All right, welcome back. And we have five videos for the five finalists to share with you. And I know everyone got shuttles and some of you already changed their flights. So we would like to stay efficient. Most of the videos are under six to seven minutes, so we should be okay to wrap up. And we will allow just for housekeeping, like two minutes for feedback on the video. So if faculty would like to give feedback, please be very concise to the point because we will not get everyone out by 1230. Wonderful. Thank you so much, Mo. So getting to the fun part, we're going to start with the first fellow here, Kush Bugala from Mayo Clinic. We're going to play the video, we're going to mute it, and all of the fellows are going to present it live. And I believe all faculty have the scoring sheet. And then we'll announce the score at the end. Good morning, everyone. My name is Kush Bugala. I'm an advanced endoscopy fellow at Mayo. And I want to thank you all for the opportunity to present today. I will be presenting a case of combined ERCP and EUS guided palliative biliary drainage in a patient with altered anatomy. I have no relevant financial or industry disclosures. So our case is a 37-year-old female with no significant past history who presented with abdominal pain to the emergency room. She was found to have a 10 by 15 centimeter adnexal mass on CT thought to be of ovarian origin. And so she underwent surgery. She underwent an X lab with removal of the left and right fallopian tubes, a salpingo-oophorectomy, and removal of the right adnexal mass. Surprisingly, pathology on this showed metastatic adenocarcinoma thought to be of GI primary. And hence, she underwent an EGD, which showed diffuse thickening of the lesser curvature in the antrum. Pathology from this EGD revealed poorly differentiated adenocarcinoma with signet cells. At the same time, she also underwent an EUS, which showed wall thickening of layer three and four in the lesser curvature, body, and antrum. After discussion at a multidisciplinary tumor board, she was recommended the following treatment. She underwent neoadjuvant chemotherapy, followed by high-tech therapy, and then underwent a robotic-assisted subtotal gastrectomy with Roux-en-Y reconstruction. She was doing well and then had a surveillance CT scan six months later. Unfortunately, she was found to have a soft tissue mass near the hilum, causing intrahepatic biliary ductal dilation. And so for the purposes of acquiring tissue as well as relieving the biliary obstruction, she underwent an ERCP. This was performed with a pediatric colonoscope given her altered anatomy. So just to recap, she had a subtotal gastrectomy with Roux-en-Y reconstruction. And a five-fringe pancreatic duct was – stent was placed to facilitate cannulation. So as you can see in the top left picture, that was the configuration of the scope required to reach her papilla. She had a native papilla. And then on the bottom left, you see cannulation has been achieved. The cholangiogram showed a complex hilostricture, which was balloon dilated to six millimeters. Tissue was obtained. And then a seven-fringe by 12-centimeter plastic stent was placed in the right hepatic duct. And so a patient was recommended a serial stent exchange program for the plastic stent. Tissue did reveal metastatic adenocarcinoma. Given logistical and financial difficulties, the patient requested a long-term solution. She couldn't adhere to a serial stent exchange program. And so we decided to opt for a combined EUS and ERCP approach to drain her liver. We first start with drainage of the right hepatic system. So using a pediatric colonoscope, the previously placed plastic stent was removed. And then access was gained. The cholangiogram shows a severe complex right intrahepatic duct stricture. All the access biliary segments were balloon dilated. This shows a pretty significant waste. And then a 10-millimeter by 6-centimeter uncovered metal stent was placed across the stricture. Initially the plan was to place two stents in a Y configuration. But given the use of the pediatric scope, the positioning and the limited accessories that were used, that was not feasible. And so after doing this, we moved on to the left hepatic system. And we decided to drain this using an EUS-guided approach. So here you can see the endosonoscope was inserted into the stomach. And access was gained into the left system into a segment two duct. Here you can see contrast injection. And then this is being reproduced on fluoroscopy. You can see that the left system is being delineated here. And the stricture is seen in the left main hepatic duct. And so at this point, a hepatic gastrostomy was created. Here you can see balloon dilation of the tract, followed by placement of a 10-millimeter by 8-centimeter fully covered self-expanding metal stent across the tract. Lastly, a coaxial 7-fringe by 7-centimeter double pigtail plastic stent was placed across the fully covered metal stent. And so, to summarize, we opted for a combined ERCP and EUS approach as follows. For the right system, we performed an ERCP with placement of an uncovered metal stent, and for the left system, we performed a hepatic gastrostomy with placement of a fully covered metal stent and a coaxial plastic double pigtail stent. Patient was seen approximately eight months later as in follow-up. She was asymptomatic and doing well. Her liver enzymes were stable. And on the CT here, we are able to see the stents, which are in good position. The yellow arrow points to the right-sided uncovered stent, and the green arrow to the left-sided hepatic gastrostomy. So palliative biliary drainage and malignant hyaluronabstruction is often challenging, and combined approaches are often required for obtaining more than 50% sectoral drainage. This is what's recommended by most societies. This can be in various forms, including ERCP with bilateral stenting, ERCP with percutaneous drainage, and ERCP with EUS-guided drainage. So this can either be in the form of an EUS-guided hepatic gastrostomy with biliary stenting in the right side, or a EUS-guided hepatic duodenostomy with biliary stenting in the left side. This is especially helpful in cases with altered anatomy, where using an enteroscope or a pediatric colonoscope may make traditional ERCP and bilateral stenting more challenging. And so ERCP and EUS-guided drainage can provide effective internal drainage and potentially improve the quality of life and survival, especially for younger patients who may not want percutaneous drainage. And so in conclusion, the use of an enteroscope and pediatric colonoscope poses many challenges, including the angle of cannulation, as well as use of accessories. And this may make ERCP with bilateral stenting challenging in patients with altered anatomy. In these situations, a combined ERCP and EUS approach can provide an effective internal alternative to using ERCP with percutaneous drainage for management of palliative management of malignant hyaluronic structures. Thanks.

adenocarcinoma

neoadjuvant chemotherapy

ERCP and EUS

palliative biliary drainage

malignant obstruction