Welcome, the American Society for Gastrointestinal Endoscopy, EUS and ERCP special interest groups appreciate your participation in our Thursday Night Lights joint webinar on EUS and ERCP challenges. My name is Taline Artinian, and I will be the announcer for this presentation. You may submit questions and comments throughout the event via the Q&A box, and we will address your questions and comments after the presentations. Please note that this presentation is being recorded and will be posted on ASGE's online learning platform, GI Leap. You will have ongoing access through GI Leap to the recording and a PDF of the slide deck as part of your membership in the ERCP and EUS special interest groups. It is my pleasure to invite Dr. Antonio Mendoza-Led to introduce the speakers and start the webinar. Dr. Led? Okay. Well, thank you, everyone. Thank you, Taline. Thank you, Triptesh and Pharrell and Dr. Barron for inviting me over today to collaborate with you in this exciting meeting for the EUS. I am going to be your moderator for tonight for this event for Thursday Night Lights, and we will start with our first speaker, which is none less than Dr. Viral Oza. Viral Oza is a gastroenterologist and interventional endoscopist who currently serves as the medical director and chief of gastroenterology at Bon Secours Mercy Health in Greenville, South Carolina, and also serves as an associate professor at the Edward V. Young College of Osteopathic Medicine in Greenville as well. He is also currently the chair of this SIG that you are interacting with tonight. And without any further ado, I'm going to let Dr. Oza take the stage. Thank you, Antonio, for having me. I'm going to have Dr. Kothari go ahead and share the slides. All right. So welcome, everybody. Thank you, Antonio, for the wonderful introduction. Dr. Kothari and I are in charge of the EUS SIG, and we're happy to be here to talk about some therapeutic EUS's tips and tricks. Those are my disclosures. You know, objectives. Initially, I was going to add in endohepatology, which then I realized after I started making the slides that this is going to be a very broad field, and I could take the whole time and not save any time for anybody else. So I narrowed it down to some more specific topics, specifically EUS-guided ablation, EUS-guided coiling and injection, as well as EUS-guided bile duct drainage. So we'll start with EUS ablation. You know, EUS ablation, I like to think of it as a new kid on the block when it comes to therapeutic EUS. It is exactly what it sounds like. It's endoscopic ultrasound-guided ablation of tumors and cystic lesions as well. There's a newer modality to treat pancreatic cancers, and you may have seen a lot of publications in literature coming out. There was one that came out earlier this week in GIE on EUS-guided ablations, specifically for pancreatic lesions. It's used excessively for pancreatic neuroendocrine tumors, and it's actually becoming the standard for treatment of small neuroendocrine tumors. For adenocarcinoma, it's an ongoing research field. That being said, there have been some very promising results on using EUS ablation to combine this technology with chemotherapy. There's two types of ablations. One is radiofrequency ablation, which is the most widely available in the United States. Microwave ablation is available, but it's not commercialized heavily yet in the United States, and I can certainly see that happening over the next few years. So the concept essentially is using high-frequency radio waves to produce heat that damages malignant tissue. The good news here is that there's minimal damage to the surrounding tissue. The additional way with which this actually works is after the ablation is done. So, of course, there's direct impact from the thermal energy, but after the ablation is completed, there's an immune response, which actually results in more damage to the malignant tissue. There was a meta-analysis of 14 studies published fairly recently of a total of 158 patients. The clinical success of RFA ablation was approximately 84%. It's ideal, as I mentioned earlier, when combined with chemotherapy, particularly in adenocarcinoma. Small pancreatic neuroendocrine tumors are the ideal situations where you can use this. I actually have a patient that I've done three cycles of ablation on. It was a small functional neuroendocrine tumor, approximately 1.8 centimeters. The patient just this week had a CT scan, a DOTATATE scan, to see the activity of the lesion, and it was essentially inactive. Lesion patient symptoms have all improved. So it definitely works when used in the right patients. Ideal cases are small PNET pancreatic neuroendocrine tumors. It can be a curative approach, and like I mentioned, does require multiple sessions. This is an EUS image that I used from one of the publications. In slide A, you can see the hypoechoic lesion. In the pancreas, the B, you can see the needle tip, which is very hypoechoic, puncturing the lesion. And when the ablation starts, you actually see these little white dots that kind of pop up, and that tells you that energy is being delivered. And ultimately, when you're done, it looks like that. Moving on to EUS-guided coiling and embolization, EUS-guided coiling and embolization is something that I feel like should be handled in hands that are well-versed in EUS, and people who have been doing EUS for a long period of time should be tackling this. It requires direct puncture, and in fact, when I first started doing EUS-guided coiling and embolization, you know, we go through our entire training, medical school, residency, fellowship, advanced fellowship, and we're taught one rule. Don't hit a blood vessel. Don't hit a blood vessel. Don't make anything bleed. And here we are, we are purposefully hitting a blood vessel. And not only that, we're actually deciding to hit a varic. So it's certainly nerve-wracking, and I'll be lying if I say that every time I do this, I'm like, please don't bleed. Please don't bleed. And part of me is like, my heart's in my mouth every time I'm doing this. And it's good to do that because you're respecting the pathology there that's in front of you. You know, IV antibiotics are usually given for EUS-guided coiling. And I'll show you some pictures here in a second as to the exact steps. You usually start by measuring the size of the varic, which then helps you decide the coil size as well. I typically use a 19-gauge needle. You can also use a 22-gauge needle. Again, I'll show you some breakdown of when to use which. You remove the stylus that comes in the needle itself, and it starts