Good afternoon, everyone, and welcome to the afternoon part of the advanced fellow endoscopy course. We're here at the IT&T Center in Chicago, and we appreciate all the attendance this morning. And this is a relatively new way of doing the hands-on course. We are allowing a virtual option for that, which I hope you find helpful. And given that we don't have a very large group, please feel free to ask any questions or maybe direct the course of the discussion in any way that you might find helpful. My name is Mo Al-Haddad. I'm a professor of medicine at Indiana University, and I'll let my colleague, Katie, introduce herself. Hi, I'm Katie Vozo. I'm the advanced endoscopy fellow at Case Western University. All right. So we have several things that we're going to demo today. Please, again, let us know if there's a priority for you that you'd like for us to spend more time on or maybe a technique that you'd like for us to demonstrate more than once. But the things we're hoping to cover today include basic ERCP, EOS, and some of the therapeutic endoscopy, including potentially some third space, if you're interested in that, EOS-based applications. And we do have a plethora of supplies here that hopefully will serve us well over the next couple of hours as we demo the versus techniques. Shall we start? Sounds great. All right. So we'll just work by kind of... So we have a side-viewing scope set up already, and we do have these tabletop models. They're PIC models. And this one should hopefully be as close to the human anatomy as we can get it, including liver, gallbladder, bile duct, and we will use this for our ERCP and EOS demonstration purposes. There we go. All right. Wonderful. Again, knowing that this will never be like the human anatomy, big stomachs tend to be a little bit more difficult to navigate sometimes. They tend to have more of a J-shaped stomach, and sometimes getting through the pylorus may not be the easiest task, as you tend to need an element of retroflexion almost to get through the pylorus. I feel like we're seeing it. I hope we have good insufflation on this as well, Katie, as we get through, because that might help you. I think so. Good. And we're getting closer. Yes. We're getting warmer here. Yes. We're hugging the greater curvature, getting to the bottom of the stomach here. Okay. Just looking around for the pylorus. It might be up on the side. So I see at this point we have 11 attendees. I hope that you're able to see us well, hear us well, and know that you can submit your questions, and we'll see them right away. We'll probably toggle back and forth between demo and answering questions. All right. I'm not finding... Yeah. So this is interesting. I'm going to have to... Sometimes the way these are set up may not be quite the way they are anatomically. So you may see me sometimes trying to direct the scope. That's not cheating, but that's trying to be effective in our time management and making sure that we get where we need to go. I feel like I'm sort of getting warmer. Yeah, this is a fairly large stomach, I have to say. And I am going to show you here by showing the pylorus. Okay. If you interflate, I will direct you to that. Okay. Okay. Do you see any of my... Let's see. Let's see. I think it's below... All right. Okay. I would say interflate, and let's look again at this location right here. Okay. So I'm kind of like fully retroflexed. I do not have gastric outlet obstruction. That would have been... We can demo a few things in that case if it's indeed what we're dealing with here. I see... I feel like I see you. Not where I'm expecting. Okay. Yep. So as it happens with these pigs, they're extremely J-shaped, as in the pylorus is almost as high as the G-junction. Yeah. Sometimes. You're sort of like, I'm retroing. You're almost retroflexing, which is hard. Into it. Which is very hard. Like almost there, I think. Yeah. Yeah. Let me see if I can direct your scope where... There you go. You're going to do denim now. Okay. Good. So we'll kind of do our maneuver here. Left right on. Looks like you're just around the sweep here. Okay. Okay. I would come back a little bit. Okay. So in pigs, you'll encounter the papilla probably a little bit sooner than you think it happens. Okay. Okay. So it's more proximal than you think. Okay. So pull back, pull back, and let me show you exactly... where the papilla may sit. Yeah, it would be somewhere right here. I think you're still further down. I would come back by probably 3-4 cm and look the other way. See where I'm pushing? Right up here. Is that looking promising? Yes, that looks like a papilla to me. Alright, very good. Okay, so. Again, this does not look like a human papilla as much. Do you see the orifice by any chance? I think it's like probably under. So how do you want to interrogate this one, Katie? Maybe with the tip of the cannula we can try to. So I have a tome here that's open and ready for you. Perfect, thank you. Okay, so I'm going to go ahead and spread this out. Make sure this bends well. And there you go. Alright. Just working on passing the tome. So what's your number one tip for new fellows trying ERCP? Position, position, and