So we'll start here. So this is a DJ, this is the technique we use, which is the assisted technique where we put a nasobiliary drain deep into the small bowel. So here you can see the obstruction is severe enough that there's no way to get a scope across. So we're just using a wire and then over that wire and actually through the scope, we're gonna place the nasobiliary drain. So here you can see it going through. We're gonna slowly advance it, advance it deep into the small intestine. And we actually will then do an exchange where we leave the nasobiliary balloon and remove the scope. And then part of that, obviously then you have the nasobiliary drain coming out of the mouth. So you have to do a nasal exchange after that, which I think is my least favorite part of the procedure, basically where you're putting your hand deep into the throat and doing an exchange. But then you can start the infusion or you can see a nice distended loop of small bowel. In this case, just for confirmation, we're gonna inject some contrast, access it. You can see it's filling nicely. It's filling the loop where the nasobiliary drain is in. So you know you're in the right place. And then here going with the lumen opposing metal stent. And you can see that why this technique is considered so difficult is because you have very small space to work with, even when you've distended the jejunum properly and you lose some visualization from the cautery effect as well as the lesion of the stent. As I told you, I always preload with a guide wire. So there I was advancing the guide wire after the first flange. And this is the methylene blue, which I also infuse as I'm doing the case. And I always dilate right then and there every time. So here you can see the stent being dilated. And then in this case, I put a pigtail afterwards, like that. So then, just as important, so this video actually you already saw, so I'm gonna skip over that. But this one, one of my favorites, similar to one you saw earlier. But here we think everything went great. We're dilating. We think we're done with the procedure, all complete. But then, whoops, this is what we see after we've dilated. And at this point, we've already given up the guide wire. So you have several options here. But what we decided to do was actually try to salvage this. So we went down with a double channel endoscope here. And through one of the channels, this is a rat tooth forceps. We're gonna take the bowel and hold it in place so that it doesn't move away. And through the other working channel, this is a needle knife catheter where we're gonna actually puncture the jejunum here and then use the catheter to insert a wire. So here you can see both the catheter being advanced and the wire. And it's taking the shape of the small bowel, which is excellent, but we're gonna inject some contrast just to make sure. And you can see here the small bowel filling very nicely. So after that, this is again my salvage rescue stent that I won't do these cases unless I have one in the unit. This is a through the scope esophageal stent. This is the Tywoon. And you can see again, it's being deployed where the distal end is in the jejunum. It's going through the axios and then the proximal end is in the stomach here. And then we've injected some contrast and you can see perfect salvation and bridging of the GJ. And this was the upper GI series that the patient got the following day and you can see a salvage stent. So I like to show that just because I think it's critical when you're doing these procedures to, sometimes you're gonna see the unexpected, things can look great and you can be fooled and then you just have to be ready to deal with whatever comes and I think this was the first time that we did this when this is a situation where I work in a unit where we always have at least two advanced endoscopist scoping at any given time. So this is a time when probably both of us would be in the room and be like, okay, how are we gonna fix this? What's gonna be our next step? And I think the key is just to stay calm, stabilize the patient and then kind of troubleshoot together and brainstorm and this is what we've come up with. And we've had to do this one or two other times since then, but the patients do just fine. So I think it's important to show both the perfect but also the non-conference bias cases as well. In these two or three cases, what happened for this to occur? I think for JJ, I think what happens is just when you can be, in this case actually, we didn't even puncture the dejunum. So I think you can see there wasn't even a puncture hole there so probably what happened is that it just pushed it away and didn't actually puncture into the dejunum at all so it just deployed in the peritoneum. But I think there's been other times when it has actually gone into the dejunum but then popped out for whatever reason during deployment or from retracting. I think with the JJ especially, it's a small lumen and we know that there's a lot of withdrawal when you're deploying the stent and we've changed our technique a little bit so now we do the technique that we were practicing earlier in the lab where you're deploying a little bit, pushing, deploying a little bit, pushing. But in the earlier days, we didn't necessarily know to do that and I think that that's what resulted from those. Amy, what about using a LAMS instead of esophageal stent in that case? Have you, I think you used the length, the esophageal stent for the length to be sure that you were bridging everything, is that right? What about using just another LAMS? So we've done that for bridging as well and I think certainly that's another option potentially. I like the esophageal stent, just because it gives you a little bit of a buffer. You have