployed into the peritoneum. So one end is still in the jejunum, but the other is in the peritoneum. So now what are you gonna do? You can't leave, right? You gotta fix it. So here she was able to salvage the opening into, because she had that wire, right? She had that wire. So now over the wire, she's reloaded another stent. In this case, she's using a fully covered esophageal stent, right, because she was nervous. If we try another, you could have done another Axios, but that one didn't go so well. So here you can see up here, took a fully covered esophageal stent. Because here, not only are you trying to create that gastrojejunostomy, but you wanna be damn sure they don't have a perforated leak. And so that worked well here, and then putting in that big tail stent to prevent it from moving on. Second way this can go is the opposite problem. Yep, question? Do you need to remove that? I mean, it's gonna come out with the fully cover you put in probably as a single thing, or when you pull it out? You're probably not gonna pull anything out. Nothing's coming out. It's a terminal, right? Yeah, this is, yeah, right. This is as a terminal. Yeah, right, so typically we're doing these in palliation of unresectable pancreas cancer or gastric cancer. There is more I've seen, and I've done a couple in benign cases, but you gotta be prepared to deal with a complication in a benign case is, I mean, they're both bad, but you gotta know what your exit strategy is. And that's a good one. If you're not gonna, are you gonna remove it or not, you gotta know that in advance. Here's another way this can go south. So here you can see the stent. This is a gastrointestinal ostomy. It's in the jejunum, pull in. And now what they were doing, I'll pause it. They had it perfect, right? Could have gone home and enjoyed their cocktails, but they said, you know what? We need to dilate it open. Really want this thing to drain really well. You know, we wanna, so here's a dilating balloon. Oops. How do I get it? Okay, sorry, I'll let this play. Sorry. So they get it in, beautiful job. This is actually Todd Barron's group. Todd's probably getting ready to go to the gym or whatever he does, you know, and now they're dilating it with the dilating balloon and then take a look and then, oops, the balloon pushed that thing out. So now we're in the peritoneum, where, who knows where anything is. So the proximal part's in the stomach, the distal lens is floating, and here's the hole in the jejunum, okay? So now what are you gonna do? Oh, here, they made a very nice cartoon to make it seem like they planned this. So now they're basically, this is what we called notes back in the day, right? You have a scope in the peritoneum. He's salvaging the same hole, right? So now you take a guide wire, put it down, and get that secured, and because it went so well, you know, here, in this part, I'm not 100% sure, they removed the old axios. I'm not 100% sure that was necessary. They remove it, now they're gonna go down, and because it worked so well the first time, they're gonna put another axios in once again, and you can see them bringing it back together. Now, the nice thing about the axios is, you know, it brings those things together, and that's what allows you to do this safely, and there you go, saved, right? But you gotta be committed to that. You gotta be ready, you know, in addition to doing the original procedure, you gotta be ready for some of these salvage techniques as well, all right? So finally, I know we've gone a little late, but adverse events are gonna happen. Prepare for the procedure and the complication, and then share your events. Talk about them, you know, publish them as our faculty here have done. One thing I've noticed is sometimes in the room, as it's happening, no one else knows what's happening, right, because they just don't, either they're not tuned in, they're not paying attention, or they just don't know, right? And you're freaking out and sweating, and everyone's just, you know, playing Candy Crush and doing their own thing, because nobody knows what happened, because the technique is so advanced already, the complication's like 10 times more. So I make it a, you know, I say, guys, we're gonna take a time out, we have a problem, this has happened, I need you to pay attention now, and you're gonna go get the tools we need, you're gonna stay here, and we're gonna fix this. And don't be discouraged, guys, it's gonna happen, learn from your complications, and keep on going. Thank you. I have to, I feel like I want to respond to Ken's, you know, I've seen this blood, I call it the blood in the track sign. I do not, there's no evidence that it corresponds to bleeding. I've seen it, I haven't done anything about it. I mean, it'd be worth like prospectively observing it, but I know Ken's like super careful about it, but I don't necessarily agree with that. I agree 100%, I mean, I usually, I mean, again, I don't pull it out rapidly, but I'm not waiting there to see any blushing. I mean, you've got some liver, I don't want to push that liver out, that's like my booty, I need to get everything out, right? So I don't do that, and I mean, again, we'll have some bleeds, but it's not a usual occurrence, I would agree, yeah. Good point.

complications

therapeutic endoscopy

adverse events

therapeutic EUS

planning

bleeding

reducing adverse events

case examples