position. It's pretty much, so make sure you're you are in a very stable if you can, maintain a short position. And we heard this morning sometimes it's hard and sometimes you for stability you'd have to go into a long position. But I think for everyone starting off with ERCP, making sure that you are in a good, stable, short position as much as possible. Then I'm just opening my elevator. I'm going to introduce the catheter. And I do understand that insufflation here might be a little bit difficult. And I don't think I would do this in a human patient obviously, but just to kind of expose and see where we're trying to cannulate. Sometimes a papilla does not declare itself immediately once you get into the duodenum. So lifting folds and doing exactly what you're doing using your scope rather than the catheter, but allowing your scope to kind of straighten out some of these folds is a really good, is a good technique. Okay. I'm not seeing the papilla quite yet, but it could be hiding right behind Right there you think? While you're looking, I am going to go back in and make sure that we are in a good location. I see your finger, okay that's, that is promising, but I do, look the other way we might, this might be just a blindfold, Katie look and see if there is, like over here, yeah, any other, okay, papilla looking, what's that on that fold, right, there, yes, sorry, no worries, okay and the other problem we see with pigs is that their, the VM is really thin, it's paper thin, their esophagus is also very thin, so sometimes it doesn't mimic what we see in humans directly, I'll come back just a little bit and let's look around, I'm still, like you are, trying to see where the, where the landmarks might be. I have to direct you again okay oh I'm reducing and I feel like I'm seeing you're back in the stomach okay I think you have a bend in your go ahead and straighten all your knobs will do straight and push forward now okay okay now come back a little bit okay and just stay that location okay and let's see now it could be see what's on the tip of that now that we're looking at this could be a really what we're looking for okay I know we're trying to look behind that mound but it could be actually the tip of it oh at the top after right there right there okay excellent again this would be the equivalent of a saggy papilla and humans where you're and then I'm gonna do a little tip towards yep maybe put on a little more come back a minute when I get a little bit closer so that's the other tip is working closer to work closer if we can again we don't know if this is what but I imagine this is that but the levees on what we're seeing okay again it could be a very tiny little orifice right yeah I think you are you are where you need to be anatomically okay what I can see yeah it looks promising just might be the nose you know my piece to nose that's true not things that are easy to control in an animal model like this one good so so maybe now what we can try obviously you can always try a little contrast or ideally a wire might be I think you engage that the orifice which is good which wire do you have a preference of what you want to use um it might have it did it come pre-loaded it did maybe yeah did actually we loaded that yeah perfect so why don't we try that I know we don't have fluoroscopy but we're gonna have to trust what we see here okay okay there it is okay it's coming through I'm getting some resistance okay Okay, I think the wire is going through some at this point. Oh, there, we're rolling back on ourselves, yep. Reflecting. And, at least right now, direction wise, you know, this is not a typical, you know, usually we'd want to be more directed towards the 11 o'clock position. Yes, this is a little odd. It's a little odd. Yes. And I think our audience appreciate the challenge that we face working with these types of models rather than human. Okay, so you're in a really good spot now, closer to your 11 o'clock orientation. Right. Do you want to lead by the wire before the tip? Sure. I can get you a tip of the wire. Yeah. I can see. That helps. Yep. Any, maybe a little more. Sometimes what happens with the saggy papilla, the duct is doing this, then coming up. Do you want to sort of scoop up that curve as you come up? Yep. Sometimes that might. Any luck? Yeah, I think, I thought the wire went in for a little bit. Again, not having fluoroscopy is a handicap in this situation. I don't see it coming back to us. So that's reassuring. Yes. Yes. Oh, no. Now we came off. Okay. So this is usually when I'm like, attending, do you want to try? Take a look. I really don't think I will have, because I think you had all the right techniques in there, Katie. I don't know if we have an alternate location to where the papilla is. So again, short scope, I'm going to lock into the position, if I can. Let's take some of that. Okay. Let's try this. Interestingly, the whole dynamics are reversed, so right left torque is everything's is exactly the opposite direction as in human. Okay, well, let's see if we can lead with the wire here, and knowing that we may not be able to successfully candidate the super stricture