Good evening, everybody, and welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's webinar. My name is Ed Dellard, I'm the Chief Publications and Learning Officer here at ASGE, and I will be one of the facilitators throughout tonight's presentation. Our program tonight is entitled Update on Endohepatology. Please note that this presentation is being recorded and will be posted on GILeap, ASGE's online learning management platform. You will have ongoing access to the recording in GILeap as part of your registration tonight. I also want to acknowledge the gracious educational programming support from Olympus for the remainder of the 2021 ASGE Thursday Night Lights programs. Thank you. Before we get started, please note a number of features in tonight's platform so you are aware of the many resources available to you during and after tonight's program. 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Dr. Yu, the webinar is all yours. Great. Thank you so much, Ed, and thank you to ASGE. My name is Marvin Yu, and I'm at Brigham and Women's Hospital in Harvard Medical School. It is my absolute pleasure to be hosting tonight's webinar on a topic that is near and dear to my heart, endohepatology. It's also a distinct pleasure to be hosting tonight's webinar with my friend, Jason Samarasinha. Good evening, everyone. Marvin, the pleasure is all mine. It's been a great run up to this point, getting this webinar together, and we're really looking forward to this. It's a lot of excitement being built over the last few weeks, and I'd like to thank you for that. I'm Jason Samarasinha. I'm an interventional gastroenterologist at UC Irvine, and it's my pleasure to get us started here. All right. So tonight's moderators will also include our good friends, Dr. Ahmed Baserbashi, who's assistant professor at Washington University in St. Louis, and Dr. Jennifer Kolb, also assistant professor at the VA at the Greater Los Angeles Healthcare System. I'm also delighted to acknowledge our guest faculty. We have a very esteemed and diverse group of faculty. They include Dr. Ken Chang, chief of the division of gastroenterology and executive director of the H.H. Chow Digestive Disease Center at UC Irvine. We also have Dr. Ken Bindmuller, director of the interventional endoscopy services at Cal Pacific Medical Center. He'll be joining us a little bit later in tonight's program. And I'd like to introduce Dr. Harsh Khara. He's an interventional gastroenterologist at the Geisinger Medical Center. He's an associate professor of medicine. He's the director of endoscopy. And he has tremendous experience in the field of endohepatology, particularly in the areas of EUS-guided liver biopsy and shear wave elastography. Harsh, welcome. Also, I'd like to introduce Dr. Raymond Rubin. Dr. Rubin is a general and transplant hepatologist at Piedmont Hospital in Atlanta. He was the actually founder of the Piedmont Liver Transplant Institute and is the chief scientific officer at Piedmont. He has been a large proponent of EUS-guided portal pressure measurements, and I believe at this point, with his interventional GI colleague, Dr. Minesh Mehta, has probably done some of the largest numbers in the United States. I would look forward to hearing the hepatologist's perspective on endohepatology and the collaboration happening over at Piedmont. Ray, welcome. And last but not least, Dr. James Katravisas. James is a friend of mine. He's an interventional radiologist at UC Irvine Medical Center, definitely one of the most highly skilled interventional radiologists that I've ever met. He's an expert in TIPS, BRTO, CARTO, vascular interventions for portal hypertension. He's got just tremendous knowledge and has been a tremendous resource for me and has been extremely generous with his time and knowledge and willingness to collaborate. James, we hope to learn a lot from you tonight. Welcome. So, the goal of tonight's webinar is twofold. The first is to highlight recent advances in endohepatology, and the second is to highlight the recent formation of the ASGE endohepatology special interest group. It is our hope that this newly formed special interest group can serve as a vehicle to promote collaboration as well as to advance this emerging field. We are hopefully planning for an in-person networking event at next year's DDW, and if you are not a member or interested in membership, please contact Steph Morales at ASGE at the email shown on the slide there. I'd like to take you through the agenda, and Marvin, I think we're doing a pretty good job with the timing so far. You're going to go up next to talk about an update on EUS guide-delivered biopsy, followed by a discussion with Dr. Khara. I'm going to give a literature update on EUS PPG and have a short discussion with Dr. Kenneth Chang, Dr. Chang, a short discussion, and then, Marvin, you're going to do a literature update on a gastric barocele coiling. We'll have a discussion with Dr. Kenneth Binmuller, and then we'll have a roundtable discussion of endohepatology with all of our panelists, followed by a short wrap-up. We're going to start here with the update on EUS guided liver biopsy, and please, this is going to be sort of a quick shot update on EUS guided liver biopsy. This is maybe five or six slides, and I really want to get into this conversation with Dr. Harshit Khara. We have a very diverse group of audience participants, and I just want to make sure that we're on the same page. So, if you've not seen an EUS guided liver biopsy, this is what it looks like. This is the view of the left liver across the stomach. One of the first things that you'll notice is that the liver parenchyma is reproducibly very, very close to the transducer, regardless of body habitus, on the order of about a centimeter. So, you can see everything. What you just saw right now was the 19-gauge needle performing its excursion into the liver parenchyma. There's a Doppler window that you may or may not be able to appreciate that actually visualizes the intervening blood vessels and bile ducts to avoid. And so, there are various techniques for EUS liver biopsy, but I would say that most of us are using 19-gauge needles, maybe one or multiple excursions, and some degree of suction. So, this is what EUS liver biopsy looks like. It's technically very straightforward. Both the left liver and right liver sampling is possible. Obviously, you're also performing an endoscopy or an endoscopic evaluation in addition to the sonographic examination, so you're almost getting a two-for-one, if you will. It's a very quick procedure on the order of 10 to 15 minutes in experienced hands, and the recovery is also pretty fast. It's not the traditional several-hour recovery after a traditional percutaneous liver biopsy. So, the advantages of EUS liver biopsy, again, sampling, bile ovarian sampling is possible. Both endoscopic and sonographic examination is performed, and I think this makes sense if the patient requires or has more than one indication for liver biopsy or endoscopy. So, other indications could include variceal screening, for example, sonographic examination of the biliary system, and portal pressure gradient measurements, which we'll get into shortly. There is emerging data to support that patients are experiencing less pain because of avoidance of going across the abdominal wall, and again, faster post-procedure recovery. Disadvantages include the requirement for deep sedation, and there's probably a higher cost, although that can be mitigated if there's multiple indications for endoscopic evaluation. This is a recent study, meta-analysis from Mohan and GIE in 2019. The published diagnostic rate was 94 percent. The adverse event rate was 2.3 percent. I would say that this meta-analysis looked at a very heterogeneous pool of studies, including studies that used needles like the QuickCore needle that are no longer commercially available, and was pretty heavy with FNA needle studies, which I think many of us are moving away from. I think it's safe to say that the diagnostic rate is probably a little bit higher than 94 percent at this point, and the adverse event rate is probably a little bit lower than 2.3 percent. Lots of studies on EUS liver biopsies over the past five years, including from many endoscopists on this panel and in the audience. And so, I want to present a very sort of quick summary of the state of the literature for EUS liver biopsy. By no means is this an exhaustive summary of the literature, but this will kind of give you a sense of where we're at. So, in terms of defining optimal technique for EUS liver biopsy, there were a group of studies, including from the Geisinger group, that looked at FNA needles versus FNB needles. And most, if not all, of these studies show that the FNB core needles were superior. So then, this begs the question, well, which particular type of core needle is better? Is it the 19-gauge Francine tip or the 19-gauge fork tip? And these are studies from Nieto's group in Florida, from UC Irvine, and from the Lehigh group. And all of these studies