Our next session is an endo-hangout program on esophageal and gastric variceal bleeding. This is a program intended or designed some time ago, about a year ago, for virtual provision to fellows, especially, and Amitabh Chak, the originator of this program, has really made it into, I think, a popular and practical session that any one of us can gain from. Today, our moderator and host is Ashley Foe, who is a professor of medicine at Case Western Reserve University in Cleveland. She's on the faculty at the University Hospitals and Medical Center and the Cleveland VA Medical Center, where she's director of endoscopy. She serves on the GI field advisory committee to the VA central office and is a member of the FDA advisory panel for GI and genitourinary devices. She's currently a senior counselor on the governing board of the American Society for Gastrointestinal Endoscopy and is past president of the Ohio GI Society. Her clinical interests within advanced endoscopy are the management of complex pancreatic ovillary disease, GI cancers, and EMR of early esophageal cancer and large colorectal polyps. Ashley is a busy person, and we look forward to her coordination of a program over the next hour and a half regarding variceal bleeding. Thanks, Ashley. Thanks, Brett. Welcome, fellows, to another edition of ASG Endo Hangout. As Brett said, Amitabh Chalk sort of came up with this idea when, during the pandemic, the fellows were a bit starving for endoscopic education while they were stuck not doing cases. So this was his idea, and it's really supposed to be a video-based educational endeavor where we'll show videos from the various panelists, and you guys just ask questions. And I think, you know, I always learn a lot, and I hope you guys will all enjoy it. I'm going to first introduce Ellie Vergara, who works for the ASGE, who has this all organized, so she can explain to you how it's going to work. Ellie. Thank you, Dr. Chalk. We trust you all have enjoyed the first two sessions of the program and are ready to dive into this Endo Hangout session. This is, again, ASGE Endo Hangout with G.I. Fellows, Management of Sophia Jewell and Gastric Variceal Bleeding. We have attendees joining us from all over the world, and American Society for Gastrointestinal Endoscopy greatly appreciates your participation. There are a few housekeeping items. We want this presentation to be interactive, so we encourage you to submit your questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question, and hit return to send message. Please note that this presentation is being recorded and posted in the Fellows program section on G.I. LEAP, ASGE's online learning management platform, within a week. Now it is my pleasure to introduce our two fellow moderators, Dr. Ahmad Zerouchi and Dr. Daniel Ellis, who will help facilitate the incoming questions. I will now hand the presentation over to them. Thank you very much, Ellie. Thank you to ASGE for hosting this webinar, to our panelists for their dedication to fellow education, and to all of our viewers and listeners for joining today. My name is Ahmad Zerouchi. I am an advanced endoscopy fellow at the Brigham and Women's Hospital, and I'm excited to co-moderate today's session with Dr. Ellis. Hi. Nice to meet you all. I'm Dan Ellis. I'm a third-year fellow at Osher Hospital in New Orleans. It's my pleasure today to co-moderate the session with Ahmad, and to help facilitate passing your questions along. We're going to begin introducing our panelists for today. First off, we have Dr. Marvin Yu, who is a faculty member of the advanced endoscopy group at Brigham and Women's Hospital and Harvard Medical School. His clinical and research interests are in ERCP, interventional EUS, and endoscopic hepatology. Our next panelist today is Dr. Yannick Stahp. He's the chairman of the Department of Gastroenterology at Osher Medical Center in New Orleans. He's a recognized leader in advanced endoscopy, and has authored numerous publications in the field. His clinical and research interests center around interventional EUS, pancreatic biliary endoscopy, and new endoscopic technologies. Next up is Dr. Richard Wong, who is an advanced and therapeutic endoscopist at University Hospitals Cleveland Medical Center, and is a professor of medicine at Case Western Reserve University in Cleveland, Ohio. Dr. Wong's research focus is in acute GI bleeding, both upper and lower GI, variceal and non-variceal. Dr. Wong has pioneered the use of endoscopic Doppler ultrasound probe in the United States, and published the first original article in the U.S. on the use of Doppler probe in acute peptic ulcer bleeding. Our fourth panelist and moderator today is Dr. Ashley