orifice, but at least we can maybe and now I need to get a little bit closer. Or is it deeper? Is it under? Yeah. Could it be somewhere behind the fold? Yeah, that's what I'm wondering, like even lower. I don't know, maybe not. I feel like I investigated there too. Yeah, you went as far as almost D3 with your initial. I feel like the wire might be going somewhere. Oh, no. Okay, let's see if we can reposition, and then again, I think that our audience will get the kind of the gist of this in terms of what we're trying to do. Yeah. What we're trying to do. I wonder if these things also or these things develop that verticula around their papilla. Oh, so maybe we should be. That would be the other thing. Sometimes you see pigs tend to have that verticula in the esophagus quite a bit, which can make it very hard to decompress a little bit and see if I can redirect myself down to D2. Yeah. Yeah, I can help too. Let me see. So I think so. This is actually a good demo how J-shaped these are. You get the G-junction here, you get the pylorus up here. Yeah. You can see. So getting the scope up there is often a challenge. Right. In a situation like this. I think this may look like a duodenum to me. Yep. And well, actually, that's pre-pyloric. OK, maybe I just popped into the duodenum here. OK. Let's see if I can get back into that location, and then what we'll do after that, we'll just say this is likely, this is what we're going to treat as a papilla, basically, and we can maybe field some questions or if you want to demo maybe a technique from there. Okay, let's do this, I'm going to have you hold the scope, let me direct it manually so we can go back at least to the duodenum, because it does need a little bit of manual interference here. Okay, let me see where your scope is, I'm going to manually direct you right there to the duodenum. Okay. Okay, you're in the duodenum now, take a look and see if you can see any other potential papilla, or papilli, and you can come back a little bit if you like, and then the papilla should be right here, and come back if you can about 5 centimeters or so. Okay. Okay, slowly coming back. Come back some more. Okay. Come back a little bit more and straighten your scope if you have a bend at the tip of the scope, just relax all your dials, go back to neutral. Okay. And come back a little bit more. All right. And right there. And look. Ah. I think that's what we were before. Yeah. So it must be a really tight biliary orifice. Yeah. Anatomically, from what I can see, this is where it should be. Right. But let's, we will assume that you're in the, you know, this is a native papilla that you're looking at. Right. And let me hold this for you. Okay. And I also want to be cognizant of time. Yeah. Because we have several other techniques to demo today. Right, which are way more fun, which will be way more fun than watching us struggle. Yes, yes. I agree with you. And be less, hopefully more enjoyable to everyone, less stressful on you and I as we try to. Yeah. But I think our audience will get the, you know, the technique of trying to engage. Yeah. Lead with a wire, try with the biliary orifice, the right orientation, short, stable scope, which we could never achieve, obviously, in this case. And deep wire insertion, followed by the catheter. Yep. Trying to see if there's anyone monitor for questions at this point. We're still looking good on that side. Okay. All right. And let's take this out. Okay. Perfect. I would like to see if we can get an EOS scope because we have a lot of nice accessories. Already on this. Get some of the air out. Those are essentially things we can drain FNA or do potentially transmural drainage on. We obviously will have to switch to an EOS scope at this point. But what we have here, essentially, we have a variety of EOS FNA needles, and we have also a lumen opposing stent that we hope to be able to demonstrate. Those typically get a lot of attention in courses like those. So hopefully we can get some of that demonstrated. Yeah. For you. We have a Fuji-based system. We have a Fuji-based system. I have to say neither one of us works with Fuji usually, so please excuse any hiccups or inefficiencies. But we should be able to take a look at the anatomy, pig's anatomy. Not that much different when it comes to the location of the liver and the pancreas and the bile duct. We have other accessories built into this model to allow drainage and FNA. All right. We're rolling? We are. All right. All right. Looks like we have light. I always forget to check my balloon. Oh, it looks like air is coming. Okay, so that's not ideal. The bottle is completely full. Go ahead and refill it one more time, Kitty. Okay. Sometimes the second time gets you the fluid. Second time's the charm. There we go. There we go. One more time. It's always a good test before you put down your EOS scope. Make sure that your balloon is functioning and that you're able to have good acoustic coupling with a tight balloon that does not leak. This is your ABCs of EOS. You know, it helps if we have suction. Yes, suction definitely helps. There we go. Okay. Yeah, getting some support. Okay. I think we're