I'm going to show you another video. And I do not want any commentary on the editing, because, you know, I never got to take Raju's course. So this is hot off the press, and it's one of my colleague's cases that she let me take. Fifty-seven-year-old with newly diagnosed pancreas cancer with mets to the liver who presents just recently with recurrent nausea and vomiting and a CAT scan that showed gastric outlet obstruction. So here you can see important things to think about when you're going to do ERCP on these patients. They look like maybe you're going to have trouble getting down there. But in any case, came with a gastric outlet obstruction. You can see some liver mets. So what are our options here? So what are options for someone who, I don't know, I don't think I really showed a really good area of the CAT scan, but it's sort of like D2, D3 area. So what kind of things can we do, you guys, for gastric outlet obstruction, unresectable pancreas cancer? Shout it out. Okay. What's the standard of care right now in 2023? Duodenal stent. Right. So duodenal stent. Sure. GG. What other options? GJ. That's for duodenal stent. GJ. Okay. Anything else? PEG. Venting PEG. If you really want to be, that's kind of like the end, the end, right? What else? Like a surgical GJ? Right. Surgical. So correct. You guys got them all. So, you know, our, you know, reasons we don't want to do surgery is someone has a bad cancer and I'm not going to live that long, and it kind of seems like a big deal to do that. If you want to start them on chemo, they have to have a period of waiting. So surgery, you know, is effective, but maybe a little aggressive. Duodenal stent is sort of what we standardly do, right? We put a duodenal stent in, and typically this works really well, although my present fellows think that EUS guided GJ is standard of care. So this patient gets a GJ. That's the plan. So what I'm showing you, because we didn't have video from the first part, is that basically we put a nasocystic drain down into past the tumor area to fill up the jejunum or distal duodenum. We usually use a combination of saline and a little methylene blue and a little contrast. So this is just showing, again, I don't have video of this, but this is the tube, the wire going down, and then the tube going down, and you see a little contrast here sort of showing where we're going. And then here's a still picture. So this is an image of the small bowel, you can see, and it's getting filled. So you basically put this connected to the foot pedal and you're just cranking it in, because you're basically trying to make it like a pseudocyst, right? The trick is, it's not really adhesed, right? So this is where we all get a little anxious, you know? And so people have been using, OK, should we put a wire down first? So you guys played with the Axios yesterday, so you see that you can put a wire down there. So you could go with the needle, get in there, aspirate, OK, I see blue, this is good, put a wire down, and then deploy the stent. But then people are having issues with this, because the question was, was the wire pushing you away, and then sort of shifted to going no wire. So here you are, and you just keep cranking, and you keep cranking, and you're trying to make this big. And some people have said, I think Jen Maranke once, when I had a conversation, was like, oh, it's super easy, just fill it up, really big. And I don't know, Jen, what are your tricks? Because you seem to think this is very easy. We moved away from puncturing it. We would first puncture it, get a wire in, and then put the Axios over the wire. And things, there's just too much. It moves away from you. And so now we just go straight into it, and we start burning before we even really tent things. What do you do if it's like, doesn't look like it's filling, staying there? What's that? Like, does it always fill just the way you like it? Well, sometimes it takes a good bit of time. Sometimes we have to look for a good loop of bowel that's getting filled. Sometimes we have to be kind of patient. I think that this part of the procedure is the most challenging part. Sometimes it's like, oh, yeah, we're just going to get a tube down across the stricture, across the tumor, and it's going to be fine. Sometimes that's the hardest part. And so I think that glucagon does help. I don't think we've done glucagon. So what do you guys think of this? Does this look OK? Are we good? I always get worried because the colon looks very much like the small bowel. OK. Does this look like colon? I mean, there's still a lot. You know, you have to look at this distance, right? Make sure it's nice and close. So I don't know if this is the final image that they used. You could aspirate it if you have concerns, and then if it's blue, it's not the colon. Right. Right. OK. All right. So they put the axios in. That looks pretty good. Yeah. Yeah. Let's go back to that. Yeah. So, you know, I think that that's kind of not the angle that you'd ideally want, right? Because the axios has, you know, the catheter that's where the cautery is, is actually deeper than where the stent, you know, starts to open. So you really want to be a little bit more oblique. A lot of depth. And have a lot more runway instead of, like, perpendicular to it, like it is kind of now. After you've deployed that flange, it was really, really... Yeah. So you want to have more runway to do it and be a little bit more oblique to it than perpendicular. I know you guys know what you think is going to happen, but... OK. So the stent is placed. And look, we got blue. So this is the beauty of the blue, right? Then you see the blue coming through and everybody feels good. Life is good. Yeah. OK. So there it is, right? Isn't that cool? Yeah. OK. So here's a