showed that the 19-gauge Francine tip was superior. How about wet suction versus dry suction? José Nieto's group, I think, kind of put wet suction on the map with their retrospective observational study in GIE in 2018. And then, the Geisinger group performed a prospective crossover study that corroborated that wet suction was superior. How many passes? How many actuations? So, I think, again, the Geisinger group has led the way here in terms of studies. They have shown that bilobar biopsy is better due to regional variations in various disease states such as NAFLD, and they recently published a randomized prospective study showing that three actuations were superior to a single actuation, and I think that makes intuitive sense. So, my read of the literature at this point, I would suggest, indicates the following for optimal technique for EUS liver biopsy, and we'll ask Dr. Carr what he thinks about this, but 19-gauge core biopsy needle, and specifically the Francine tip, multiple passes, and if possible, bilobar is better, multiple actuations better than single actuation, and wet technique is better using either saline or heparinized saline. This is my last slide, and I just wanted to summarize studies out there comparing EUS liver biopsy yield versus IR, either transjugular or percutaneous. So, again, the Geisinger group in the first study, their Pineda et al., back when they were using FNA needles, 19-gauge FNA needles, seven passes compared to transjugular compared to percutaneous, and it's actually an error there. What I should have said is EUS is comparable to transjugular, and in their study, it was EUS was superior to percutaneous, and then fast forward to the third item there, Shuja et al. from University of Florida, Jacksonville, in a similar retrospective single center study, they also concluded that EUS was comparable to interventional radiology techniques. There has been a recent paper, however, from the Orlando group, and this was a randomized control trial of 40 patients where patients were randomized either to EUS liver biopsy or percutaneous. The EUS liver biopsy was within 19-gauge Francine tip, two passes, and the liver biopsy was a percutaneous 16-gauge single pass device, and they concluded in their randomized control study that percutaneous was superior to EUS. Of note, all cases were diagnostic, and there were no differences in complete portal triads, but there was a statistical difference in terms of the total specimen length. So percutaneous was 26 millimeters, EUS liver biopsy was 16.5 millimeters, and this led to more optimal specimens in the percutaneous group at 58% versus 23.8% for EUS liver biopsy. There were no adverse events for either group, and finally, they did a cost analysis where they showed that EUS liver biopsy approached or was actually in excess of $3,000 versus $1,800 for EUS—excuse me, for percutaneous liver biopsy. On that note, I would like to invite Dr. Harsha Khara from the Geisinger Group. Obviously, they—you know, I would say at this point, Harsha, thank you so much for being here, first of all, and secondly, you guys have—at Geisinger have probably published the most on the subject of EUS liver biopsy, and I just wanted to reflect that in the—in the update—literature update. Can I ask you first, what is your personal technique for EUS liver biopsy? Did I capture it with that summative slide? Do you have any pearls that you can share with the group? Well, thank you, Marvin and Jason, and ASGE for this opportunity. Thank you. It's nice to be on the platform with other colleagues who share the same passion as we do for endohepatology and more particularly for, you know, things revolving around EUS liver biopsy. And, you know, that was a great representation and a summary of the data that has been made out there. So, you know, as you mentioned, it's something that we've been involved with very early on with many members on this panel as well as people on the participant group, and this has almost become the preferred method for our hepatologists for workup of EUS gut and liver biopsy. And my question always is, why not? I mean, all the data shows that this is safe. It's clinically effective, and patients love it as compared to, you know, laying on their side and getting poked either transjugularly or percutaneously. So my personal experience is similar to what you just summarized. When we do this EUS guided liver biopsy, we do prefer the 19-gauge Francine tip needle. We almost exclusively use wet suction technique with three actuations, so two passes. We always do bilobar based on the data that you shared that there is definitely variability, especially in the NAFLD patients, and there was significantly missed fibrosis if you just did unilobar, one or the other. So we always prefer to do bilobar, so it's one pass per lobe with three actuations per pass, and we use wet suction with that, and the specimens are sent separately, left and right lobe. However, the analysis is done as an aggregate. And this specimen is processed on-site, so we assess for the specimen adequacy, and if for any reason if there is visually less specimen, so as to say, we do perform an extra pass either in the left or the right based on the access, and, you know, in altered anatomy ruined by gastric bypass patients, we're also able to get unilobar sampling, which is always more than adequate. It's just you're not able to get a bilobar specimen. Great. Thank you, Harshit. And Harshit, I know that, to be fair to the Orlando group, they're not here tonight, but can you comment a little bit on your views on their conclusions about percutaneous being superior to US liver biopsy? Thanks, Marvin. Thanks for bringing that up. I think that was a very well-needed RCT, you know, that question always comes up, especially with our hepatologists and our IR colleagues, and we do this in partnership with all parties. So, you know, this is done at Geisinger in partnership with IR and hepatology, where hepatologists did perform percutaneous biopsies and our IR colleagues performed mid-guided biopsies as well. And I think, you know, based on the retrospective data that you've shown, we have shown that it's actually superior, you know, definitely not inferior, but superior to percutaneous access and comparable to transjugular access. One of the things I would comment on is the sample size is only 40 patients. We're comparing, you know, 21 USLB to 19 patients. And my point always is, at the end of the day, the patients don't care if I get them a 19-millimeter specimen or a 26-millimeter specimen. At the end of the day, it's the yield. Am I able to get them the diagnosis? And the answer is yes. Now, if you do that with a 19-millimeter specimen or 26, that really doesn't affect the pathological yield. So if you read the fine print, there were two patients in the US liver biopsy group where they were, quote, unquote, inadequate specimen. But actually, they were not. The point they were making was, if they separately assessed the specimens of each pass, they were inadequate. But when they put it together, they were able to get diagnosis. So the diagnostic rate between the percutaneous and the USLB was both 100%. So both, all patients had 100% diagnosis. Now, coming to the optimal specimen, where the definition of optimal was 25 millimeters of specimens based on the RPG, I think if you look at our ASLD criteria, as well as the British societies, I think the optimal specimen length, to me, is a length that gives me diagnosis. And our pathologist, as well as with the Orlando group, were able to read all of these biopsies. So one is to do with the sample size. The second is to do a diagnostic. The other important part is, in the supplementary section, if you look at the methodology, the USLB was done with no suction. Now, this has not been a validated or a standardized procedure. So all the published data has been with some form of suction, either air suction or a wet suction. But none of these adequacy specimens were ever done with no suction. And I think the Florida group definitely does the FNA, FNB, and the liver biopsies without any suction. So I'm not sure how generalizable that is to the endohepatology community out there. Harshit, Harshit, thank you so much. I'm sure there are going to be additional questions for this portion of the EUS liver biopsy. But unfortunately, this is going to be a quick shot on your favorite topic, Harshit. So we're going to move on to the next topic of portal pressure gradient measurements. I would ask the audience, if you have additional questions for Dr. Kaur or for the panel at large, please include it in the chat box and we will try to get around to it, at least by the time of the roundtable discussion. It's my pleasure to talk about something near and dear to my heart, portal pressure gradient measurement, and then interview the person that created this procedure. So a little background, portal hypertension is a serious complication of liver sclerosis. The hepatic venous pressure gradient or portal pressure gradient accurately