live now on the EOS imaging. All right. Wonderful. Let's take a look. And now you must be just past the GE Junction. If you want to kind of look around and see if you can identify the typical anatomical structure. So the very first thing you would do past the GE Junction is identify the celiac takeoff. For any of you who are just starting to learn EOS, you know this is kind of the easier part, which along with the left lobe of the liver should be something you would hopefully get to within the first few cases that you do on your own. Obviously, ultrasound waves travel a lot better in absence of air. So it's always good to have either a good water-filled balloon or completely decompressed lumen or a water-filled lumen if you're doing that. Endoscopically, you can always cheat and see where you are. It looks like we don't have a great light on the scope. There we go. Here we go. You can tell that you're actually, you might be just still above the GE Junction. Oh, you think you're too deep in there? Deep, deep. Okay, why don't you come back. Coming back. Yeah, come back and start off, straighten your scope and start off at the GE Junction. Okay. And this is where I think you might be in a good spot right now to do that. So we have several structures built in. Those are not naturally occurring cysts, but that's one you can see over there. We can use that for FNA purposes if we need. Nice. You should be able to see the liver. There's another structure here that might be used for FMD. It has soft tissue and you can also drain this as well. Cool. I think we're about to have a lot of fun. Yes. So there you go. You see one of the cystic structures built in. We can assume that's a pancreatic cyst. I still haven't gotten a great look at the liver, but maybe it's... And it would be probably just right there. Again, the liver is artificially sort of propped up next to the GE Junction here, artificially sort of propped up next to the GE Junction here, so it may not occur where you expect it to occur naturally. Yeah. I've seen a quick glimpse of the liver. Maybe that's it? Maybe that's part of it. That's a finger. Yeah, definitely not something naturally expect to see. Okay, but we can look for some of these. So, what you do typically you follow the CDX trunk, the first branch that comes off as a left gastric artery the CDX trunk itself becomes a splenic after it gives origin to the common hepatic. So, typically that would be how you get to the pancreas is by following the main trunk as it becomes a splenic and that leads you typically to the body and tail of the pancreas. I think part of the pancreas has been removed here and replaced by these cystic structures. You may be seeing one of them. There's one, there are actually a couple. Yeah, the one you just moved. I don't know if you can see. That one will simulate a gallbladder and this one is another one as well. I don't know if you can see. So, we can pretend this is a gallbladder and we can demo the gallbladder drainage technique if you guys are interested. I don't know if there's a way to show us if that's what you want to see or if you want to see more traditional FNA, FNB type of interventions. Just let us know. We can also do a traditional cyst FNA as well. We have a smaller cyst not too far from where you are here. And that is more for FNB. It's a solid, mimicking solid tumor here. So, while we get going, what do you want to do first? Let's do... What's that? FNA? It is FNA needle. You want to demo FNA of that gallbladder-like structure, cyst, potentially. Pretend it's a cyst and then we can... Then we can probably move on to a LAMS placement, if you like, across that. That sounds great. Okay. So, to do that, why don't you come back so we are definitely at the... There we go. That would be... Perfect. So, you can pretend this is either a peripancreatic or a pancreatic fluid collection or a large cyst that you would like to FNA. Okay. So, a few tips, obviously. Like ERCP, keep your scope straight as much as possible, your tip in neutral position. Otherwise, the FNA sheath will not come out of the scope. But once you do that, you... The first thing I do is exactly what you're trying to do here. Can I help you out? Yes, please. Which is I like to pull the stylet back just by about half a centimeter or so to expose the sharp edge of the needle. And you relax the needle. Unlock. Unlock this. Okay. And then we can demo Doppler, obviously, and this had a very X-plan. This is not pertinent, but Doppler usually will tell you where the blood vessels might be so you want to avoid them. The next thing I see some difficulty with occasionally is getting the needle out of the sheath. Now, you know the sheath is actually out of the scope, but the needle is not yet out of the sheath. So, if you face any difficulty or high friction, do not push through. What you might want to do is, again, relax your dials, advance the sheath, and I don't know if you can zoom in on the sheath part of the needle, which is the bottom dial right here. And let's pretend we're doing that, Katie. Okay. So, I'm going to relax this and then advancing the sheath in a neutral, see it's coming on