by simply opening the coil package, inserting the coil package into the needle, and then pushing the coil out into the varic under direct visualization. So here is step one. Step one is, this is actually a cook-based coil that you open the package, have it, it has to be sterile. You keep it on a sterile field. When you actually push the coil out, and that was just a dummy coil we pushed out just to show what it looks like. When you magnify that and go and zoom in, you actually see these little fibers that come off the actual coil, and these fibers actually increase the surface area of the coil, which helps start the clotting process in the varic itself. So the coil apparatus, the picture one that you saw earlier, is loaded onto the back of the needle, and then the coil is pushed into the needle with the coil loader. The coil loader actually comes with the needle, the coil itself, so you can easily push that in directly into the EUS needle. The coil is then pushed all the way to the tip, and then into the vessel with the needle stylus. So that's the stylus that you removed at the start of the procedure. So this, I think this might be a video, I'm not sure, no, okay. So that one, that picture, we'll go back one, for some reason this video doesn't work, but anyway, this basically shows, this is the needle coming at the angulation. You can see the needle coming in into the varic, and the hyperechoic structure within the varic is actually the coil itself. I usually, after inserting the coil, I do tend to inject either Surgifoam or Gelfoam. This is cheap. It is easily available. International radiology in most institutions have this, and they actively use this for controlling their bleeds. So if you just go and ask them, they'll just give it to you. It's three or four dollars. It comes in a square or rectangular sheath, and you essentially just cut it with the scissors, and then you just shake it up, and it becomes this very viscous material that you can actually inject after the coil has been placed. You pull your stylus out, and then you can, I usually hook up the Gelfoam in a syringe directly onto the EUS needle and just push it in. You can also use glue. The problem with glue is that it can embolize, and it can cause problems. Now coils can migrate out of the varics, and especially when you place it and you finish the procedure, and you go back in and look, and you say you see, like this picture shows, the coil sticking out, don't panic. That's expected. That's normal, and that is okay. If you don't see the coil sticking out, that is also okay, as long as on EUS you can see the coil within the blood vessel. In the future, the coil may migrate out of the varics, and that is fine. Don't pull on it. Don't tug on it. It is completely okay and normal to have. So again, this is what I was referring to with Gelfoam. It comes in these little rectangular sheaths. You can actually cut it with either a scalpel or a scissor. You can cut the pieces and push it into this little, just a syringe, empty syringe, and you can just mix it up with a little stop cloth and saline and just go back and forth. So it becomes really, really viscous. It's easy to use. It's cheap. It's gelatin-based. There's very little risk of downstream embolization. So how do I do it? Remember I said that the first thing you want to do is you start by measuring the varics, and I'll be honest. I actually just literally took a picture of this exact slide from Dr. Ben Moeller's lecture at DDW a couple of years ago, and I have it as one of my favorites on my phone on an album called Endoscopy Album, and every time I have a case, I just pull it up, and now it's become second nature. But you start by measuring the varics. If it's a small varic, less than five millimeters, then you can use a 22-gauge needle or a 19-gauge needle. Remember I said I like to use 19-gauge needle more than the 22, just a personal preference. You don't use, I usually don't use a coil. You can just simply use a gel foam if needed for an active bleed, and that usually stops the bleed. If it's a medium-sized varic, five to 10 millimeters, then again, you can use a 22-gauge needle. Medium-sized in this circumstance, if you use a 22-gauge needle, should be 0.018 inches. Normally one coil will suffice, and that should be enough. If it's a large varic or a giant varic, you want to try to use a 19-gauge needle, because then you can use a little bit larger coils. You can use 0.035-inch coils, and then you can use anywhere from one to two, or if it's a really large varic, then you can use even more than two coils to push directly into the varic. So remember, in between the coils, you don't want to pull the needle out. The needle stays in place the entire time. You need somebody to help you, a tech or a nurse, to get the coil ready for you and then help you load it into the needle in between coils. So whatever happens, once you place one coil, and if you're going to put a second one, don't pull the needle out. That will reduce the risk of bleeding. Next slide. So this is just a very brief and quick overview, you know, EUS-guided pancreatic drainage. I'm going to go through some indications and steps. These are high-risk EUS procedures and, again, should not be done without proper training and being very comfortable with basic EUS and doing some other basic therapeutic EUS procedures. Next slide. So pancreatic gastrostomy is the pancreatic drainage of the EUS, which is basically from pancreatic duct to stomach. You can also do it in post-whipple anatomy, chronic pancreatitis patients with dilated pancreatic duct. And I am honored to say that the first time I heard about this was in one Dr. Barron's lecture at DDW, and Dr. Barron is, I'm on the same stage with him virtually today, and it is an honor to be here. So my learning about this is from the guru himself, and he can certainly add more to it. Next slide. EUS-guided biliary drainage, there's different, multiple different steps in biliary, that's not steps, different types of procedures with biliary drainage. Dr. Kothari is going to go over some of them. There's EUS-guided rendezvous procedures, there's Koli-Doko do it in ostomy, hepatical gastrostomy, and then gallbladder drainage, which Dr. Kothari is going to discuss later. So what are the tools required? Well, at the bare minimum, you need a linear therapeutic scope, and you need a 19-gauge FNA needle. I also use a long wire, either a 0.035 or a 0.025-inch wire. I use a non-jacketed wire, i.e. ones that don't have a coating. So if you have the Boston Scientific JAG wires, then those wires actually have a coating. So if