reflects the degree of portal hypertension as the single best prognostic factor in liver disease. We know this measurement can guide medical therapy and predict liver decompensation and even cancer risk. So a normal portal pressure is between one and five millimeters of mercury, and it's considered clinically significant portal hypertension when the portal venous pressure exceeds 10 millimeters of mercury. The current standard for measurement has been for years a measurement performed by interventional radiology by a trans-trigular approach, and some of the disadvantages with this is some may consider this a little bit invasive, uses ionizing radiation, and it only does indirect measurements of the portal venous pressure. Recently our group, led by Dr. Chang, developed a simple technique for EUS guided portal pressure gradient measurement. It uses a 25-gauge needle, some non-compressible tubing, and the compact manometer you see on the left there. And so we first looked at this several years ago in an animal model where we went to the, it was a porcine model, and we joined with our interventional radiology colleagues at the time, and we did EUS guided puncture of the various veins and actually arteries in the pig, and then we had basically joint pressure measurements with our interventional radiology colleagues to compare. And what you see on the left panel is basically the IR balloon catheter, and you can see our needle basically measuring at exactly the same location, and you can see here kind of the EUS equivalent of this image. And as you can see, there was excellent correlation between the trans-trigular pressures as well as the EUS guided pressures. So once we established that this might actually work, we set forth to do the first human study. This was using the system described, and we included patients with suspected or established liver cirrhosis with portal hypertension. These were exclusion criterias, and all the procedures were performed by two endosynographers. The primary endpoints were really feasibility and safety, and the secondary endpoint was really looking at sort of the clinical correlation. So we had defined groups that were sort of considered high risk for cirrhosis versus low risk based on kind of procedural imaging, endoscopic laboratory studies that demonstrated evidence of portal hypertension. We looked at the group that had varices and didn't have varices, looked at the group that had portal hypertensive gastropathy and they didn't, and then groups that had thrombocytopenia and then group that didn't. So this is the equipment setup of the original device that we use and the currently FDA approved device is very similar. So 25 gauge FNA needle. This is the manometer and then heparinized saline. So we connect the manometer to the non-compressible tubing, attach the heparinized saline. And once the stylet is out, you attach the non-compressible tubing to the inlet of the FNA needle. And then we place the manometer at the level of the mid-axillary line. This is to represent keeping it level at the phlebostatic axis of the heart. So when we do EUS guided portal pressure gradient measurement, we're actually doing a transgastric transparenchymal puncture of the hepatic vein. And then again, a transgastric transparenchymal puncture of the portal vein. And I think this is part of the reason why this is so safe. You're going through essentially liver tissue before you go into the vessel. So here's a video demonstrating. So here we can see on EUS, we've gone through the liver parenchyma, we've punctured the hepatic vein. And then we flush with a little bit of heparinized saline and you often see, and you'd like to see some bubbles from the heparinized saline in the vein. And then what you'll see is the numbers on the manometer will go up high and then they'll come down and then they'll stabilize. And this is very similar to the way it's done with interventional radiology in terms of looking at these numbers, we usually take three measurements in the hepatic vein and then take an average of the hepatic vein measurements. And then we'll come out of the hepatic vein and move to position for a portal vein puncture. And here you can see the needle in the portal vein. Again we're going to do a flush of a small amount of heparinized saline. The numbers will again go up and then come down and level out. And in this case, the portal venous pressure was 26, hepatic venous pressure was 12. So the portal pressure gradient was 14 consistent with clinically significant portal hypertension. So when looking at technical success, there was 100% technical success. There was a range of PPG gradient measurements between 1.5 and 19, and there was really no complications. When we looked at those clinical subgroups, patients that were deemed high risk for cirrhosis had a higher PPG than those that were deemed low risk for cirrhosis. Patients with varices, as expected, had higher PPGs than patients without. Patients with portal hypertensive gastropathy had higher PPGs than patients without portal hypertensive gastropathy. And patients with thrombocytopenia also had higher PPG measurements. So this was very encouraging. It appeared that this method is feasible and safe. And given the availability of EUS and the simplicity of the manometry setup, this could be a promising breakthrough for getting information for our liver patients. And so we've since continued this work in a multicenter study. And this was presented at DDW. So in January of 2020, this device was FDA approved and marketed under the name Cook Insight. And for this initial multicenter study, we included four institutions. It was UC Irvine, Dallas Methodist, Brigham Women's, and Mayo Clinic in Florida. There was 49 patients. There was no procedure-related adverse events. And similar to our single center study, patients with esophageal varices, portal hypertensive gastropathy, and thrombocytopenia had clinically or statistically significantly higher portal pressure gradient measurements. In a lot of these patients, we looked also at their liver biopsy results. And patients with a PPG greater than 5 were 10 times more likely to have advanced fibrosis. Patients with PPG greater than 10 were 13 times more likely to have advanced fibrosis. And the PPG measurement correlated with some commonly used scores for liver disease, such as the FIB4, APRI score, and MEL score. Our group also did a single center retrospective study specifically looking at same-session EOS PPG and EOS liver biopsy. And we found that in all the patients that we've done this on, technical success has been 100%. And there's been no early or late major adverse events. Also interestingly, the mean PPG measurement increased with progressively advanced stages of fibrosis. And for every one millimeter of mercury increase in EOS PPG, the risk of having stage three or four fibrosis on histology increased 1.3 times. So with that, that's a short overview of the literature on EOS PPG. And I'd like to welcome Dr. Kenneth Chang. Dr. Chang, thank you for joining us. And you have really single-handedly probably trained most of the world in this procedure. So we'd love to hear your thoughts on how you think it's going. And if you have any, why don't we start with, what do you think the learning curve is for PPG? And do you have any tips about technique? First, I just wanted to really thank you and Marvin for taking the lead and forming this ASG-SIG. This is really, for me, a dream come true, seeing something that you and I worked on almost 10 years ago in a lab when it was nothing more than a dream. And now it's going mainstream, and we're teaching many talented endocrinographers to help patients with liver disease. So I couldn't be more thrilled. As we get older, we get happier when things like this happen. Anyway, so to answer your question, right, Ken Bimmler? So in terms of learning curve, I would say that for an experienced endocrinographer who routinely is doing FNA and FNB, it's really a short learning curve. Everyone who's done the workshop, they report back to me by email or chat that five cases later, definitely 10 cases later, they feel they've really got this. So technique is really easy. It's really learning the liver anatomy to take some time. And the more cirrhotic the patient is, the more distorted the liver anatomy is. So there's some nuances there with a more advanced cirrhosis. But in general, compared to everything else that the interventional endoscopy world does, this is a really short learning curve. So technique-wise, I always start with methodically, I look at the liver, palpate the liver, look at the liver edge for any blunting, look at the surface for micro nodules, look at the parenchyma for nodularity. So quick lay of the land, then I'll routinely do shear wave, right and left lobe, again, to get a sense of the score of fibrosis. And then I'm preparing for the PPG, where I'm looking at the liver anatomy, in particular, looking at my target vessels. So my first target vessel is obviously on the hepatic vein side, 70% of the