the small screen. This is typically, when you see it moving out without difficulty, that means you're in a good position. Typically, it's about one and a half to two centimeters out on the scale that you have printed on the needle. So, now we're good. Your needle should be coming out easily. All right. You see it? I do. There you go. So, that's the echogenic structure, and you can puncture through typically rapid, one quick, rapid step. There we are. And there you are, obviously. At that point, remove the stylet. We can use suction, aspirate some fluid. If you're sending some for cytology or tumor markers, you can do it now. Or if you're doing, if this is more of a soft tissue lesion, I see we're demonstrating the fanning technique, which is great. Fanning technique is a great thing for enhancing your tissue acquisition capabilities as you go through various sections and trajectories in the lesion, going back and forth. During that time, you can apply full suction, half suction. We haven't done that yet here because we are going to use the same track for LAMs. So, we wanted to preserve that gallbladder, if you will, as intact as possible so we're not draining it prematurely. Good. Okay. That sounds great. Do you... Oh, we have a question while we're on FNA needles. That would be great. Preference on which FNA needle to use seems like a lot of it is provided preference. Yes, it's very true. To keep this more high level, you have a 19 gauge, which is typically done mostly for either liver biopsies. I'm talking about random liver biopsies to assess for fibrosis and inflammation. Or for, as we saw this morning, EUS guided interventions, interventional EUS. This is where you go to the 19 gauge. For tissue sampling purposes, you're very unlikely going to use any 19 gauge needles. You're going to use either 22 gauge or 25 gauge. 22 gauge basically would be good for your run-of-the-mill pancreatic masses, liver masses, gists, or any lesions that are sub-epithelial in nature. More recently, we've had the new generation FNB device, the fine needle biopsy devices, which basically utilize slightly different technology at the tip to accrue more tissue. And there are several on the market out there, obviously. Today, for the sake of demonstration, for example, we have the Acquire platform from Boston Scientific. And I tend to use 22 Acquire and 25 Acquire for pancreatic masses, for example. They tend to give you more tissue per pass, according to several studies. So I guess to answer your question in brief, it depends on what you're using it for. For pancreatic cysts, to get fluid, any standard FNA needle is fantastic. For lesions that you'd like to get more solid tissue from, instead of epithelial masses, possibly a core biopsy device or a fine needle biopsy device would be more appropriate. Okay. Again, that's a topic we could talk on for an hour. Yeah, absolutely. It's an area of very dense and rich research that we've seen in the last 10 years. And there's just a whole lot of needles now on the market. Now, we got the 22 stem line out. We will put this aside. Okay. Now, a lot of people are interested now in transferral drainage. And I think this is one application that, from doing these courses over the last 10 years, this comes always ahead. Can you teach me how I can drain a pancreatic fluid collection? Yes. So, we're lucky today. We have actually a LAMS device. This is manufactured by Boston Scientific. It's Axios. It comes in three sizes as far as the diameter of the saddle, which is 10, 15, and 20. And this one is a 15. The length of the saddle is typically 10 millimeters on these stents. However, the newer generation comes with the option to have a 15-millimeter length of the saddle. And that allows you to drain some of the collections that might be further away from the wall of the stomach or the gut where you're not exactly seeing that favorable 5, 6-millimeter distance, which is your safety distance to be able to deploy a LAMS. But it's more in the 10 to 12-millimeter range where you can probably opt for a longer saddle like the 15-millimeter Axios. So, you're in a great position. Again, this is a sheath. This is an all-in-one, multi-step deployment device. And it does require, obviously, heat because it's heat-enabled. So, I don't know if we have grounding for this model that will allow us to use heat. Oh, that's a good point. We just need something to put on the metal, I think, right? It's ground-worthy? Oh, okay, good. Excellent. I didn't see that. We'll just transfer that. That's okay. And so, again, the number of applications for LAMS has expanded quite a bit from the classic pancreatic and pedipancreatic fluid collections, which we've done for several years, to recently doing things like gallbladder drainage, as we saw in several videos this morning, and US-guided gastrogynostomy in cases of gastric outlet obstruction. So, I am going to pull the LAMS out. And the manufacturer actually made this a little bit easier for those who are just learning the device for the first time by providing the four steps involved in the deployment process in numbers. So, basically, you go in sequence from one to two