you have, you need a non-jacketed wire, which I believe Olympus makes one, and I'm not sure if, who else makes one that is easily available. We have Olympus at our institution, the VisiGlide wires. You need a dilation balloon to dilate the tract once you have the wire access established. And then you need a stent of some sort, either a plastic stent or a metal stent. You can use a double pigtail plastic stent, or you can use a fully covered or partially covered self-expanding metal stent. In rare cases for hepatical gastrostomy, there's some case series and case reports out there that you could, that have used the lumen-opposing metal stents. They're more excessive, more used in choledochoduodenostomies, which is from bile duct to duodenum, more than hepatical gastrostomy, simply because there's a limit in terms of how the length of the actual stent, the maximum length is 15 millimeters as available in the U.S. If you have a longer one, then you certainly can use that, and I know there's some in development, but until those stents come out, I think doing fully covered or partially covered metal stents or double pigtail plastic stents is the safer way to go. So these are just different pictures showing exactly how to go about doing hepatical gastrostomy. So this first picture here is actually showing EUS guided rendezvous versus the EUS scope with the wire axis that goes transpapillary. In the second picture is placing a stent over that in this anti-grade axis. In picture C, this is a choledochoduodenostomy, which is placing a lumen-opposing metal stent between bile duct and the duodenum. All right, in slide D here, you can see a pictorial representation of what a hepatical gastrostomy might look like. This is placing a stent directly between the left intrahepatic duct and the stomach. You obviously need to have dilated left ductal system for that. If you don't have a dilated left ductal system for whatever reason, then you cannot do a left side hepatical gastrostomy. Doing it on the right side is possible. I have seen case reports and case series on that. It is technically challenging because of looping in the scope and scope positioning as well. So what choice of stents can you use? You know, this slide is very wordy. In essence, to keep it very simple, I don't put metal stents in the pancreas. If it's a pancreatic drainage you're doing, then you want to try to use either a straight or a double pigtail plastic pancreatic stent, which are available on the market. Lumen-opposing metal stents should only be done for EUS choledochoduodenostomy. Hot spaxus is not available in the US at this point to the best of my understanding, although I did see it on display at DDW. My understanding is they are very much similar to the Boston Scientific Axio stents. EUS hepatical gastrostomy, when you're doing those for primary drainage, I always put a fully covered self-expandable metal stent. You can use either the viable stent that's on the market, or you can use any other self-expanding metal stent. As a rule, I also tend to place a double pigtail within the metal stent after the metal stent has been successfully placed. That's just a personal preference. You don't have to do that. So final takeaways, and I'm going through a little bit fast because I want to make sure there's enough time for the next two speakers, but final takeaways from this, always respect the procedure. Always make sure that you're looking at the anatomy, you're comfortable, you're prepared for it for every single time you do the procedure. Don't take it for granted. Anticipate any potential issues. Discuss with the team what you're doing. Prepare for it. Make sure everybody's comfortable with it and on the same page. For ablations, it's very useful for small pancreatic neuroendocrine tumors. Adenocarcinoma has good data for usage, and honestly, with every passing week, I see more and more information coming out about EUS-guided ablation and how helpful it is for adenocarcinomas. For coil injections, for coil placements, sorry, gel form injections can be very helpful and can be a life-saving procedure. It does require preparation of the needle and the coil before you puncture the varix, meaning make sure the coil is ready to go. You've preloaded the coil into the varix so that once you puncture the varix, you can easily deploy the coil directly into the varix. For EUS-guided pancreatic duct and bile duct drainage, you need to know your limits and you need training for those procedures as well. Always ask for help either before, during, or after. I have certainly reached out to my colleagues during procedures. I still do asking experts who may have some more experience with certain things than I do. That's never wrong and always recommended. Okay. Well, thank you, Dr. Rosa. So right now, we're going to continue with our second speaker, which gives me really a lot of pride and joy to present. Dr. Ditesh Kothari and myself were co-fellows back in the day, and we shared our three years of training at Lenox Hill back in 2010, I believe, right? So after that, Dr. Kothari has excelled in his career and has achieved so much more than I have. And right now, he is the Director of Developmental Endoscopy and an Associate Professor at the University of Rochester. And he is going to be talking to us about EUS-guided techniques as well. So Dr. Kothari, please. Thank you. Thank you, Antonio. And thank you, Viro and the entire ASG group. Today, we are going to talk about, I have 15 minutes left, and then I have to hand over to the guru of endoscopy. So we'll talk about the EUS-guided gallbladder drainage and also some GGA, and then also talk about EUS-guided transgastric ERCp that is H. So talking about the gallbladder drainage, we all know that the outpatient around 600,000 and inpatients 300,000 underwent cholecystectomy in 2018. And we all know that laparoscopic cholecystectomy is the gold standard for patients who are surgical candidates. So the question posed to us is what happens to high-risk population who are not surgical candidates? And what are the options available for high-risk population who are surgical candidates later? So that's where we have three options for patients who are not surgical candidates acutely. And the first one comes into play, which we all know is the percutaneous gallbladder drainage. But again, with the percutaneous gallbladder drainage, that is a PTGBD, has served as a temporizing method for drainage for many, many years. And its role in management is ideally to function as a bridge so that the patient can go for surgery later on once the acute crisis is taken