Foe. She's a professor of medicine at Case Western Reserve University School of Medicine. She's an advanced therapeutic endoscopist. She is on faculty at University Hospitals Cleveland Medical Center, and serves as the director of endoscopy at the Cleveland VAMC. She is also the counselor on the ASGE governing board. Dr. Foe, you want me to start with this first case? Okay. All right. It's a pleasure to be here with everybody today. This first case that we'd like to present to you is a young woman, 51-year-old woman with alcoholic cirrhosis. She has a history of decompensated cirrhosis, as you see there. And she presented critically ill with large volume hematosis. And this is a picture, a representative picture of her endoscopy four months prior to presentation. So she had no esophageal varices. And then you can kind of see the gastrovarics there in retroflexion. It's a large cluster that you see there. And so maybe the first question that I'll throw out to the fellows is, according to our current serine classification system, what kind of gastrovarics is this? And feel free to submit your answers via the Q&A function. And I'm going to keep talking while people submit their answers, if that's okay. So we have, according to the serine classification system, we have four sort of general categories. We have isolated gastric varices and gastroesophageal varices. If you have esophageal varices, you're in the gastroesophageal varices, either one or two. Two is what we call cardiofundal varices. And then GOV type one are extension of the esophageal varices along the lesser curve. And so typically for those small GOV ones, you can ban those also. Okay. This one is an isolated gastrovarics because there's no esophageal varices. You just have this large cluster in the fundus. So this is an IGV-1 or isolated gastrovarics type one. And so the IGV-1s and the GOV-2s are what we call the cardiofundal varices. These are the ones that bleed the most. And these are the ones that are most challenging for therapy. The last category is IGV-2s. Those are much more rare. Those are the presence of gastrovarices sort of in other areas of the stomach. So those are your four categories for gastrovarices according to the SARA classification system. All right. Next slide, please. Okay. So this is the initial endoscopy. Just to remind you, this patient is critically ill. She's in the ICU. She's intubated. I believe at this point, she's on three pressers and has been transfused many, many units of packed red cells. And you see this very large, almost like a placental clot occupying most of the stomach. It extends actually beyond the pylorus. And then in the retroflex position that you'll see shortly, you can't even see the gastrovarix endoscopically. So maybe the next question that I might ask the fellows and maybe opening this up to the panelists is what are you guys thinking right now in terms of next steps? What are our therapeutic options at this point? Can I ask a question, Marvin? So not necessarily related to variceal bleeding, but what are your tricks for when you're going in, it's the middle of the night, someone's bleeding, and you get in and you have this big clot in the stomach. What things have you found to be useful that ever work for clearing the clot, be it a device, a drug, moving the patient, things like that? Yeah. It's a great question. Obviously, challenging situation, sort of moving a large clot like this. Sometimes we will give prokinetics like Reglan. We will sometimes actually recommend it before the initial endoscopy if there's a suspicion of a large clot like this. We have used the BioVac, sort of aspiration system. That allows us to kind of, it's a kind of a high volume aspiration system that hooks up to your endoscope or if you have a clot buster scope, that works even better. And that allows you to clear clot probably more efficiently than with just the regular gastroscope itself, but still can be very challenging, especially for a situation like this. We've used over tubes before in the past with limited efficacy, but that can help sometimes, assuming that we're not dealing with an esophageal variceal bleed. And then sometimes moving the patient more supine or even, you know, right lateral decubitus can sometimes help kind of moving the head of the bed up can sometimes help to sort of clear the fundus, but that can also be very difficult. Yeah, I just kind of like the moving the patient trick. I don't know. I think these clots are frustrating though. I mean, I think even when you give Reglan half the time, we, you know, or erythromycin, which we usually can't get IV, or they don't get time and, you know, and you get in there and you're on