time, I'll find a great, beautiful middle hepatic vein that is perfect angle, perfect trajectory. But 25% of the time, I wind up looking at the left hepatic vein as it's coming towards the middle hepatic vein, and that may be a friendlier, better target. Very seldomly, it's off-label, but I'll target the IVC because everything else is really difficult and squirrely. Next on the portal vein side, 90% of the time, it's that umbilical portion of the left portal vein, and everyone who took the workshop remembers how to identify the umbilical portion of the left portal vein, you know, with the ligamentum venosum and ligamentum teres. Less than 10% of the time, I'm doing the right portal vein and targeting the right portal vein. So that's the second step, identifying the vessel. And then you prepare the device, and the cookboats can go through that really carefully in terms of how to prepare the device. Then when you're ready to target, your needle goes, like an FNA, through the liver parenchyma into the vessel, center of the vessel, so you don't hit the wall and measure the pressure off the wall directly, but in the true lumen. Then you do the general flush, you equilibrate, measure three times, and remove the needle under eFLOW. So before you remove the needle out of the parenchyma, you're making sure there's no flow in the needle track, which is very uncommon with a 25-gauge needle. So you do the hepatic vein side, then you do the portal vein side, and that's it. You take the three numbers, and usually I take the three consecutive numbers that are quite tight and precise. If I get a number that seems to be off, I'll repeat another measurement until I get three in a row that are fairly tight to each other. So that's a technique in a nutshell. Dr. Cheng, thank you. And in typical fashion, Jennifer Kolb is cutting us off and shutting us down. So we're going to move on. This will be our third and final quick shot for going into the roundtable, and this quick shot is on EOS coiling of gastroparesis. I just wanted to provide just a little bit of background so we're all on the same page. Moving left to right, gastroparesis can obviously occur in the setting of cirrhosis and portal hypertension, but they can also occur in the setting of splenic vein thromboses, very difficult to treat when they bleed historically. The SARIN classification system is the most commonly utilized classification system for gastroparesis. On the top, you have gastroesophageal varices types one and two, which represent extensions of esophageal varices into the proximal stomach. And then you have the isolated gastroparesis types one and two at the bottom. And it's really the gastroesophageal varices type two and the isolated gastroparesis type one, which are otherwise known as cardiofundral varices, that are really the best targets for EOS guided injection treatment. Okay, just very briefly, the gastrobaric treatment algorithm is a little bit in flux, but for management of bleeding gastroparesis, it's important to keep in mind that at least according to AASLD guidelines, the treatment of choice is tips. There are other endovascular options that I think Dr. Katravisis can go into, including BRTO or balloon-assisted retrograde transvenous obliteration. There's a version of BRTO called CARTO that uses coils and gel foam. But in actual practice, endoscopy will be used, at least initially, for confirmation of gastroparesial bleeding. And depending on the center and the experience and the overall comfort level of the endoscopist, endoscopic hemostasis therapies for gastroparesis can be embarked upon. So we can still do band ligation for small gastroesophageal varices type one. And then you can also perform a thrombogenic agent injection. This can be performed under direct endoscopic visualization, and traditionally this was cyanacrylate, really based on Nibs Ohendra's work in the 1980s. And then more recently is EUS-guided injection therapies, and I'm a little bit biased, but I think that EUS guidance provides a more controlled intravariceal delivery of hemostatic agents, and that's what we're going to talk about tonight. Jason, you can kind of go through these, but so there are options for what to inject and how to inject. Again, the traditional endoscopic therapy for cardiofundal varices was direct endoscopic injection of glue, cyanacrylate, otherwise known as tissue adhesives. And then more recently we have EUS-guided direct injection. We do have Doppler to provide real-time feedback of the hemostatic effects of our therapy. And so in this particular case, I'm showing you coil injection with an adjunct, it could be traditionally glue or another substance like gel foam or thrombin. We have published a recent meta-analysis on looking at EUS monotherapy with cyanacrylate alone versus coil alone versus combination therapy with the combination of coil and cyanacrylate. And the combination therapy seems to be better than monotherapy, leading to higher clinical success rates and lower rates of re-intervention and lower rates of re-bleeding. The adverse event rate is acceptable at 10%, much lower than monotherapy with cyanacrylate alone. This is maybe a 45-second video showing how EUS-guided therapies can be helpful in the setting of acute bleeding. In this particular patient, there was so much blood that endoscopic visualization of the bleeding gastric varices were not possible, but we're able to see the bleeding gastric varices using endoscopic ultrasound. And so we use, ideally, a transesophageal approach that's ergonomically favorable. You can use fluoroscopy, it's not absolutely necessary, but it might be something to be considered, especially if you're first starting out with EUS-based therapies of bleeding gastric varices. And here we're essentially injecting coils, which we have borrowed from our interventional radiology colleagues, followed by an adjunct, in this case, gel foam, but traditionally it has been cyanacrylate. So in this particular patient's case, this is sort of the pre-picture of the isolated gastric varices type 1, and then you have the middle picture showing hemorrhage and then the one-year follow-up. So at this point, I'd like to invite Dr. Ken Bidmore, I'm actually delighted to see you. I know that you were running a little bit behind with your cases, so we very much appreciate your time, Dr. Bidmore. Dr. Bidmore, obviously, has had a very storied GI career, most recently well-known for inventing Axios, but prior to that, he was really the godfather of EUS coil-based therapy of bleeding gastric varices, and probably has the most experience with this. So Ken, thanks so much for being here tonight. And maybe you could just start us off with your technique for coil therapy. Thank you. I hope you can all hear me well. Is the sound good? Excellent. So I've been really privileged because I've been able to witness the evolution of the use of cyanacrylate for the treatment of gastric varices from its very beginning with Nib-Cyhendra. So I joined his department in 1991, and he had first described the use of cyanacrylate injected under endoscopic guidance, I think it was somewhere around 1983 or 1984, somewhere in that time frame. So he had already developed this method, it had become mainstream when I joined his department. And right outside of the endoscopy suite, we had a helicopter pad, and literally we had helicopters landing every hour with a gastric variceal bleeder, because these patients really did not have good options. TIPS, which was done surgically back at that time, did not show good results and obviously is very, very invasive. And we know about the shortcomings of the treatments that were available endoscopically, which was sclerotherapy. So the results were disastrous with that. And even banned ligation, the results there were also very poor, except for the very small caliber varices, so basically the junctional varices. So we were injecting glue from morning till late at night in these gastric variceal bleeders. So I had the opportunity to get a lot of experience using cyanacrylate, and we mixed what was N-butyl-2 cyanacrylate, which polymerizes very rapidly. So literally, if you're not injecting or your assistant, very forcefully, very quickly, then it polymerizes inside the catheter. You don't even get it into the varix. And you need to remove your catheter, your needle, sclerotherapy needle, very quickly, because otherwise you risk that the needle will get stuck in the varix, because the glue is indeed just that. It's a glue. It is adherent, and it will stick to everything, including your sclerotherapy needle. So it did require a great deal of technical skill and speed to inject this. So we mixed it with lopiodol to slow down that polymerization. But the lopiodol has the disadvantage that it makes the solution a bit more viscous, too. So there's a trade-off there. But it does have the advantage as a contrast media. We could also perform the injection under fluoroscopic guidance to document that we were obliterating the varices. So this is endoscopy-guided glue