care of. But many patients who undergo PTGBD, they are never a candidate for surgical resection of the gallbladder due to their comorbidities or they're not candidates due to surgical interventions that deemed not a candidate for that. And that will result in a permanent drain, which then leads to the complications and high recurrent rates of cholecystitis, bile leakage. Sometimes patients also have some complication of bleeding, pain, and cosmetic dissatisfaction, which then brings us to the patients being referred for internal drainage. And which brings us to the next one is the transpepillary cystic gallbladder drainage, which is the ETGBD. Again, it's ERCP with a cystic duct stent placement is a technically challenging, you need a very highly skilled technician or you might need a cholangioscopy just in order to get into the cystic duct. So it has a high rate of both technical failure as well as you will need re-intervention for the stent occlusion also to change the stent every three monthly if the patient is not a surgical candidate. So that's the biggest flaw that we have with the ERCP with cystic duct stent placement. So then comes our last option, which is the flavor of the last four to five years is the USGBD, which is the US Gallbladder Drainage. So this was in 2012, Dr. Itoi, Ken Minmolar and Dr. Janak Shah's group, they came up with this study of clinical evaluation of LAMs for pancreatic pseudocystic gallbladder drainage. So this is basically a lumen opposing metal stent. It's made of nitinol with a silicon coating. It's a shape of a dog bone stent trying to connect two cavities or two organs if I have to say in a very simple language. So this is one of the videos of the gallbladder drainage where we see the patient comes in with cholecystitis and to us, we first look at the Doppler, make sure there's no signs of any vessels coming in our way. And then we inject contrast and then try to deploy the axial stent based on the size of the gallbladder, we can select the type of the gallbladder stents, which we had already mentioned. And then this is, the stent is already deployed in the proximal area and now it's in the stomach. We make sure that it's dilated pretty well. So here you would see that on suctioning, there will be some, we are dilating first with a balloon, which is lesser than the stent size. And on suction, you will see some pus coming out along with some gallstones as well. So there was a study done and published in Endoscopy in 2020 by Mohan et al, which compared endoscopic ultrasound guided gallbladder drainage versus ERCP, that is a cystic duct drainage versus PT-GBD. And I would like the audience to look at the green circles first, where we talk about the technical success rate, which says that the EUS-GBD and the PT-GBD has a very good technical success rate with a good clinical success, especially in the EUS-GBD. When it comes to the adverse events, it's noted that the PT-GBD has a 15% adverse event compared to the other two. And there's a recurrence rate, if you look at the red circle of polycystitis in patients with PT-GBD or also leakage. So that's one of the highest recurrence rates we have noted in the three modalities. So the take-home points for this procedure itself, the EUS-GBD, which was published in AGA clinical practice update in May, 2023, was that this is a flow chart that we should be following is if it's a patient coming with acute cholecystitis, is a poor surgical candidate. And if you see that the gallbladder is perforated on the imaging, then there's no questions asked, patient goes for PT-GBD. But if there's no perforation on imaging and patient is able to tolerate sedation, there are two options. One is the trans-papillary cystic gallbladder drainage, and the other is the endoscopy ultrasound-guided gallbladder drainage. Now, the other caveat is that why EUS-GBD cannot be done, the criteria is that if the patient has uncontrolled ascites potential future candidates for cholecystectomy, and if the patient has a choledocholithiasis, then why not just do one thing and get two things out of it, remove the stones as well. Or if the gallbladder wall is 10 millimeters away from the GI tract. On the other hand, if the patient has a duodenal obstruction with a gastric outlet obstruction, and a large stone burden within the gallbladder, then EUS-GBD would be the ideal candidate. But in short, if both of them fail, then your last option is PT-GBD. So that's why we go hand in hand with our interventional radiologist, as well as the surgeons, that this is not that we are stepping on their territory, but it is just a situation where if they reject any patient, then it could be our patients or vice versa. So that is very important in order to put that across your division, and to talk to your surgical and IR colleagues, so that you get more referrals in such scenario. And again, this is not a 2 a.m. procedure. We have to be very careful. We cannot be doing EUS-GBD at 2 a.m. in the morning, just trying to prove a point. It is a procedure where things can go south as well. So we have to be careful. Let's talk about EUS gastroenterostomy, or GJ. So the goal here is trying to make sure that any patients who come in with gastric artery obstruction, could it be benign or malignant? There are other etiologies with benign etiology, could be chronic pancreatitis, peptic ulcer, or caustic ingestion, or sometimes even malignancy can cause gastric artery obstruction. So it's current modalities that we have been using is a surgical GJ. For malignancy, we use duodenal stenting, and we also have the EUS-guided gastroenterostomy, which could be used for benign as well as malignant. So here's a case of a 72-year-old male present with adenosine of the uncinate process of pancreas, and there is a gastric artery obstruction involving the D3 and the D4. So here we see that the 1T scope is taken, and we try to look at the second, third portion of the duodenum, and we are unable to get through. Fortunately, we could get the wire through the D3 and the D4, and then through with the A balloon, we go over the wire, excuse me, inject contrast in the duodenum, make sure we are in the lumen, and we have crossed the D3, D4 structure. A nasobiliary train is passed over the wire, and then it is connected to a solution of sterile water, methylene blue and contrast, and under fluoroscopy, we make sure that we insufflate the duodenum with almost 500 to 600 ml of the solution, and then switch on to an EUS scope once we have a good idea about the jejunal which is being opacified, and then we plan to deploy the hortexia stent, and the same