to three to four, and we will demonstrate that today. As you can see, there are two phases of deployment. There's the inner flange or the flange away from the deployment, and then the proximal flange or the flange closer to the scope deployment. And each one of these essentially has two steps built into it. So, you have a total of four steps involved. And to be able to pass this almost 11-french sheath, sometimes it's a struggle if you're doing this with a duodenum. So, also, make sure you have a straight scope as much as possible. What my nurses also help me do is they wet the sheath itself so you're not getting much of any friction. And then you let it sit sort of neutrally on the hub of the therapeutic linear EOS scope, because that has to go on a therapeutic linear EOS scope. Now, once you're in that position, what you'll do is that, first of all, you will make sure the patient is grounded, make sure your settings are correct. I use an Herbie-based system, and they have specific Axios type of settings. It's usually a pure cut current. The next thing you do is you test the passability of the sheath outside the scope. So, how do we do that? Unlock. Okay. So, it may be hard for you to see. I know. I was just thinking that. But at the bottom of the sheath, you have a lock, unlock. Maybe you can turn the scope, Katie. Yeah. You have a lock, unlock button right here. So, that's the first thing you do. You unlock this. And, again, you can lock and unlock as many times as you want. You unlock this, and that would allow you to advance the sheath out of the scope. Let's find that cystic structure again. We're very close. There. Okay. There it is. Perfect. So, now it's unlocked. Okay. So, where you see the arrow number one pointing downwards, you push down on the entire sheath. And you watch it come out pretty much like an F&A needle comes out in the same angle. There you go. Perfect. And you start to pinch the wall. So, this means that you are in the right projector. Okay. So, obviously, you'll see some air interference there. What you can do, you can suction whatever air you may have left next to the scope. There you go. Oh, I like that. You can put a small balloon up if you want. Try that as well to kind of keep air out of the picture. But then, there you go. Good. Excellent. And then, usually, as you push this out and you think you have very good opposition with the structure. Good. That might be a better angle actually, Katie. I like that. And we're not hot. We're not hot, are we? Let's get that. Let's connect the cables so we are heat enabled. There we go. Perfect. All right. I want to make sure we have the right program as well. So, I'm going to look and see. Usually, those are pre-saved. Let me see. Hot Axios. There we go. And you follow the yellow pedal because that's your cut setting basically. Okay. Oh, hang on. I'm not getting the green on the grounding. Now, it's green. I'm not getting the monopolar. We're hot on the, getting a yellow signal on the. There's no connection of something. It's still yellow. Oh, there we go. Well, it's still yellow, but I got the hot Axios now on the screen, the settings. Want to try it, Katie? Yeah. Okay. So, we can try it. Again, you'll know immediately if you're not having any heat. You won't get much of any penetration of the stomach wall. So, we'll position you again here. There you go. You can reduce the balloon size. I think you have a little bit too much. That's kind of getting you a little bit. Hindering. Yeah, it's getting in the way. Just a little bit of balloon sometimes. No more than just the film to lock the air away. And you must be. Yeah. There you go. Okay. It looks even bigger now. That's good. Okay. Okay. So, I'm unlocked. Unlocked, advanced. I'm going to see where I stand. You're good. Okay. Now, on the yellow pedal, if you start to see some interference, that means you are active. Try a tap, a short tap. Oh, yeah, we're live. Good. Okay, now. So. Forward. This is the freehand technique, by the way, which is what we use for pretty much all PFCs, pancreatic fluid collection. Consistent forward movement until you penetrate into the collection. Okay. Go ahead. Are you in? Yep. Okay. Now, you may not see where you are exactly. I thought I was. That's okay. So, come back and re-aim. Sometimes, I would reduce your balloon 100%. Okay. So, it's not pushing that structure out of your way. Okay. And get 100% opposition with the gallbladder or with this. There we go. Okay. Let me. And then, again, you push. Get that out again. Okay. Now. There. Perfect. Beautiful. See, you can go in until you get close to the contralateral wall. Sometimes, you don't have to go all the way, but at this point, step one out of four is complete. You lock your device, and then what you do. Get this off. You remove that yellow spacer. Okay. I'll show this to the audience. Usually, they keep this to protect you from doing step two prematurely. So, this is your safety lock. Remove that, and then you would unlock the handle, which is that top part, and then depending on the size of your hand, you can do this. I don't know if you can demo this technique, which I like because I have