post-procedure. I don't remember. I think he came in maybe earlier with some nausea and vomiting or something. And you can see, that looks good, right? We're happy with that. So he was admitted seven weeks later, had been getting Fulfurinox, and he was having diarrhea now with food intake and intermittent nausea, vomiting, and it's feculent. All right. So this is my attempt to try and do... I had to slide the blue as my mouse trying to move through the CAT scan. And I'm going to try and pause it, see what you guys think. OK. So wait, let me go back. So here's sort of our... So question is, what's going on here? Can you guys tell anything? A little fuzzy around there. I don't know. It's sort of hard for us to tell here. But there was some concern about a fistula to the colon. You can see I didn't do quite a good job as others. OK. So here's a little video. So here's our stent. I couldn't put it all together, you know. So what do you guys think of that? I don't like to see that. You guys, what do you think this is? Poorly prepped colon. Here for chronic constipation. All right. Here's another video. This is the bigger, longer video. Yeah. So Axios is taken out. And you can see we go in here into the fistula. And we've got two lumens. Any thoughts as to, like, what happened here? There's our small bowel. It basically withdrew back. The distal flange withdrew back and then entered the colon. I don't know. I don't, you know. We weren't there. Maybe the cautery tip went through both. Yeah. I wonder if there was interposing colon on the way to the jejunum. So, but initially it was fine for many weeks. So the thought was it just eroded. And that is being described now, I think. Right. There are actually a lot of cases coming out of the Axios eroding into the colon. I know there are some institutions putting a case series together. I don't think there are that many. So, I don't know. In any case, so what do we do now? Thoughts? Close the colon. Looks like a savory virus going in. Well, yeah. So first, you know, we need to figure out which direction small bowel is going, right? We had Jeff Marks come in to look to see about overstitching. He did not think that was going to work very well to close that fistula. So this is where like getting your people together. I mean, when we got the CAT scan, I was actually at one of the hospitals. My colleague who was on call got the call and we're like trying to look. Because the CAT scan wasn't entirely clear. But it certainly, the whole story sounded like, you know, this was into the colon. And so, you know, we talked to our radiology surgeon. So we sort of, you know, got the troops together. Now, I wasn't there for the procedure, but apparently there were just, you know, ten people in the room. You were there, right? I was home. Yeah. Standing room only. Yeah. Can you do a colon and put an esophageal stent across the fistula? I mean, you would have to like talk to the family and the patient. Absolutely multidisciplinary decision, but. Right. Yeah. So we were trying to figure out. Well, initially it wasn't quite clear. We were like, can we pull the axios out? Is that going to be a problem? But then when we saw this, it's clearly all perfectly fistulized. So the thought was to. Totally wild idea, but what about like an atrial septal occluder? I think it's a pretty big hole. I don't think that that would be big enough. I mean, I've never used one. It's been described for like fistulas and stuff, but it's kind of curious. How about closing the fistula from the colonic side? Yeah, that's what she was saying. With what? Like a fully covered esophageal stent, maybe. Yeah. I guess you would bowel prep them through that fistula. Yeah. We were thinking about that because you can't really bowel prep them. You give an oral prep. Yeah. It sounds like a stent is going from the gastro to the jejunum. Yeah, so the decision was to firstly figure out under flora, which was the efferent part of the small bowel limb, which is where they ended up putting the savory wire. And the decision was to put a fully covered esophageal stent into the small bowel, sort of caging off the colon. A little bit potentially caging off the efferent loop, but that was coming back into the stomach and going out anyway, so we thought it would be okay. In addition to that, I think a duodenal stent would help as well now. On top of? On top of this, right? You mean in the native stricture area? Correct. Hmm. To completely decompress the stomach and reduce the burden on the iatrogenic. That's a possibility. We may not do that, but that's a good thought. I'm surprised the surgeon didn't think that suturing would help. I would have thought that if you put a camera, a gastroscope through the top, a colon scope from the bottom, and do what Shivangi said, sew from the bottom, and then just make sure that from the top that you're not sewing small bowel. I think that would have helped. I think that would have been the more durable response. Putting fully covered stents in the colon is always a tricky game. No, this is a small bowel. No, I know, but whether you want to close it off either way, it's a tricky game because you're going to have to deal with migration, which happens in 25%, whether you clip it, suture it, or whatever you do. It's just not going to stay, and this fistula is huge. It's going to take a lot of time to close, so you have to think long-term and something durable. Let's see how they anchored it. So we didn't think of a duodenal stent. I don't know. Did you? I just watched part of it, so I don't remember. Amitabh's backing away now. Slowly, slowly. I tried duodenal stent and went to GJ, but I don't know the case. I don't remember. I don't know the case. But I do think some of the issue that's interesting with our fellows