mechanism that the distal end is in the jejunum and the proximal is in the stomach, you would see that we are satisfactorily deploying the proximal end of the axios in the stomach, and then it's dilated just to make sure there is patency, and then once it's dilated, inject contrast, make sure that we are going through the right track, and you can see the lumen on the other side and that's the jejunum, and patient really did well. So this is a study done by Geisinger talking about a systemic review and meta-analysis of EUS-GJ for management of gastric outlet obstruction. They have a good technical success, clinical success rate of almost about 90%, and the adverse events has been around 12%, suggesting that it has been a safe and efficacious modality for management of benign and malignant gastric outlet obstruction. There was a study again done, and it was published in Surgical Endoscopy by Chen and also by Mohin Kashyap, comparing the enteral stenting and EUS-GE, so the punchline of this study was that there was no significant difference in the technical and immediate clinical success. On the flip side, EUS-GE had a less frequent symptom recurrence and less need for re-intervention. So I would come on to my last topic. I still have five to six minutes. So EDGE, which we all know, and we have been doing for all of our gastric bypass patients, the option is that when a patient comes with cholangitis and they talk about everything, but the last line comes is that the patient has gastric bypass, that's where your treatment plan completely changes. And then the options left with us is, okay, is there a double balloon in your unit? If not, again, even if we have a double balloon, but again, doing a Roux-en-Y ERCP, it's literally a nightmare because you would not have the equipments that long required for double balloon ERCP. And again, the position of the scope is very unstable. The sphincterotomy that we are going to do, again, this is a very difficult position. So it's a nightmare for the endoscopist. The other option left is the laparoscopic ERCP. If a surgeon has to give us a lap port, just in order to get in and do our work. But that's again, you need a coordination with a surgeon in order to get in and do the procedure, which is sometimes difficult. So that's where the Roux-en-Y gastric bypass, that is the EDGE, which is endoscopy ultrasound directed transgastric ERCP comes into play, where we are connecting the gastric pouch with the excluded stomach, with the lumen opposing metal stand. And it could be a two-stage procedure. So the study was done by Kahalain. In 2015, Kahalain talked about this novel technique. So basically this was 2015, they did a procedure. And it was published at that point. And six patients were part of the study where it was done in two stages. One was 81 minute stage and the second was 98 minute. There was a gap of almost six days in between, but now we recommend that I normally do it in a span of at least, if it's not urgent procedure and just a CBD stone, we would call the patient in a week or two and do the second stage. But if there's a patient with cholangitis and crashing, definitely you can do it in a one-stage procedure that is a index ERCP. So in this procedure, there was no ERCP complications and there was only two PEG infections noted as per the study. So this is my final video that I would share with you. This is the Roux-en-Y gastric bypass, the H procedure. You first go in with a gastroscope, make sure that you have a look of the gastric pouch, making sure that you know the lay of the land, the roadmap, switch onto your EUS scope, find the excreted stomach, which I would not say as the sand dollar sign because there has been some reported cases where intestine has been also called, the colon has been reported as a sand dollar. But again, you look at this features and then once you start, you are in the right position, instill it with methylene blue, sterile water and contrast, try to inject contrast as much as possible and some drops of methylene blue. And then once you fill it up with almost 500 CCs and you will see a bag of fluid filled area, deploy a distal end of the axios. And again, the same concept, you have the proximal end in the gastric pouch. So this was an index procedure and the patient was cholangitic, was dilated, the balloon was dilated, the ERCP scope was passed through this axios and ERCP was performed for CBD stones. So it's important that even if you are not doing the axios at the ERCP at the same time, it gives you an access, there's always an access left. In this scenario, a PD stent was placed and the CBD stent was also placed after the removal of the stones and then the patient was brought in after two weeks and all the stents were removed and also the axios stent was removed. Initially, when this procedure was started, we used to close the area with sutures but now we have stopped doing that and because allowing that to have a proper healing on its own is the goal right now. And with this, Peter and I would like to talk, would like to end the talk and would hand over to Antonio to introduce Dr. Todd Barron. Okay, thank you very much, Udesh. So right now I'm gonna, it's my pleasure to introduce the man who needs no introduction really. Everyone knows who Dr. Barron is. He, just for critical reasons, I'm gonna say he currently serves as a professor of medicine and director of advanced endoscopy and therapeutic endoscopy at the University of North Carolina. I have a brief case that's completely different than where we've been in terms of more of a lecture style. It's just a show and tell case. I'm happy to do that. Or if you think that you need to address the questions from the audience, we can do that as well, whatever you would like me to do. But while you're thinking about that, I have a case that is clearly ERCP related but certainly very different than what you've seen before. So this, I entitled this finding the lost minor papilla in a patient with pancreas, tobesim and acute recurrent pancreatitis. So this is a 64 year old woman who had multiple attacks of acute recurrent pancreatitis beginning in 2019. She had no drug related attacks, nothing related to alcohol. She had an empirical cystectomy performed after the first episode and then was found to have documented pancreas tobesim. There was a really reputable endoscopist at another institution in another state who did two ERCPs but he could not locate the minor papilla. And he was referred to me for another attempt at ERCP. So I can't remember the last time I could not find the minor papilla and we failed to identify the