injection. And that had, over the decade to follow, become the standard, the treatment of first choice for gastric variceal bleeding, at least for fundal varices. Now, let me actually just sidetrack just for a quick second to talk about that classification which you showed, which is the SIREN classification. And it's obviously well-established. And it has been well-validated. So I'm not questioning the classification. But personally, I think this classification is too complicated. It divides these gastric varices into these four different types. And really, you only need to differentiate two types. And that's junctional varices and non-junctional varices, so true gastric varices. So I don't even think of junctional varices actually as gastric varices because they have a completely different pathophysiology. And anatomically, they reside in a different layer. They are in the lamina propria versus the submucosa for gastric varices. And they also are different in their morphology. And as a result of that, because they're so much bigger, the treatment needs to be very different. So you cannot treat true gastric varices with band ligation or sclerotherapy. But you can treat junctional varices with these modalities with great results. So in my book, it's really just these two types. And unfortunately, most of the varices that we call gastric varices turn out to be junctional varices. So you don't even have to talk about glue. You don't need it. But for the 25% of the patients with gastric varices, that's about the number if you include the IgV1 type, which are the fundal type from the SIREN classification, and the GoV1 type. So if you combine these two, I think it's GoV1 or it's maybe GoV2. See, that's why I hate these classifications. But the one whereby you have junctional varices that extend to the fundus. So you really have two different population of varices there. It's getting confusing, right? So if you just look at patients with fundal varices, that comprises maybe a fourth of the total population. So it's really not as large a population as maybe is advertised. And I say that only to remind the audience that, yes, these modalities with glue injection, now with coil, now hybrid, they're wonderful. But most of what you're going to be seeing in your practice is going to be junctional varices. They may extend a little bit in the stomach, but they can be very well treated just with band ligation, or if you do sclerotherapy, with that as well. All right, so now let me go back on tracks. I wanted to make that divergence only to emphasize that we are talking about the treatment of fundal varices. And there are many, many challenges there. And so if we start now with the sinoacrylate glue, that polymerizes very rapidly, and it plugs up the lumen of the varice. But the limitation, there are two limitations, of the standard endoscopic guided treatment, which I've been doing for years. And the first is a complication, which sadly, I saw too often. And I personally had one patient suffer from hemiplegia after glue embolized across an open foramen ovale into the arterial system, went to the brain, and the patient stroked out. And that was devastating to see. And on the CT scan, there was glue distributed throughout the brain. So it got me to thinking about how we can avoid or prevent embolization of the glue, because that was the nemesis. That was really the main drawback of sinoacrylate injection, that if it didn't completely polymerize in the varice, it could then embolize to distant sites. And really, virtually every organ, including the coronary arteries, there have been heart attacks after glue injection, in fact. And if the patient has any AV shunts or so, or a foramen ovale, then it's going to get into the arterial system. And so when you realize, even though it's not that frequent, but there are many, many case reports and fatalities from embolization, well, it certainly has inspired those of us who have been using glue a long time to think of alternative ways to avoid the embolization. And so one of those options is the coil. Why not substitute the glue for the coil? And I had thought about that. The issue there is it has to be done under US guidance, of course. You can't put a coil in under endoscopic guidance. Or I'd say you risk that that coil could be going into some para-variceal space, and you don't want that. So in contrast to the glue injection, where you can feel the resistance, you can see if it's blebbing, if you're in the submucosa or so, you have ways to confirm that you're in the varicose with coils. A lot more is at stake now if you are not clearly inside the varicose. So I started with coiling under US guidance. And that was, for me, the shift in the paradigm of how we treat these gastric varices. No one was really doing this under US guidance. We did use US, though, but for a different reason. It was to confirm complete obliteration of the varices after treatment. So the treatment was done endoscopically, but using a radio-scanning echoendoscope, usually, we did that only to confirm that the varices were obliterated. And why is that? Because there was a study in, I can't remember exactly, 2000, I think, around then from Hong Kong, showing that if you're comparing on-demand cyanoacrylate injection versus untold obliteration. And when they compared the two groups, the results were significantly better in the cohort of patients that underwent repeat glue injection until complete obliteration was documented by US. So US has a role, but it was only diagnostic, not to guide the injection. So now we're making this shift to using coils under US guidance. And it really was just in one of those days where I was just so frustrated pushing those coils, because you have to put in a large number of coils to obliterate the lumen. You've got color doppler. You can see if the blood flow is reducing. And I'm not going to stop putting coils until I see the blood flow stop. And I was putting in a dozen or more, sometimes 20 coils, to completely obliterate these large varices. They're all larger than 2 centimeters. They're very large, and they're convolutes there, like huge grapes or so hanging from the wall. So you're putting in a ton of coils if you want to achieve obliteration only with coils. So that got me to thinking, wait a second. These coils have these wooly fibers. And could this act as a scaffold to retain the glue at the site of injection, namely where the coil is located? And could this then prevent embolization? So I did some ex vivo studies, just testing in a container of heparinized blood. And I put a coil in there, and then I skirted the glue in there. And I found that all the glue was attached to the coils, and none of the glue remained in the containers. And so that's how I started this technique of combining glue and coil. And so now the coil serves a different purpose. The coil is there solely as a scaffold, really, to retain the glue. It also reduces the flow in the varices, too. So it also reduces the risk of glue embolization. So these two factors, I feel, are critical in at least significantly reducing the risk of embolization. And we still see it occasionally. It's thankfully been asymptomatic always. We have a few patients that, where we got CT scans and the check, and we saw evidence of glue embolization, it's hard to say what the timing would be of that. But thankfully, I have not had a single bad outcome from embolization since I've adopted this technique. So suffice it to say, now, all of our patients now are treated with this hybrid technique. And we'll put one or two coils, depending on the size of the varice. Thinking of the coil really there to hold the glue in place, sort of slow down the flow a bit. Although, I will tell you, it doesn't slow it down that much. I mean, there's a very rapid flow in these varices. So then I use the Dermabond. And let me tell you something about Dermabond. When I came to the United States from Hamburg, Germany, cyanoacrylate was not FDA approved yet to be used. It wasn't cleared for anything. I couldn't use glue. Well, it was my luck that very shortly after starting, I was at UCSD at the time, Dermabond was FDA cleared for topical use, for skin use only. And I thought, wow, well, I'll be using it off-label, but at least I've got this glue. But it had a very long polymerization time, a longer polymerization time. It's about three to four times longer than the N-butyl 2 cyanoacrylate, the standard histochryl that's used in all the studies, most of the studies. And I thought that would be a negative at first, until I realized, well, number one, I don't have to mix it with lipidol. I don't have to worry about it actually solidifying in the catheter when I inject it. I don't have to worry about my needle getting stuck in the varix after I've injected it. And it seemed to me, as I thought about this, and I can't prove this to you, but if you just let it drip in there very slowly, especially if it's going to attach to the scaffold of a coil with its wooly fibers, you want it just to drip in there. You don't want