All right, so we're going to start our last session of the afternoon. Faculty are going to review interesting cases and open forum for questions. We'll try to get through as many of these as we can in the last hour here. So as some of you heard, I have an interest in gastric varices, so I'm just going to show you nothing particularly crazy, but just here's a typical gastric varix, right? You guys have seen these before, and this was sent to us for primary prophylaxis. So things to consider, number one, we talked a lot today about identifying the varix versus the feeding vessel or perforating vessel, but the thing that I consider to be the most important is you want to treat what's bleeding. And so it's very important when you go down there, you may see a large complex of dilated veins, but you want to find the one that bled, and that's going to be one that's in the submucosal space of the stomach, not ery-gastric. And so here you can see we've identified it, the needle, it's punctured. We use a 22-gauge FNA needle, and through that we're deploying, these are .025 diameter wire coils that fit through the needle. And here you can see once the needle's in, you're not removing the needle, the needle, you puncture. And it's very important to keep the needle flush, first of all. So the whole sequence is you unpack the needle, take out the stylet, flush with saline, go down, puncture, and then you have your coils. You load them, you advance them, and you can see, like Dr. Lee mentioned, we're really stuffing it. You can see we're using multiple coils here. And then the one technique I'm using here at the end, if you can see, I've actually kind of trailed outside of the varix and deploying the last one within the gastric lumen. And there you can see I flushed some saline. Now I'm going to repuncture it to put my glue. Very nice and easy. And these are very soft. These are not like hard pancreas masses, so you don't have to like jab it. It'll just go in nice and easy. And now, first you'll see some saline come out again, and then a little bit, probably less, you know, about 1, 1.5 cc's of glue is all we're going to use here. And you'll see this kind of hyper-echoic material start to build up in there. So I'm just gently doing that. And actually, I don't push. I like give puffs. It's kind of like puffs with my thumb. As I see it fill up, that way I don't over-inject. And now I see that it looks pretty well occluded. We'll run the Doppler here in a second. And as I'm drawing the needle, I'm giving little puffs, little puffs to kind of plug up that hole. So this is very typical, straightforward tech version of this. And here you can see there's no flow in that varix afterwards. And then to see what it looks like, I always will stop and then replace it with the EGD scope to be absolutely sure that I didn't induce bleeding. The best thing about EUS is you can't see anything outside of what's going on. But you know, you can't play dumb too long. And so now we go back in. And here you'll see what it looks like. And these are things I like to see. There's the coils that I intentionally deployed on the outside. And you can see some of the glue that I was squirting as I came out. And that's what's going to anchor that in, prevent embolization. And then we'll bring them back in three months and see how the thing looks. All right? Can I do one more real quick? All right. So we just heard Dr. Storm talk about EGD procedure. So here's a version. This was a woman who was, I think, 60 years old, had a prior Roux-en-Y gastric bypass for weight loss, and then presented with metastatic small bowel adenocarcinoma with multifocal bowel obstruction. She was palliative, but had terrible recurrent admissions for small bowel obstruction. She was seen by surgery. They said, no way. There's nothing. You know, hostile abdomen can't intervene. She was seen by IR for IR placement of a G-tube. They said there's no window. So then we were called, kind of, is there anything you can do? So we saw the patient and thought, well, we have technique to access the remnant stomach. Let's see if it makes sense. So here we're doing quick scope. We could see the gastrointestinaloscopy is not itself obstructed. We wanted to make sure. And now we're going to access the stomach. And it's already distended, right, because she's obstructed distally. But nonetheless, we're going to inject contrast, so unlike we heard, to confirm our location. Now that it's filled up, we're going to place our lambs and create the gastrogastrostomy. Now one thought was, well, if you just create the gastrogastrostomy, isn't that enough to decompress? If it's decompressed distal, then you're just going to create a loop. You're not going to actually decompress the patient. So we thought that beyond just doing that, the patient would benefit from a venting PEG tube. So once we created the bridge, as you can see here, next step, which we'll get to where we're drawing our lambs and deploying it. So now we wanted to access the remnant stomach. So we are dilating here. Amy, you'll be happy to see we're dilating on the same day. And yes, thank you. Thank you. And once we've dilated, and here you can see what that looks like. And it is important to watch and do this carefully. This is not like a stricture. You don't want it to move, like we heard. So we're doing that carefully. Now we're going to advance with the EGD scope into the stomach. And now we're going to try to do a PEG tube. So here we can see our finding trocar. We find it. And now it looks like a good old PEG tube, right? Seems to be going pretty smoothly. So we'll see what happens. I won't be showing you the video if it didn't have a twist. We grab. Everyone knows how to do a PEG tube. Now we're going to feed the wire through the tube. We're going to grab it with the snare, like usual. And we're going to pull out. It's going to look a little bit funny, because as we pull out, it's a little bit different as we're going to pull through the lambs. Now we're going to come out, tie the PEG tube, and now we're going to withdraw it. And for some reason, I just had an inkling, maybe I should watch this as it goes through. Never really seen it before. So we're watching it. And we're like, man, this is cool. This is going to make a great GIE video soon. And we're watching it, and we're watching it. And I swear to God, I did not anticipate this, because I just didn't think about it. This happens right around here as we're pulling, and we're pulling, oh. So I didn't think about that, because I was so excited for everything else. And now we've got to get that damn thing through, otherwise we haven't accomplished anything. So luckily, it just took taking a little snare and giving it a little twist and a squeeze, and kind of closing your eyes and pulling. And then next thing you know, boom, there it is. And PEG is done. Thank you. I think you planned this, I think. Yeah, I didn't plan that. To get this applause, I think. Oh, let's do this. This was because the PEG was an emergency. Yes. I wanted to do the same thing. Yeah. Yeah, yeah. This was an emergency PEG. There was no time to let the track mature. The patient did, she did get symptomatic relief, which was passed at home hospice a couple weeks later. Awesome. All right. Thank you so much. Thank you.

gastric varices

bleeding varix

needle and coils

glue application

bowel obstruction