minor papilla despite exhaustive search and administration of secretin, two separate injections, two vials of secretin. So we just wanted to make sure that we, the other physician wasn't incorrect on his diagnosis nor the MRCP. So of course we shot a pancreatogram or that they could be incomplete tobesim but it was complete pancreas tobesim. So what we ended up doing is of course you would say, well, of course you're gonna do an EUS guided drainage. The problem is this is the EUS images from the stomach and we could not identify a pancreatic duct and on MRCP outside, there was no pancreatic duct dilation. We still tried puncturing across and then into the pancreatic parenchyma and pulling back and seeing if we can inject and we couldn't inject or identify a pancreatic duct. So from the bulb, however, you could find the pancreatic duct was reasonably, it wasn't actually dilated by exact dimensions than normal, but it was certainly visible. And so we punctured through the duodenum going retrograde instead of anti-grade into the pancreatic duct. Then we passed a 0.025 inch Visiglide to the tail. Then I dilated the tract with a 543 catheter even though these are designed to accept only 018 wires, you can actually get a 543 over an 025 Visiglide wire, although you have to really lubricate the wire with some sort of oil. And then I just placed a five French pancreatic stent without having any further dilation, a five French plastic stent to the tail. There was actually a fair amount left here in the duodenum. So here is it immediately after the puncture passing through the duodenum wall from the bulb. So we repeated the ERCP a month later, here's the same site, now the site is mildly ulcerated, but healing. And we pulled out the stent and cannulated through the pancreatic duodenostomy and you can see a pancreatogram and we were able to actually pass the wire out through the minor papilla. And then once we did that, it sort of straightened everything out. And then I placed a pancreatic stent from the pancreatic duodenostomy through the minor down to the duodenum so I could find the minor papilla. And you can see the endoscope position is very, very odd. The ERCP scope position on your left is almost looking at the lateral wall and we expect the minor papilla, of course, to be on the medial wall, so it wasn't present. On the right picture, that's the endoscopic view of the stint that I had passed, antegrade through the pancreatic oduodenostomy down through the minor papilla. And then I performed a minor papil sphincterotomy right over that stint. So I didn't have to remove the stint that I just placed. I performed the minor papil sphincterotomy, but I then made sure that I directed a stint out through the minor, and I put a small spot of India ink so that it could be found if needed in the future. The patient actually did well, despite puncturing a relatively normal and healthy-appearing pancreas quite a few times through the stomach. She did well. The pancreatic duct stint was removed as an outpatient two weeks later. Both the first pancreatic puncture and the follow-up ERCP that I did were completed as an outpatient, so the patient was not admitted. And the first time I made this slide, it was six months, and I talked to the referring doctor today since this case is about a year and a half old, and he said there'd been no further attacks of acute pancreatitis. Thank you. Well, yeah, that's impressive. We're gonna open up for questions at this point. Let's see. First question we have here is, I guess this is for Dr. Oza. Do you prefer to feed her vessel, and if so, what are hints to find those? If not, how do you decide which vessel to inject? Yeah. Yeah, so that's a great question. If you can find the feeder vessel, then that would be the ideal solution, is you can then get a coil directly into the feeder vessel. What I normally do is I use the Doppler on the EUS scope to see if I can find any signs of a possible trickle or flow from the varix towards the stomach. And if I can, then I just trace that back. But that doesn't always work. So my best solution is just put it in the varix and clot them all off. Okay, thank you. Next question is, I believe for Dr. Kothari. For transplantary transcystic duct stenting, do you really need to bring patients back for exchanges? In cases I've done, basically this person's saying that he usually doesn't bring patients back for stent exchanges, but mostly because these are patients, elderly patients with poor prognosis. So do you see recurrent chronic cystitis and the need to exchange stents after you've done this transcystic approach? Yeah, I wouldn't bring them regularly, to be honest with you. But it's basically the same concept what we do for our pancreatic pseudocyst or the gallbladder drainage EUS guided. So I think if the stents, they get clogged and the patient tend to develop cholecystitis recurrent, then we have to bring the patient. So that's what I meant to say. It's not a must that you have to bring the patient every now and then, just to change it. Okay. I have a question myself about that. I recently did like the second or third transcystic drainage last week, and about two weeks, and then the patient came back the following week and his stent was clearly, he had cholecystitis again. I couldn't, I could have exchanged the stent, but I tried to do an EUS drainage, but the gallbladder was just not in the right position. And he came, we ended up deciding he was going to go to percutaneous drain. But it is the first time I see that the stent occludes so quickly. He might've had a lot of sludge, I guess. Dr. Barron, I have a question. How long did it take you to make that wire, make that turn in that small piece of- The second procedure actually- You've made it that 180 degree turn of that wire. That's impressive. Thanks. Honestly, I was surprised that it was not as difficult as I thought it was going to be. I thought that with further advance, it was just going to back up into the dorsal duct. And I thought I was, honestly, I thought I was going to have to use a rotatable sphincter tone. That was my initial plan. When I first saw, when I injected, I said, ah, I'm probably going to have to use a rotatable sphincter tone and get it to turn down, thinking that with the catheter I used, which was just a standard tapered catheter, and somehow it went around that corner. And it wasn't, it didn't take me hours, I can tell you that. But I wanted to comment on the gallbladder stents. I think there's so much heterogeneity in the studies that have been out there. And I think there's also, there are some