to be injecting it with high velocity and have it stream and embolize. So actually, this was serendipity, that I could only use Dermabond. And so even though now we have, of course, histochryl available, we have other cyanoacrylates, I still use Dermabond, because I think it actually is the better glue to use for this application. So I use it without diluting. And there's one other advantage. I actually use it with saline. If anything, I want to speed up the polymerization just a tad. But if you use histochryl and butyl 2-cyanoacrylate, you have to dilute it with distilled water. If you use saline, then it absolutely will solidify in your catheter. Kent, I'm sorry to interject. No, give me a lecture now, I'm sorry. No, that's a fascinating historical overview that's obviously informed your technique, and I wish we had more time. I'm sure there are many more questions that we can potentially address in the round table discussion. But thank you so much for that. So at this time, I'm just going to ask our panelists to turn on their webcams, and we'll commence with the round table discussion. And I'm going to hand things over to Jen and Ahmed at this point, so thank you. All right, well, I am going to pick up on that momentum. Thank you so much, Dr. Ben-Moller, for describing to us really the historical context, the evolution of how you manage gastric varices. I'd like to direct the first question to Dr. Katravisis, and really to bring you into the discussion to tell us from your perspective, from an interventional radiologist perspective, really how do you approach gastric varices, acutely bleeding, patients who are referred to you, what are your considerations, what is your workup? And really when you think about the different options for managing them, what are the things going through your mind as you're treating these patients? Sure, thanks for having me here. It's great to be hearing about what you guys are doing. I think it's very cool, all these different techniques that you guys are coming up with, it's really amazing. So for the gastric varice bleeders, they've all been scoped by you guys before they ever get to us. And so, our main concern is that, it's basically isolated gastric varices if we're gonna go to a BRTO or a modified version of parto, carto or whatnot. They have no high risk esophageal varices because typically our procedure will make that worse when we close the shunt. And the other factor is we really need the shunt, a gastro renal shunt is typically a big shunt that connects to the left renal vein, that's how we access the varices to shut them down. And so, those are two of the main things that we look at. Great, thank you very much, Jen and Dr. Katravisis. I wanted to move things a bit and ask Dr. Rubin a question. Dr. Rubin, as sort of the person that's really taking care of these patients and overseeing their care with various liver pathology, one, I wanted to ask sort of your input on endohepatology and the role of all these novel interventions we're doing through endoscopy. And really what's going through your mind when you're seeing a patient in clinics that requires an evaluation of portal pressures and will require some form of liver biopsy and really what your algorithmic approach is to this patient. Thanks for having me on that, thanks for the question. So, I should say just as a hepatologist, the way that I got interested in this field was by attending a lecture that Dr. Chang gave at the Local Endoscopic Society here in Atlanta a few years ago. And one of my associates and I went back to our relatively new associate who came from Geisinger, who had been trained by Karsha and said, hey, we have to get this portal systemic gradient measurement technique. When can we start? And it was right around the time of the FDA approval. So, as far as when we look to our endoscopic colleagues to help us with assessment of these patients, I think part of it depends on, you know, if a patient already has very well-established portal hypertension, we understand the etiology of their liver disease. To be honest, we may not have a great need for those patients. I think where it comes up is when we're starting a broad diagnostic workup where we may not only need, say, a diagnostic liver biopsy to either confirm a diagnosis or to parse a diagnosis when there are various possibilities, but also at the same time, when we might have other indications for upper endoscopy. And especially one of the places where we've really leaned on Manesh Mehta at our institution is if a patient with suspected liver disease who may have portal hypertension on the basis of radiographic studies preceding our seeing the patient, when we have to give an assessment of what we think a patient's perioperative risk might be. So a great example, I would say about a quarter of the people that we've seen at our institution where we've done the endoscopic ultrasound portal systemic gradient measurement has been in patients who are being assessed for either kidney transplant alone or simultaneous liver kidney transplant. In patients who have either no or very mild portal hypertension, kidney transplant alone may be the right solution. On the other hand, certainly if the portal systemic gradient is 10 or higher or there are other complications of liver disease, simultaneous liver kidney transplant is what's relevant. So for us, when we involve our endoscopic colleagues really depends at what stage we are in their evaluation and whether or not we need that additional information from say the portal systemic gradient measurement or the one-stop shopping assessment of endoscopy to screen for varices, diagnostic liver biopsy, portal systemic gradient pressure measurements and even ERCP at one sitting. Because especially if we're doing a somewhat time-sensitive evaluation of a patient, if we're talking about three or four potential procedures that are delayed in time and require separate sedation versus one-stop shopping with one sitting, there's real value obviously to the latter in certain situations. Thank you, that was great, Dr. Rubin. Jen, if you'd like to go next. Sure, I'm going to pick on Dr. Chang. So, we know we can do PPG now, but the question is really in which patients have you found as the endoscopist really this to be most successful and how do you communicate with your hepatology colleagues about which patients this would really be ideal for? What scenarios? Great question, Jen, thank you. Thanks, Dr. Rubin for your input there as well. So, I'll answer by saying there's about six different categories of patients who get referred to us. We have a very mature PPG practice. We've done over 120 cases. So, I'll just quickly go through these categories so you can get a sense and I'll highlight the ones that are most common. So, the first category are the worried well. These are the patients with no clinical evidence of cirrhosis but have a nonspecific concern for possible hypertension maybe preoperatively. Their spleen is enlarged incidentally, their platelet count is low incidentally, but they have no other signs of cirrhosis, but they're worried or the surgeon's worried. So, that's one category. And that's usually we find it's a rule out meaning the PPG pressure is normal. The second category is our largest category and that's where the etiology of the liver disease is a bit uncertain and or the severity of the fibrosis and cirrhosis is also uncertain. And the more uncertainty you have in both of those areas, the more impactful your EUS and endohepatology procedure is. So uncertain etiology, the most common is, is this NAFLD or is this NASH? Is this seronegative autoimmune hepatitis? Is this overlap hepatitis? So there's a reason for a liver biopsy and maybe also PPG, but more on the liver biopsy side. On the flip side, looking at severity, a patient may have mildly elevated liver tests, but the FibroScan doesn't seem to fit the clinical scenario. Either the FibroScan is, you know, stage 3-4 and you don't believe it, or the FibroScan is stage 1-2 and you don't believe it. And the imaging says, oh, you've got a nodular liver cirrhosis, but clinically it doesn't fit. So when the severity is uncertain, then EUS PPG becomes very impactful. And the home run cases in this category are the patients that are NAFLD versus NASH. You confirm NASH on your liver biopsy and the PPG is elevated like 6 or 7, but no varices, no portal hypertensive gastropathy, and you diagnose an elevated portal pressure and NASH, now you have strong footing to really be aggressive with a bariatric procedure or an endobariatric procedure. And that's really the home run in this second common category. Third category, patient has clinically known portal hypertension, they have cirrhosis, there are varices present, but the question is, should you ban the varices or not? What is the real risk for bleeding? Or I've started the patient on non-selective beta blocker, is the beta blocker dose enough? And we have the opportunity to do serial PPG to make sure that we're putting the patient out of risk way with the