large hands, but I understand this can be tough. Yeah, I'm like, uh. So, gently, you start pulling, and as you do that, this deploys the inner flange. See how the flange is opening, and it's opening, and it's opening, and when it opens completely, it locks in place, and sometimes, we can do this if it's not deep enough, and there we go. So, the inner flange, and we can show you, so you can see it from there, is fully deployed inside the collection. So, now, step two is complete. The first half of the deployment is complete. That's the inner flange, and now, we will finish by deploying the- Step three. Mm-hmm. There we go. All right. So, now, what you do, you unlock. The very first button you unlock, you go back now and unlock one more time, and what that does, basically, it allows you to pull the entire sheath, pull the entire sheath backward until that flange starts to collapse, and here's a demo. You don't want to pull too hard because you don't want to dislodge the whole thing back to the stomach, obviously, but you pulled enough to see the beginning of a collapse in that flange, and then, once you are there, you lock it, and you go to step four, which is the last step, go back to the top of the handle now, unlock that light gray part of the assembly, and go to the same technique. Now, I like to deploy the proximal flange in the scope- Okay. ... and then back away from the wall. I think this is what a lot of people are doing now, which means you essentially stay in this very stable position until it deploys, right? And now, you back away from the wall, and you push the catheter out, as you can see on that scale. There it is. Yay! Fantastic. And you can see now there's some drainage. I don't know if you can magnify that picture, but you may be able to see in live endoscopy views there, and then, obviously, you remove the grounding and the electrical cable, and then you remove- Good. You remove the- Device. Good. Cool. And then, depending on what you want to do next, you could potentially dilate this LAMS. You could put a double pigtail in it. If you're draining a necrotic collection, and you want to make sure it doesn't get clogged, you can put a couple of double pigtails in it through wires, or you can leave it to drain naturally without dilation. If you're only dealing with a low necrotic collection content, or just a pseudocyst, which would be what you want to do. Cool. Thank you so much. Looks like we have another question. Some of the speakers. I'm going to read the question. I wonder if everyone can see the question, but essentially, the approach, direct access approach for access. Any reason not to do this over a wire? It seems like that would provide a safety net if it didn't deploy correctly. That is correct. You can deploy this over a wire. However, I can tell you the pros and cons for this approach. In a pancreatic fluid collection, if you puncture, and then it doesn't go well, you go back and puncture again, typically not a big deal. Remember, these collections have mature wall, and they're stuck on the stomach. But the stakes are higher if you're doing an edge or a GJ, because essentially, if you lose your access, then you have a hole in the gut that you have to work with and close. What I found that sometimes having a wire may push away your target gut rather than actually make it easier. I see this especially with GJs and sometimes with edge, where as you advance over the wire and the wire buckles into that target lumen, it may push away the entire limb of either gastric remnant or the limb of the jejunum you're trying to access. I'm not saying do not do it, but you'll hear from some of the experts that they prefer the freehand technique because it's completely flawless. The chance of having a problem from that is really, really small if you follow these tips accurately. And you've done a fair number of practice the deployment of these quite sufficiently before your first live case. So yes, good question. Not as much of an importance in pancreatic fluid collections, but it could have some impact on the easiness of accessing the target structure in cases like edge or GJ. However, if you have a maldeployment of an axios, you probably, and you would like to salvage it, you need a wire at that point. And there are different things that have been described about how you recapture a maldeployed axios. I think there are four different ways that have been described recently about where the maldeployment is. It depends on where the flange is. Did you puncture both sides and you got your stent all the way to the target structure and then it got maldeployed or did it get maldeployed just in the first phase of the deployment? So I guess it depends on how far along the process you were and how you capture it. Almost always depends on your ability to get a wire across to the target structure, whether it's adrenum or stomach or whatever that is. And then going over that with either another axios or a fully covered stent to bridge that essentially the track that you use the first time, which is now perforated basically. Brief questions. Anything on axios or on lambs? I know this is the brand we use