patients I've seen that, frankly, have strictures within the cystic duct. I'm not going to say that it's common, but my point is we think that these work, we know they're going to occlude. We all know biliary stents, bifrench stents are going to occlude within a couple of weeks, seven French in a month, 10 French, three months. We don't put 10 French stents in. So one option would be to actually use the smallest possible stent, knowing it's going to occlude, with the idea that you're going to get a wicking effect on it. Because if you use a bigger solitary stent that completely occludes the lumen, and then it occludes, are you going to be able to drain around the stent? I know that there are publications from Mayo that have looked at putting side by side, I've done that a number of times. But I guess the point is, really when you try to look at it, the approaches are really all over the place. And I have seen patients who do very well with no stent exchanges, and others that come back with cholecystitis, and like you did, if we can do the US guided drainage, we think it's probably superior just because you have a much bigger lumen that you're dealing with. But I think there's still a lot of, because the studies have really all been retrospective for the most part, if not all of them for the gallbladder trans-papillary, it's hard to know. A medium in our own series, years ago, we were all over the board with diameters of stents, how many stents, it's just not standardized is the problem. Thank you. I agree. The next question we have is for Edge, are you securing the lamps with suture or clips? And does it depend if it is single stage or two stage procedure? So basically if it is a two stage procedure, we do not secure the lamps with anything. We just let it sit. But if it's a one stage procedure, then definitely it would be a good idea that we actually suture the lamps to the gastric pouch and then try the scope because there's a high risk of migration in this scenario. So I think that with proper placement, there was a really good photo image that was presented during the Edge case that briefly went by. I think it's important to realize that your initial puncture when you see the excluded stomach is almost always what you're gonna puncture it through the body or the antrum. But that's not the place that you want to put your axios. What you then wanna do is fill the stomach up with a lot of fluid and I do them on their back, some people do them on their side, but it's gonna, the water is gonna flow toward the patient's head like it always does. And then when you filled it up adequately, you pull the scope back so that where you're high up in the stomach as you can be and still have a good apposition. And what that does is it really lessens the angle. The angle coming down is much less acute than when you're going through the body or sometimes people don't realize they're in the antrum and that angle coming through the axios will go to the pylorus. And that's what I think contributes a lot to the dislodgement is the torque that you're putting on the end. And sadly, I've learned what I'm telling you over doing these last 10 years. So I'm more comfortable now doing a single stage without really doing anything to anchor the stent as long as I like the angle. The other thing I do is I'm prepared to manage a dislodgement because if it is dislodged on the way out, I keep my guide wire that I just finished the ERCP. And as I'm backing out, if it's dislodged, I keep my wire and catheter and then put in a TTS partially covered or fully covered a soft gel stent that'll close it right up. And those tend to do well. So somebody could probably look at a cost analysis of each of those approaches at a time analysis, but I'm not saying that you shouldn't be very, very careful. And I agree that you should, if it's a very elective procedure, and certainly if you had to do any sort of EUS evaluation, some of these you need to pass an EUS scope. There's no way, I don't care where you put it, that you're not gonna dislodge it with an EUS scope, a big EUS scope. If you need to say, let's say a mass in the head of the pancreas in a gastric bypass patient. So I'm not minimizing the difficulty. I just think we can do better with placement. If we do better with placement, I think it can minimize the displace, the dislodgement that can occur. Excellent. Yeah, I agree with Dr. Barron. I actually do the same thing. I actually have the patients in reverse Trendelenburg a little bit, not a whole lot. And I actually keep them at an angle as well, almost left lateral. Yeah. The gravity does the job for me and kind of keeps, pulls the water in one area. And I do pull the scope back a little bit. Yeah. And then when you're in doing so, the other thing is you're gonna be looking toward the patient's left side. It's kind of up and rotates. So you're looking directly to the patient's left fluoroscopically I'm talking about. And usually that's where you're gonna go. That's at least the way I do it. Thank you. And next question is, well, it was already sort of answered here, but I guess we can ask for a consensus. What is your favorite position when you're doing it? I do all my, I do every single intubated patient on their back. Totally. I have done that for years, but I don't have a problem with people telling me that they think a procedure is better on their side. It just tends to work for me. Yeah, for edge. Go ahead. Go ahead, go ahead. Yeah, for edge, I usually have them on the back. Like I mentioned, slightly left lateral. That usually works best. Yeah, I agree. I normally put it in a left lateral with a slight tilt in a back position. So that way we can get the maximum, I would say gravity as Dr. Todd explained before. Yes. Thank you. So next question is, do you leave big tails across the axis when you do a gallbladder drainage? I do always. I put a pigtail through every axios for every indication except for a gastroenterostomy. Because there I think it interferes with food passage, although maybe not, but that's the only ones that I don't. And I've always done it that way. Again, not saying that's the right way. I'm just saying that's the way I do it. It makes sense to me, but I can't tell you that there are, you know, incredibly supportive data. Other than Waldorf necrosis where the, you know, I think they're starting to show, at least in retrospective studies, less bleeding, I think. But the reason to do it, I think, is prevent stone impaction. If they have stones in the gallbladder into the axios, you can prevent a buried axios or not prevent it. But if you ever have that