a little bit of area on both sides so it gives you a little bit of a safety net but you can also hook, you can make the LAMS almost connecting like a ladder, like one like this and then use the flange of, the proximal flange of the first one for the distal flange of the second and kind of make them connecting like that. So either way I think is okay. The first, the distal flange of the first LAMS will prevent the two walls from coming, opposing, right? That was done through a LAMS. I guess you already had the LAMS still there, right? LAMS is still there. I mean, yeah, I mean, I think, you know, this is another one that I would clean up in a few months. You know, I'd bring the patient back, remove everything once the fistula is mature and then just put one. This was a good rescue. This was very good. There's a lot of ways to rescue. Amy, can I make a comment? Thank you for sharing the process when there's a, you know, adverse event or something that is unusual how you manage the endoscopist. Something that I think we lack, procedurists or in medicine in general. The training that pilots in airplanes get in situations of unusual, there's usually two people. One is troubleshooting and communicating with the pilot and one is doing the work. Because the capacity to cognitively, you know, innovate when you're doing the work is decreased. And this is training that physicians lack. So what you guys are like, probably this is the biggest learning lesson is if you're in a situation where you need innovative thinking, that's something you don't do every day, having two people is very helpful. Yeah, I feel very lucky to be in a lab where we always, we almost always will have two of us there on any given day. So, you know, we're always there to help, you know, troubleshoot and brainstorm. I think you're right. It's very helpful, especially in uncharted waters. No, I agree. I just want to say that we always have more than one person available. Like I wouldn't do this at 6.30 p.m. on my own. Just because if something were to happen, it's just no one there, even IR may not be readily available and so on. So I think having two people and we'll often, it doesn't matter whether you're senior, junior, who it is, it's just one other person who can either troubleshoot, come up with some innovative ideas, and, you know, maybe handle some accessories that some of the nurses or techs may not be able to do. So I think having that second person in the adjacent room always helps. I was gonna say the same thing. We'll often tech for each other sometimes too in very difficult cases or when there's something that goes wrong and we need to make sure that we salvage or save our wire access. Sometimes, you know, if my colleague is scoping, I'll run over and take over handling of the wire or teching just because, you know, nobody really understands how to work the accessories the way we do. There's an online question about will there be a good tract when we rescue a salvageable stent since it looks like the edges of the stomach and small bowel are close to each other. I mean, will the fistula still form? I'm not quite sure what they're asking, but it looks good. Yeah, but what they're probably asking is that like the jejunal wall where you make the puncture is still a little ways away from the gastric wall because of the flange of the axios, which is outside the jejunum, right? Yeah, I mean, I think, you know, the human body is amazing. Like this patient, the fistula is still formed. I think whenever you have tissue that's opposed, you know, in some areas, it will, I mean. You could see the omentum. It's a really nice video. You could see the omentum floating through the aperture of the lumen opposing stent. And so I get the sense, because I've seen this too, Amy, and I also like the Taiwoo TTS for this. I get the sense it all socks in. And when you come back and remove this stent in a month or two, you do have a really nice fistula's tract. It's mature and you can pull out your stents confidently. Could you potentially get more CO2 in and try to find, locate the stent? Because, you know, you know it's going to be there. I mean, you could potentially grab it. Could you potentially grab it or no? Is it going to be go? So the bumper was deployed outside. I mean, could you potentially find that hole in that stent? I don't think there actually was a hole in this case. I think what happened is that we just pushed the jejunum away when we were deploying and we didn't actually puncture through the jejunum. So in this case, we didn't need to find the jejunum hole because there probably wasn't one. Because when we looked at it, the bowel was right there. So that was, I think, the loop that we were targeting and it just never made it inside the lumen. But yes, I think if you are in the lumen and you're sure you're in the lumen, it's ideal to find the puncture site because you'd want to close that if you're not going to use the same tract. If you had punctured the jejunum... One last question for the sake of time. If you had punctured the jejunum, what would your options be? Would you have done a notes or...? Yeah, I mean, you can use the same technique just to search a little bit for where the puncture site was, try to use the same tract. I like the double channel scope in these cases because it gives you the option to both hold on to the bowel and that just gives you a little stability so that you have a little bit more leverage to push your stent through. But whether you do it to the loop that's right there or whether you fish a little bit to find the puncture site, I think either way is still successful. Awesome. Thank you. Thank you. Andy, you're up next.

nasobiliary drain

placement

rescue procedure

stent placement

unexpected complications