call and you're just so it's so frustrating because you've already, you know, it's something's under there somewhere. And then you're sort of stuck with this big goober that you can't move. So I think, yeah, I was going to echo that. I think the moving really sometimes does help. I, you know, I agree. I remember times I've almost put the patient upright and, you know, they're in the ICU, they may be intubated, but we just raise the bed, you know, almost as close to 90, I mean, not quite there, but still at a really steep angle to promote that clot to sort of go downward, more caudal. Right. Like sometimes even watch, so, you know, get the fellow to move the patient or you're, the fellow has a scope, you're moving the patient with the camera sort of set steady, so you can get a sense, did I, did I move it? Did I see, you know, everything I need to see? Because obviously this is a huge clot, but, you know, which sometimes look like, but sometimes it's just, you know, right in the wrong position. Yeah. You know, actually, I like that at one point, I, you know, if a patient like this and you're suspecting has a lot of large volume hematemesis and suspected variceal bleed, I think it's important to intubate these patients for airway protection. You know, especially if it's expecting a large volume of blood in the stomach, because when you start moving them, they'll start aspirating. That's the problem with the moving. So intubate these patients, put them in the ICU. But I agree with Dr. Shah and Dr. Ru and you too, that moving is actually the quickest way to shift the clots or the other methods of the BioVac or the erythromycin take time. So moving, if that works, is the quickest way. All right. Are we ready for the next slide or do you want us to tell you what we would do at this point? So, so I, so we want you to move the patient. Yes. Yeah. So I'll say that I cheated and I kind of knew where this was bleeding from. So I dropped down an endoscopic ultrasound scope, a US scope. So we can, we can go to the next slide. So you have that easily up in your ICU or how does, how does that look like? No. Yeah. So this is where I call my fellow and ask them to move the machine up to the ICU. Yeah, no, no. Remember this is, this is 3am in the morning. Yeah. This, so fortunately this happened during payload hours. So we had, we had a, we had an opening in the endosuite for, for, for a more controlled setting, a more controlled procedure. I, you know, I would say also that sometimes if you see this, if you see someone this critically ill, you know, calling interventional radiology right now is not, you know, is not out of the question. So, you know, historically, you know, endovascular treatments like TIPS has been used with some, with, with some success for, for bleeding gastroparesis. You know, interestingly, not all gastroparesis happen with, in the setting of a high portal gradient, a portal pressure gradient. So, you know, TIPS will work for some of these bleeding gastroparesis patients, but not all of them. And then more recently, there are, there are centers just offering BRTO. Obviously that's, that's a balloon-assisted retrograde transvenous obliteration. That's out of the scope of this particular talk, but that, that is dependent on a shunt that's available, usually a gas or renal shunt. So there are anatomic constraints to, to, to being able to perform that and also local expertise. But those are our two IR options. And if you talk to a hepatologist, you know, they would probably be thinking more along the IR lines, just to be clear about this. So, but, you know, we are, we are endoscopically minded. We thought that we could treat this with EUS. So that's, that'll be the focus of the next couple of slides. Yeah, I think that's a good point though, about getting IR involved, because, you know, it's good to have people on the ready and they do usually happen at two in the morning. So they don't usually happen in the afternoon, in my experience. Okay. So the point that I wanted to convey here is that, you know, sonographically, you can see the whole thing. You just turn off the, the, the, the endoscope function. I mean, even, even though you can't see the varix, you can see it, you know, in all its glory here with EUS. So these large serpiginous anechoic structures represent the gastrobaracial nest. And then we have the ability to provide real-time Doppler. So the Doppler shows flow, intravascular flow, for those of you who have not, may not be familiar with EUS. And I would say that, that initially the views can be somewhat disorienting for, especially if you've not seen gastroparesis under EUS before. And so a trick that I have since learned, and I think