happen, you can always get it out because you can dilate along that tract. You know, I think it probably prevents the back wall of the gallbladder from hitting onto the edges of the axios. But again, I can't prove that, that that would be the case. And there may be a theoretical of it collapses all the way flat against the back of the stent. It may intermittently occlude, I don't know. But those are, to me, the theoretical risks or reasons of placing it. But there's not really, certainly in gallbladder, we don't have data to support it one way or another. I tend to leave a double pigtail during gallbladder drainage, simply because the first couple that I did, maybe a couple of years ago, I did not do that in patients. Both, one came back with the lettuce impaction. Yeah, in fact, that was the other thing I was going to mention. And then the other one came back with mashed potato on the gallbladder. Yeah, yeah. Sorry, I left that out. But yeah. Were those duodenal or gastric? They were actually both, that's a good point. They were both actually from the antrum into the gallbladder. So those are always higher risk of impact. I think I've only done one through the stomach and I've done them all through the duodenum because of that. But, because I knew that early from talking to people in Asia in particular, they were saying that they would actually fill up with rice and occlude when they're in the antrum. So. All right. Some people are worried about, going through the duodenum, but I think it's certainly not as thick. I mean, probably in herself had a case that it went great and it separated out from the antrum and she didn't know if it was the length, the distance, the motility. So, I don't know if it's, you gotta worry about the wall thickness and that you're got the length you need for those through the stomach. Okay. We're gonna try to get to a couple more questions before we have to finish. Last question. Triptash is telling me we need to be done. But the last question here that we, I would like to address to the audience and the panelists is, for GJ, do you always use a nasobiliary drain to fill the loop or is just injecting through a 19 gauge mixture of contrast methylene blue into your target loop enough before you deploy the lance? I prefer to use a nasobiliary drain all the time. That is my preference. I don't know what you guys do. I prefer the nasobiliary drain. And I would like to know Videl's technique as well. He's smiling because he knows. Yeah. The only time I've used the needle technique and we published a series at our institution where people that rarely, you can't pass the guide wire through the obstruction is one, I've done it. Yeah, I saw that one. Yeah. I've also done it in duodenal switch patients where you've gone directly from the stomach in so you can shortcut and get back. And somebody that clearly just didn't even have a lumen at all. It wasn't even there. Post-surgery Whipple, it retracted and it never connected somehow. And we did that, but I think it's too dangerous. The problem is that you pull out the needle and you can't re-infuse where if you have a nasobiliary tube, you can take your time, hit the pedal, wait, put more water. Whereas this, once the needle's out, you're going to lose your fluid. You don't have a balloon on either side to hold it in. So you got to move fast and it's dicey. Yeah, agreed. Yeah, so I actually don't use a nasobiliary drain. Our cancers, at least what you see here, I can't even get a wire across. It's extremely challenging. Maybe it's because I'm in South Carolina and we have really bad cancers. I'm not really sure. So I've just gotten accustomed to doing a direct technique, do a 19 gauge. I'll use a wire sometimes through it, almost actually 50% of the time I'll end up using a wire through the 19 gauge. After I've infused it, I usually have the patient paralyzed. I also give glucagon. Patients, of course, intubated for the procedure. They're usually on their back. I always have them on their back for these procedures. And then followed by, I just quickly, like Dr. Barron said, you have to be relatively quick. You can't wait for five, six minutes, but because they're paralyzed and I've never really had an issue. I've done several of these. If it goes well, it goes well. And I'm going to knock on wood here. You know, I don't, I hope it doesn't, I don't jinx myself here, but it's been fine so far. Well, those are the most unpredictable of all the EOS procedures, I think. The small, bad ones range from being incredibly easy to completely disastrous. And I think that we need to make it more predictable and safer. Yeah, one thing I would recommend to everybody who's listening into this is when you do the cautery for, especially for GG and even for gallbladder, you know, take your time with the cautery. It's not a quick jab. You kind of want to do a slow, you know, hit the pedal and kind of slowly push into the jejunum or the gallbladder because you're actually burning through a fairly thick wall. And gallbladders, it sometimes might be inflamed and you might go pop through pretty easily, but jejunum, you know, it's relatively healthy. So you want to kind of take your time burning into it because otherwise it's just going to push. If you do it fast, it's going to push it away. Yeah, it'll burn through the gastric wall quickly and then push it away instead of, like you said, slowly dropping into it. Yeah. Yeah, it's very important, especially the EOS guided drainages, especially edge or GG or gallbladder. If you're not seeing proper filling, I myself have aborted edges, like maybe three to four times in the so many edges that we have done because we are not able to fill the excluded stomach properly. Then you're like doubting yourself. You call your interventional partner trying to get their opinion, but at the end of the day, this is not something that you have just because you can do it, you have to do it. So that's very important for our audience. Okay. Well, if there are any final remarks from the chair and vice chair of the SIG, if not, thank you for inviting me. And this was great discussion. Thank you. This was fantastic. Thank you everyone for attending. And I think we have people from all over the world in this. So thank you so much for everybody. Thank you. Thank you. Yeah, we would like to thank our speakers and ASG staff for organizing this worthwhile webinar. Thank you all. Bye-bye.

Endoscopic Procedures

EUS-guided Techniques

Ablation

Coiling

Gallbladder Drainage

Gastric Junctions

Nasobiliary Drains

Cautery Application

Complex Cases Management

Advanced Endoscopy