Good afternoon, and welcome to our virtual hands-on session. I hope that you all enjoyed the morning. I think there was a lot of great conversation. So I am Ashley Faux, and I'm one of the co-directors of the course. Hopefully you heard me earlier, and we are recording live from the ITT Lab, where Jen Marenke from Hershey Medical Center and Ajaypal Singh from Rush are going to be showing you some techniques using EOS, and I think it's mostly EOS, right, guys? And I'm going to be monitoring the chat. So if you have questions, please feel free to put them in the chat, and we will ask questions as we go, and Jen and Ajay will take it away, and happy to chit-chat during your hands-on session. Thank you, guys. Thanks very much for that introduction, Ashley, and thanks for the opportunity to be here with you all today. Welcome to the virtual hands-on session. I'm Jen Marenke, and I've got Ajaypal Singh with me. We're going to be showing you a few EOS techniques, as well as ERCP with sphincterotomy techniques. And we're going to first start using our liver model by using EOS-guided liver biopsy. And Ajaypal, is this a technique that's commonly done in your institution? Yes. We have been doing more and more of liver biopsies recently, especially with multiple studies in the new data that has come up. Over the years, our approach has changed significantly, and we have now multiple studies and meta-analysis showing the safety and adequacy of EOS-guided liver biopsy, and we are making full use of it in our clinical practice. So the same for us. We are finding more and more reasons why patients are undergoing upper endoscopy in the evaluation of liver disease. Some are getting ERCPs, and some are also needing a liver biopsy at the same time. And so this is really a handy technique. And so I'm first looking through the liver parenchyma, trying to avoid some of our ... We've got a patient also who has terrible pancreatitis. And so I'm trying to find a good location for our EOS-guided liver biopsy. Now I will say that typically the yield is a little bit higher with EOS-guided liver biopsy if you can take a specimen from the left lobe and the right lobe. So Dr. Maranki, how is your approach, how is the patient selection for these cases work? Where do you get most of your reference from? So most of our referrals are from our liver team, are either patients who there's some concern for cirrhosis or fatty liver disease. Patients are also getting a liver biopsy if their fibroscans have been inconclusive. And so I'm just looking for a nice window here, right here. So here we have a lot of parenchyma, and I typically tend to go in a thicker part of the liver. And so I will also use a 19-gauge needle. And we generally rely on wet suction for procuring the specimen. And so Ajay is going to get the needle together for us. I'll use Doppler ultrasound to ensure there's no intervening vessels. I don't know if we have it on here. There's no flow here, so we should be fine. But in the beginning, when you are starting your practice, it can be a little bit challenging and daunting to find the right area where there are no vessels. And I still spend a lot of time in finding the right spot in the liver where I will be doing my puncture. So we'll start by using our 19-gauge needle. You can use a 22-gauge needle as well, but the yield tends to be higher with a 19-gauge needle. And it's also been shown to be a very safe procedure, even with a 19-gauge needle. There's a very low risk of a bile leak or anything like that. And studies have shown that the Francine needles might be a little better than the 4-pit needles for this case. And a wet suction technique where we take the stylet out and prime our needle with heparin saline, which we'll be doing right now, has been shown to be helpful. The nice thing with the 19-gauge needle in this position is the scope is nice and straight. If you've ever tried to use it in the head of the pancreas, it's a kind of a nightmare. But it's nice and straight here, so it makes it easy. Dr. Moranke, do you always go to both sides of the liver? How is your practice? I have been. Ever since the, you know, in discussing with David Diehl, we communicate with him a lot, and he's really done most of the research on this technique. And he really advocates for going to both the left lobe and the right lobe. And so as long as I have a great window, the left lobe almost always will be accessible. And so I at least start with that. If I feel like I have a great specimen, macroscopically when we're looking at it, I sometimes don't proceed to the right lobe. But more times than not, I'll go through the right lobe as well to get both lobes as a more representative specimen. And so I'm putting my sheath out a little bit here, typically to about two, depends on the needle that you use. And then I'm also, get my liver in place. Great, thanks. You can see there's my needle and a puncture into the specimen. You can see the tip of my needle here, and we're just going to rotate it around so I can see that. And then we're going to apply the suction. And then I'll go through three times, long throws to get a good specimen, turn off the suction, pull my needle back, and lock it closed. Jen, can I ask a question about when you pulled that needle back? Sure. Do you ever kind of move it slowly with Doppler, just to make sure that if you've gotten into a vessel that there's not bleeding coming out of the tract? Because I've heard some people describe that. I think Ken Chang, I feel like maybe made that comment about doing that. I don't generally, but it's probably a good practice to do that. We don't have Doppler on this machine today that we could tell, but certainly using Doppler before and after is a nice way to, and then you also want to look at your tract line and make sure that you don't have any kind of evolving hematoma, or when you're looking at the biliary tree, make sure that there's no extravasation of any blood in the biliary tree as well. Those are some of the things that you want to do post-biopsy. I have a couple of patients where they had some post-procedure discomfort and there was a small hematoma. So now I am very slow about pulling it out, kind of use the zigzag path. I don't know how much it helps. It's more, I think, for my psychological health than it really helps, but I do sometimes try to use that on my way out. Okay, great.

virtual hands-on session

EOS-guided liver biopsy

ERCP with sphincterotomy techniques

cirrhosis

fatty liver disease