Dr. Shah shows this in one of his other videos, you can instill water into the stomach, usually about 100, 200 CCs, and then that in a dependent fashion will sort of fill the gastrofundus and really clearly delineate the gastrobaric anatomy. And it will really show you what's endoluminal, what's intramural, and what's extramural in terms of the collateral vessels. I'll just echo with, with Marvin that I think that is a very useful way to really delineate, because you could easily be fooled and see the varix, and it's actually not even a culprit. It's one of the, it could be one of the extraluminal perigastric sort of collaterals. So the, the water fill really sort of helps. But I guess in this case, giving the humungo cluster that you see is a pretty, pretty good indication. So yeah. Yes, please. Okay. So just kind of continuing this theme, the next question is what is shown in this EUS footage? Is, is, is, is, is the arrows point to, is it the gastric varix itself? Is it the gastrorenal shunt? Is it a feeder vessel? Or is it left gastric vein? I invite you to submit your answers here. And so the answer is B, it's the, it's a gastrorenal shunt. And, and, you know, I don't expect you guys to know this. Obviously you're, most of you have not had EUS experience, but you know, all this to, you know, a couple of points. One is that, again, it can be disorienting. So you don't know what necessarily what's extramural versus intramural. You have to sort of study the area. I personally would not go after the gastrorenal shunt because that's extramural. You really want to pick your battle with the intramural portion, which is the gastric varix. And, and by the way, this is the gastrorenal shunt that could have been used for BRTO. This is what the IR folks would use for BRTO. But for reasons that I won't get into for this particular case, BRTO was not, was not, was not an option. The feeder vessel, answer C, we will get into in a subsequent case, but that basically speaks to a small vessel or sometimes a large vessel that crosses the muscle layer of the GI wall from the extramural space into the intramural space. And sometimes we will target the feeder vessel for more efficient and effective therapy. To be clear, you're, you're figuring this all out sort of in real time. So it's not, you know, like looking at this image, I honestly would be like, I, you know, I have no idea what that is. So it's more just as you're tracing it. Is that how you're sort of figuring it out? Yeah. And again, you know, Dr. Shah's technique of instilling water into the stomach really kind of makes this much more conspicuous than this particular image shows, I would say. But yes, you are kind of figuring it out in real time. Okay. Thanks. Okay. So this is, this slide is about a needle injection under EUS guidance. And a couple of things I wanted to kind of convey here. One is that it's, you can, you can see exactly what your target is, where your needle's going and that you are in the intravascular space. So I think EUS provides a level of control to the overall therapy that we had previously been missing. The second point here is that I think ergonomically, the best place to stick your needle is from the distal esophagus with the scope in the straight position and shown in the cartoon. And that, that, that is just ergonomically more favorable as opposed to sometimes what you'll see is kind of going into the stomach and retroflexing and kind of, you know, putting your scope close to the cardiofundal varices. That also can be done, but it's a little bit more technically challenging. So the distal esophageal puncture with a 19 gauge needle, obviously there is a sort of a psychological obstacle that you have to overcome of sticking a needle into a large vascular structure like this. But once the needle goes in- Don't move. Don't move, yeah. It's not, let your assistant, yeah, you're committed and let your assistant do all the work. But so any concern like going through the diaphragm or anything crazy like that? Yeah, I guess, yeah. Probably should be able to see it, I guess, but. Yeah. Yeah, I guess there is a theoretical risk of going across the diaphragm, but so far so good. Yeah, even with the 19 gauge. Yeah. Yeah. I don't know, has anybody else had any problems with this technique or this approach? No. Marvin, as you're saying too, it's extremely hard to advance that 19 gauge accurately. The more of a bend you have, I mean, just so, yeah. Retroflex is nearly impossible, but even if you're like angulated in the stomach, I don't know about you, but I get more and more difficulty just advancing that. So the straighter you are and more orthograde sort of you are, the easier to