elevated pressure. Fourth category, patient with portal hypertension, and now there's a tumor in the liver and HCC, and you're considering lobectomy versus liver transplant, portal pressure grading can be helpful. Fifth category, this is the home run case, suspicion of pre-sinusoidal portal hypertension, early primary biliary cirrhosis, sarcoidosis, or most commonly the idiopathic non-cirrhotic portal hypertension. This is where you can make EOS PPG look really good because the hepatic venous pressure gradient measurement will be falsely low, and EOS PPG will confirm the pre-sinusoidal portal hypertension. And finally, on the other side, the post-sinusoidal, post-hepatic portal hypertension, venal occlusive disease, blood carry, right heart failure, you can also make a diagnosis. So there's six categories, five or six categories, but the most impactful and common is where the etiology is uncertain and the fibrosis cirrhosis is uncertain. Sorry, that was really long answer. Oh, thank you. That was a very, very nice explanation, Dr. Chang, of implications. We're getting really good questions here. We're going to address, direct this to Dr. Yu and Dr. Bindmuller. We're going to circle back to some gastric varices. One question is really your choice of coils, 0.018 and 0.035, and really when you guys use these coils. And then maybe we can segue into what are we really injecting? I know, Marvin, you and I really discuss this a lot. We see the shunt sometimes, we see the feeder vessel, we're seeing the murogastric varices. What are we really targeting? I'd love to get your input, Dr. Yu and Dr. Bindmuller. So, firstly, it depends on size in terms of whether you use the 0.018 or 0.035 coil. And the 0.018, which fits through a 22-gauge needle, will only open up to a maximum diameter of one centimeter. So, if your varix is one centimeter or larger, and I'd actually say 0.8, you know, eight millimeters, because really the coil should be slightly larger than the diameter of the varix. So, I would say we're talking about small varices. And these small varices, if they're that small, probably can be treated with band ligation. So, I don't think there's much need for the 0.018. Now, the exception would be possibly in someone with an acute bleed and you're having trouble seeing where to band. So, the advantage of EUS is, of course, you can have a stomach full of blood, full of food, doesn't matter, you're doing this under EUS guidance. So, it would be, I think, wise, if possible, to place a coil first and then inject the glue, even if it's a small varix, to minimize the risk of embolization. So, we're talking about 0.035-inch coils. And these coils come in different lengths and different diameters. So, the diameters vary. I'm not sure exactly. I think it's, you know, up to like two, I think two centimeters might be the largest one, which is a little bit of an issue because our varices, gastric varices, are often larger, which is why I might place a few coils simply because I want to pack them in and have that second coil anchor the first one, because I'm worried that that might embolize or migrate. So, the diameter of the varix will determine that size that you select. So, you'll read on the package what the diameter of your coil, they come in different diameters, and then the length. Now, the problem with the length is we're inserting this in contrast to the way radiologists use this, which is a short distance, and they're just using that introducer. We're using the introducer just to get the coil into our FNA needle, our 19-gauge. Then we've got to push the length of the coil all through our FNA needle. And if you choose a length that's too long, like 14 centimeters becomes that long, I think 7 centimeters and 14, you run the risk that it may start to bunch up inside of your FNA needle. So, the answer in terms of my choice is 7 centimeter long coil, and that means it makes two and a half loops. If you use a 14 centimeter long, it'll make, what, like five loops or something, you know, more loops. So, you'll have the advantage that you'll have more loops in there, but you can compensate for that by just placing another coil. Thank you. Yeah, I agree with everything that Ken said. Just a couple more pearls in terms of technique. We have our patients in the supine position, intubated, and sometimes they're slightly tilted leftward. And Ken, you taught me this. If you instill fluid into the stomach lumen, it will preferentially fill dependently to fill the fundus, and that's a nice trick and that's a nice trick to really delineate the intramural vessels versus the extramural collateral vessels. Because when everything sort of collapsed down and you have these very large varices with the surrounding collateral vessels, it can be disorienting. And so, that maneuver of instilling water really delineates intramural vessels, and that's what you want to go after. You don't want to pick a battle with the extramural vessels. That's for Dr. Katravisis. We want to pick our battles with the intramural vessels. If you get lucky, you might be able to find the feeder vessel, but that's what you want to go after. Absolutely. And, you know, that is a great trick. I think we routinely do that. So, number one, every patient's intubated to protect their airway. I think it's wise to do that anyway in a GI bleeder, because even if it's not acutely bleeding, you could provoke bleeding. So, better to be prepared. But secondly, you need to put a lot of water in there to distend the stomach adequately so you can really differentiate the intramural from the extramural vessels. Great. Thank you. Dr. Karag, coming back to you to talk a little bit about liver biopsy. I know you had a lot to share with us about kind of the ideal approach and the ideal patient. There's been a lot of private questions messaged about different scenarios and how you would choose it. So, maybe you could just speak a little bit about some of those certain patient situations. Sure. Thank you, Jen. I think the U.S. liver biopsy program, this is always in collaboration with our hepatology and IR colleagues. And I think one of the things I want to touch on is the patient pathway. You know, how do you set up an endohepatology or liver biopsy program? And I think Dr. Rubin touched on that very beautifully. And, you know, we're proud to have Trane Manesher, who's now partnered with Ray over at Piedmont. But it's the low-hanging fruits, of course, are patients who need a concomitant endoscopy. That's a no-brainer. If there is any questions of total hypertension, they need a varietal screening, do you want to rule out, you know, GAVE or anything. When they're going to be getting an endoscopy and they need a parenchymal liver biopsy, you know, that's an easy marriage. You know, the patient pathway, how we developed was anybody come in for a elevated liver enzymes workup, for example. And, you know, these are the patients who end up with a multimodality workup. They end up with an abdominal ultrasound to evaluate their biliary tree, which then may lead to an MRI or an MRCP, and then separately through IR for a liver biopsy. And they end up with GI for an endoscopy. Now, you can marry all of that into a one-stop shop. So you evaluate them for elevated liver enzymes, you can check their biliary tree, as you know, we can do a better pancreatic or biliary evaluation. And, you know, as Ray alluded to, if in case you do find an ERCP issue, if there is a stone or a ductal issue, then you can convert that into an ERCP pathway. And if you don't find a ductal issue, you know, they go into the liver biopsy pathway. And sometimes it's a marriage of both, you know, patients with PSC who may need, you know, both together, but you need parenchymal as well as a ductal evaluation. So those are, you know, the easy way out. And now, as Ken mentioned, some of the feeders are also the FibroScan. You know, people thought, well, does FibroScan take away from the liver biopsy business? And the answer is no, it actually fed the liver biopsy business because there's a lot of patients with discrepancy where their FibroScan scores are different than their clinical and biochemical parameters. And now that's even more we can offer is the EGD, the EUS, the pancreatic ovulary anatomy, the parenchymal biopsy, and a much more precise portal pressure measurement. You know, as you know, with our friends with IR, they do a wedge pressure measurement. And as Ken beautifully, you know, explained, the pre-sinusoidal and the post-sinusoidal, you can get that PPG kind of married into that. Going over some of the questions that were asked in regards to technique, we always, as I mentioned earlier, do a bilobar biopsy, 19-gauge FNB needle, preferably the Francine tip. We use heparinized needle because wedge suction, as we've seen through our own data and studies, that works the best. And it's a bilobar, one pass, sorry, one puncture with three actuations. And that's kind of been the ideal. In regards to specimen processing, I think that also matters. So we filter out our specimen