is they think that the GJ is like the standard of care, right? Duodenal stents work really well, and these patients don't live very long. This patient's having progression on filferinox. It's just interesting because they now think this is sort of standard. I want to add a point because I had a case where I did a USGJ with a fellow, and everything looked great. And then you get the methylene blue, and you're like, yes, this is great. And it was the exact same person. We didn't have the fistula, but it was just USGJ to the colon, which on retrospect, you see it on fluoro. But the patient came in with the diarrhea, et cetera, and then we looked and realized that was to the colon. Don't be fooled that just because you're getting back the methylene blue that you're not infected. We must have just put so much fluid, the methylene blue, that it... That it got all the way to the colon? Exactly. Because there was no fistula. There was nothing. It was just directly to the colon. So now every GJ I do, even if I see the blue, I try to peek in with the scope and make sure it's the duodenum or small bowel. Two articles, and I think the European, whoever was doing it, was injecting contrast afterwards. Yeah, I did that. Described a case where they took the stent out because it was in the colon. I don't think we've been injecting contrast. We've just relied on the methylene blue. Yeah, I just put a 9-12 biliary balloon up to it. So I guess what I want to say is that, you know, there are... This device was made for a specific reason, and now we're doing it and using all kinds of new applications. Even in the bile duct is fraught with issues, frankly. I mean, I've had it go fine. And when it goes fine, just like you guys are saying, it's like, whoop, yep, good, go on with your day. But when it goes shitty, it's just, you know, it's just kind of the worst. Because here are these patients that you're trying to minimize things that you have to do to them so that they can enjoy the last six months of their lives, and then you screw them up with, you know, something. So, you know, have a healthy skepticism for, you know, new techniques that, you know, there may be some improvement, but, you know, if you have something that works fairly well, don't just grab onto the new thing and then think that it's great. Because it does work out really well sometimes, but sometimes it doesn't, and then you have to kind of, I mean, it is fun to think about sort of ways to bail yourself out of these things, but it's more fun when it works and it doesn't get screwed up. So, yeah, so just remember, you know, there's going to be a lot of new ideas coming at you, and you sort of have to think about what the best thing is for the patient. You know, yes, we can do EUS guided biliary drainage, but in someone who has a resectable tumor or, you know, has a benign process, like if something bad happens, that might be a really bad outcome. I mean, even though LAMs are approved for walled up necrosis and pseudocysts, it's taking us this long to really figure out, like, oh, we have to pull the LAMs at this point, and these are the things that can happen long term. So you need that longitudinal data. Yeah. A couple of questions. LAM, sorry, go ahead. Oh, I was just going to ask, so is it that the colonic fistula developed later, or do we think it was there from the start? No, because, I mean, we have imaging in between. I think he got admitted for something, and they had some imaging before that still looked okay. So I think there was a loop of colon maybe high up that somehow it eroded it. I don't know. We really don't actually, haven't totally figured it out. And then, like, I know the first part of it is putting the nasocystic drain to fill up that area, but could you also aspirate with EUS? And if you see stool, then, you know, maybe you stop. That's what I do is just puncture it. Rather than feeding the wire, I just puncture it just to see the blue. Although maybe that won't be in all cases. But now I'm even more paranoid. I think being mindful of amount of initial pumping of water you're doing and keeping an eye on the fluoro, so you're just not continuously pumping that the water makes it to the colon, and now you don't know what's the small bowel and the colon. Or you can move the patient maybe. Try and make it. I don't know. But also there are case reports of hyponatremia if you use water instead of saline. So, like, things that, like, you would just never think of that can happen, you know, when you're doing new things and being creative. So just things for you guys to think about as your new technologies are coming out and, you know, bad stuff can happen. So this is a good example, not this case, but this paradigm of you finding an application for a technology rather than, you know, the application looking for a solution. So in this particular case, using GJs for, sorry, LAMs for GJs, there is a very solid indication. And that solid indication is benign foregut strictures. Patients who have complicated peptic ulcer disease who are not good surgical candidates would be, you cannot put an uncovered stent and fully covered stents will migrate. So this is a perfect case. So you find that patient, have a discussion with your surgeon, especially those patients who have hostile abdomens. They don't want to operate. They're a perfect case for USGJ. And they have a benign duodenal stricture, benign gastro duodenum outlet obstruction, not malignant. You can do it in malignant, but bad things can happen. To this date, I have not seen any duodenal stent for malignancy that created a problem other than in growth. And that is also quite rare because they die very soon, unfortunately.

pancreatic cancer

gastric outlet obstruction

Axios stent

fistula

complications