puncture. Yeah. For us too, it's usually from that distal esophagus side and then with the water fill, you can see it nicely and target into it almost from the backside, essentially. Yeah. Fellows, are there any questions from the fellows about this? Well, actually, let me ask a question. So what if it's one of those varices where it's right in the fundus with the transesophageal view with your EOS scopes straight, it's hard to see, you know, would you then switch to the transgastric side or how would you see that? I mean, if it's not, you know, if you can't see it well. Yeah, so, yeah, we have had cases where the varices are very, very sort of located in the extreme fundus. And so sometimes we do have to go into the stomach and then do a sharper bend of the scope along the cardia to reach that particular varice. So I would say these are sort of ideal conditions that I'm showing, but depending on the anatomical considerations, if the target is really in extreme fundus, sometimes you do have to do it from the stomach. Yes, that is true. And Richard, sometimes also if it is that far and you feel the 19 gauge will be difficult, that's the time to pull out. I mean, I like using the 19 gauge much more, but you can use a 22 gauge depending on what therapy you're doing. I won't steal the thunder here. What comes next, but. All right. All right, well, kind of any fellow questions? No questions yet, but I have one specific questions for Dr. Yu and the panelists. Can you run us through really what you're thinking about in terms of needle gauge when you're looking at these varices, how you're choosing, you know, the right needle for the diameter or size or appearance of the gastric varix in terms of coils or other injectants that you're using? Yeah, good question. So usually for these large cardiofundal varices, where, well, yeah, usually for the large cardiofundal varices, I'm using a 19 gauge preferentially because I want to get as much hemostatic material in there in as quickly as possible. We'll go into this in subsequent slides, but the coils that we use for a 22 gauge are much smaller. They're 0.018 inch coils. And so, yes, you can get them down, but it's going to take a lot of coils to sort of pack in a larger space. With a 19 gauge needle, we can kind of get big coils down fairly quickly, and then you can inject whatever you want to inject fairly easily afterwards. Yeah, the other thing is there, sometimes we do see gastric varices from splenic vein thrombosis, you know, patients who've had pancreatitis or whatnot. Those kind of, in my experience, those kind of defy the serine classification system. They tend to be sort of more diffuse and much smaller. Those, they've turned out to be more difficult for me to treat. For those, I generally use a 22 gauge. They tend to be like about maybe two to four millimeters in diameter. So the actual diameter is much smaller. So I feel that the 22 gauge is better for those smaller targets. All right, let's move on. Get to the next. Yeah, okay. Okay, so, yeah. Maybe we can spend some time on this and open it up to questions and comments, but you basically had your choice of injecting. Historically, we have used glue or cyanacrylate, and that's really based on Nipso-Hendra's work in the 1980s. And Dr. Wang will talk more about that. More recently, I'd say over the past 10 years, we've moved towards coil-based therapy, or there has been a movement towards coil-based therapy. So these are the hemostatic coils in that little picture. We're borrowing that from interventional radiology. And they're very soft. They're made out of, most of them are made out of gold platinum, and they're covered in what I call fuzzies, which are a type of nylon. And so the idea is that you express these from the needle. You can backload them and then push them down with the stylet as a pusher. And you can advance as many as you want, as many as the space will accommodate. And the idea here is to sort of pack it in with the coils. And the nylon fuzzies will actually initiate the coagulation cascade. So that's a secondary mechanism for clot formation. And then I think those of us who are doing coil-based therapies, we've kind of moved to coil plus an adjunct of some sort. So usually, historically, cyanacrylate, we, our institution, we've kind of moved towards gel foam. We can talk about that. It's an absorbable gelatin sponge. We can talk about the pros and cons, but it's, I think those of us who do this think that combination therapy, coil plus something else, seems to do the trick. There's some room for debate, I think, in terms of how much coil, what kind of injectate, how much injectate, in addition to the coil. But this really seems to