into a cell that surgical pathology uses anyways. So we express our tissue through a cell where the blood, or since it's heparinized, you know, that doesn't clot, we have this liquid red specimen. We don't pour that into the formalin. We express the specimen through the cell where the liquid blood falls through and you have this clean pore of pink tissue that we transfer into formalin and that gets transferred over to surgical path. But I think that's how we started our patient pathway. And now with the addition of the US PPG, that's gotten even more robust. Thank you very much. So I wanted to ask really everybody here on the panel, I think one of the most important questions is really, you know, what do I do if I want to start an endohepatology program? What's required? What researchers do I need? And what does it take to really start a program? I'd love to get really everybody's input. I can take a stab at it. You know, as I just mentioned, I think starting an endohepatology, first of all, involves a discussion and presenting the data. You know, the more transparent and the more strongly we can show what our outcomes have been, where the complication rates are low, the success rates are great. And overall, it's about the patient at the end of the day. So if we can do right by the patient, by doing multiple modality outcomes in a one-stop shop, I don't think anybody can argue with that. And initially, of course, for the pioneers as people on this panel, it was actually harder because we started off with a leap of faith, having our colleagues trust us in what we do. But I think in today's day and age, now that there's so much data out there, you can easily go to your IR, hepatology, you know, surgical colleagues, transplant colleagues, and show them that this is what's right, that we can do this in collaboration. But it makes our patients a lot better, but also makes their management for our colleagues even better. So I think starting a program, having the right resources, you know, having the right equipment, and also the field service, right? There's always a risk of complication. So what if there is a peritoneal bleed or a subcapsular bleed? We are going to need our IR colleagues to help us out with that. You know, if there is significant issues where we need our surgical colleagues. So I think having that multimodality discussion and multidisciplinary buy-in, I think is key in starting a program. Thank you. I might add to that. I agree with everything you said. I think part of it does sometimes start with just general awareness, depending on what institutions you practice. It may be that hepatologists or hepatobiliary surgeons, even interventional radiologists may not yet be aware of the advances that have been made. To be honest, to me, this was a, every one of these presentations has been so interesting. But the discussion about the treatment of gastric barocele bleeding is still somewhat fresh for hepatologists in particular. So I do really think part of it is getting the word out that these procedures are not only, you know, acceptable and safe and can be not necessarily cost-saving, but actually even that has to be looked at. It was touched upon earlier that patient acceptance may actually be better for these patients than for other methods for at least liver biopsy. I think that needs to be studied and published so that that awareness is raised as well. And I do think it boils down to, you know, your ability to collaborate at your institution and to communicate. I think it's interesting in our own institution, while the majority of these procedures have originated in the hepatology service, I would say a considerable percentage have now come from surgeons independently who are treating patients who may have portal hypertension and need some abdominal or gastric obesity surgery is a great example. And they may actually independently be working with the endoscopic colleagues to get this information, with or without the hepatologist in certain instances. So I do think making those connections is one way to get your program started. I think it's also super important, whether you do these procedures in an endoscopy lab or an operating room setting, that obviously with cooperation from the manufacturer as well as what other trainers, that your staff is brought up to speed and that there's depth to that staff. If you're going to offer these services, one of the questions is going to come up is whether you offer them on an emergency basis as well, for example, with gastroparesis. So if it's a Saturday night and the endoscopic tech on call has no idea how to do any of this, you know, you may lose a little bit of credibility if you don't have that depth. So I think you do have to be prepared for those contingencies. Thank you. Those are excellent points, Dr. Rubin. All right. If anyone has any final comments, we'll take them. I just wanted to make a quick, you know, quick plug for really the research opportunities within the space of endohepatology. I think that there is so much excitement across disciplines, across institutions. And really, as this webinar I think has showed us, there's so much more to learn about how to really improve the care for patients with liver disease. So if anybody, any fellows who are on this webinar, any other institutions are interested in getting involved in collaborative efforts, please reach out. And I think the more people we can really get involved, the more different patient populations, there's a lot of really important questions to answer. So hopefully this can also serve as a venue for discussion and research collaboration. And with that, I think we will turn it back over to Dr. Yu. Jason, I'll actually defer to you in terms of concluding remarks. Marvin, Jen, and Amit, I think you'll agree with me in saying that this was above and beyond what we expected. This was just a fantastic kind of group of speakers. And I think we could have gone for another hour. I was just writing down so many questions. I think the purpose of this SIG is kind of multi-fold, and Jen touched on one of them. The research collaboration that we can do through this with our hepatologists, but even our interventional radiologists, I think is tremendous. And I really want to thank Dr. Catravisas for joining. And I just want to highlight one great moment that we had together where we did a joint case of basically portal pressure measurement with IR and EUS combined a few weeks ago, and happy to report the pressures were basically exactly the same. So it's that sort of collaboration that I think is really going to push the field forward. I think the clinical collaboration with hepatology and interventional radiology for taking care of our patients is going to be key. I think we can all learn so much from each other. But I think for the fellows out there, this is just sort of the beginning. And I think there's so much more to come, and I'm just happy to be here at the beginning of this. But I think even in terms of innovative devices that we're already thinking about the next wave of devices that can be used in the space. And then also educational material. I think there's sort of a paucity of videos and instructional material. And I think the SIG can potentially help fill that gap. So I'd like to say thank you for thank you to our panelists. I think the discussion was phenomenal. And on behalf of all of us, everybody have a great night. Thank you, Dr. Yu, Dr. Zamorano. The panel of experts here, this was an unbelievable discussion that you all had together. I think echoing the multidisciplinary approaches that you all were talking about was very informative to tonight's participants. In closing, I want to thank everybody for their participation in tonight's presentation. But before you log off, we would really appreciate your feedback on tonight's event by going to that networking lounge and completing our evaluation. That information is always so beneficial for us in these types of webinars and what we can provide to ASGE members in the future. So thank you for doing that for a few minutes. This will conclude our presentation. We hope this information has been useful to you. As a reminder, you can access a recording of this webinar by logging on to GILeap by going to learn.asge.org. You do not have to be an ASGE member to access this content, as our goal is to provide this information and education from our Thursday webinar topics as an open source resource to all gastroenterologists and endoscopists globally in improving their practices. And finally, our next webinar will be next Thursday, August 1st at 7 p.m. Central. This will be our endo hangout feature for GI fellows. This will be focusing on endoscopic evaluation and management of IBD. Please do plan to attend. We thank you again for your participation and have a wonderful evening. Good night.

coiling

gastroparesis

bleeding gastric varices

procedure

coils

glue

gel foam

endoscopic ultrasound (EUS) guidance

combination therapy

adverse event rate

clinical success rates

re-intervention