today, but this is the only heat enabled one we have access to in the US. I think we'll see probably more of these come in the next few years. But we have other things we can demo as well. I don't know if you can find the liver. I was hoping to demonstrate a random liver biopsy, Katie, because that's something we're doing many more of now as we have great fine needle biopsy platforms to provide adequate liver tissue. And I think I can maybe also help with that. Like is the liver kind of looking like a gallbladder? Yeah. Well, come back a little bit more. Okay. And yeah, the liver looks, you're right. Right? It's a little like a gallbladder full of sludge. Yeah. Because here's, I'm getting you right on the... Yeah. It's like almost as calcification or something. Well, we are going to pretend that this is the liver. Why don't we talk a little bit about liver-guided liver, US-guided liver biopsy for random access of liver tissue. I'm not talking about targeting specific lesions in the liver like cysts or metastatic lesions. I'm talking about just getting a piece of liver tissue for histopathology and check for fibrosis. Try that. Absolutely. So briefly, a couple of different ways to do it. You would want typically a fine needle biopsy platform, either, or you can use a 19. My needle is either the sharp core or the acquire 19, because you would want to get more tissue. Unfortunately, with 22 gauge needles, you get fragmented pores of liver. That does not help the pathologist determine the degree of fibrosis. So you really need something that gives you solid pores, basically, with minimal fragmentation. But since we don't have a 19 gauge needle, I am going to settle for what we have here, which is a 22 gauge. We'll pretend this is a 19 gauge. And I think what we want to demo is, obviously, you have a few techniques you can follow. The one I've been mostly attracted to lately is essentially the slow-pull technique. There's also the wet saline suction technique that you may have heard of as well. Yes. A lot of people are using that. But maybe we'll start with demoing the slow-pull technique, and then we'll talk about the wet suction technique. So again, you'll see the wet leftover of the liver from the GA junction. Again, if you have a 19 gauge needle, it's preferable that you do the biopsy from a proximal location so your scope is straight, which is just past the GA junction as you torque counterclockwise into the left side of the abdomen and see the left lobe of the liver, or anteriorly since part of the left lobe is actually anterior to the stomach as well. Okay. Again, with 19 gauge, what I recommend is one sharp, quick jab or puncture to get deep in the liver. Make sure you do a good Doppler assessment because those short gastric vessels in between the liver and the stomach can bleed on you. And I think I have a case I'm showing tomorrow on how this can cause either a hematoma or a bleed if you don't select your site carefully. Also, you don't want to puncture a large, either a tributary of the portal vein or a biliary structure because that would cause potential collections and subcapsular hematomas and such. But we are going to say that we've checked the Doppler. This is safe. Just imagine where your needle is coming out. Make sure there are no structures in the way and it's all liver parenchyma. Okay. And then one sharp puncture. Jab. Jab gets you deep, usually in about four centimeters in. You can measure and if you are anxious, you can lock your needle at the four centimeter mark so you're not going too far in. Most of the time, that's not needed. My recommendation before you do any biopsy is to enhance your wall opposition by using your up and down dial all the way up so you're hugging the wall 100%. Sometimes I even tell my fellow to lock it. Okay. So you don't have to keep your thumb on it. Don't have to think about it. There you go. And then get that needle out and puncture the liver. Okay. Okay. See myself sort of driving right past it. Let's see. And sliding is common in this case. Is it? Okay. Yep. There we go. So you can see you're in and usually what I recommend doing is no more than four to five long actuations as myself or my technician is slowly pulling the stylet back. So about four to five actuations as the stylet is pulled back. And there you go. The reason I like long actuations and fewer of them because I don't want to, if you're doing too many short ones, you'll basically break down the cores that you're obtaining. And then the way I like to express the specimens after we unscrew the needle, I put them in formalin and I use the stylet to slowly push the specimen out in the formalin cup. And as the liver core start to come out, I will engage the tip of the core informally and slowly swirl this in so it comes out in one big piece. So I'm very gently pushing it out. Never use air flush because it will fragment that specimen and your pathologist will not be happy with a large number of small tiny fragments from your liver biopsy.

live endoscopy course

Mo Al-Haddad

Katie Vozo

virtual option

ERCP

EOS

therapeutic endoscopy

LAMS

liver biopsy techniques

fine needle biopsy device