do the trick. And again, you can deliver these under EUS guidance. I use Doppler to provide real-time feedback about the hemostasis. And yeah, I mean, it seems to be very, very effective. So how long do you wait? So when you're doing it, you said under Doppler guidance. So you put these coils in, then do you decide then, or you're always going to do a second something else, glue, as far as like, how long do you wait to see how long it takes to get hemostasis or deciding to add more coils or glue? Yeah, so I would, so if you read the literature, most centers will inject one or two coils. Allow that to kind of set up as a scaffold, intravascularly, if you will, and then they'll inject the glue, and that's it. I personally differ a little bit based on some early experiences I had, where I will try to pack in as much coil as possible. So maybe, yeah, I'll just pack in a lot of coils and then I'll use the gel foam as a secondary agent. But I think everybody has their sort of different approach to this. So when you pack in the coils, do you see pretty quickly the Doppler signal drop? Yeah, it drops pretty quickly, yeah. I don't know, yeah. Keeping the needle in, so it's not like you have to repuncture to then put your glue in or your adjunct in. Exactly, yeah, yeah. And usually, you know, when I first started doing this, interventional radiology folks would make a big deal about the type of, appropriately sizing the coil. So in the IR world, they will say, as I wrote there, is just choose a coil that's 20 to 40% larger than the radial diameter of the vessel that you're injecting this in. And in my personal experience, what I would do is I would advance the needle into the farthest compartment away from me and start injecting there, and then move my needle back. And so it was almost like a sewing concept where it was actually going, the needle was actually going through septa or different vessel walls, if you will. And so as I was kind of coming back with the needle, the coils would sort of anchor, you know, at these sites, at the access sites. And so, you know, I found that the coil diameter doesn't really matter. I just want to pack it as much coil material as possible. And it just tends to really anchor wherever I leave it. So when you backload them, so say you fill half your needle with coils, I don't know if that's maybe way too many, can you tell when you finish one, do you see it on EOS that you finished one coil and now you're putting in another, or is it? Yeah, so we deliver them sequentially, so one at a time. Oh, okay. Right, so they're not lined up in the needle. It's just one at a time, right? Yeah. Gotcha. But to your other question, yes, you can see when you've deployed it fully. Okay. What's the average number of coils you would put in in a session? For these large ones, maybe four or five. But again, other centers would maybe do one or two and then add the cyanacrylate. So when you're saying choose a coil of 20 to 40% larger than radial diameter. So if you have a six millimeter vessel, what does that mean as far as the coil? The coils are lengthwise or? Yeah, so the coils have three important numbers. One is the coil diameter, the wire size. So for a 19 gauge needle, we would use a 0.035 inch wire. The second number is the length of the coil. And so these can come in seven centimeters, 14 centimeters, 20 centimeter length coils. And then the third number is the diameter. So if you were to deploy this in free space, some of these coils, at least the ones that I use form like a cylinder, almost like a slinky. And so that diameter refers to the diameter of that slinky. Yeah, so that's the diameter that I'm referring to there. Okay. All right. And so actually the question is, you know how much do these coils cost? Yeah, great question. So they cost about 75 to $100 each. So, I mean, in the grand scheme of American hospitalization, not really that much, you know? Yeah. So one coil is actually cheaper than an endoclip. Yeah, yeah. That's, yeah. I mean, if I were to show you a package, you would, it's so, you know, it's like so simply packaged, it doesn't even, yeah, it's certainly not an expensive item. Yeah. That's a real bargain. I think so. Yeah. Yeah. No, I was going to say, Marvin, I think it's interesting how you said your practice has changed over time, you know, because mine has too with the same way. So I'm actually in agreement with you now. I, for two reasons. So one, mainly I just pack it as much as I can at any given session. So I've actually had one very large conglomeration where I must have used 10, 12 coils in one session, just to pack them in there. But two, the other thing, which is an important aspect is the, you know, the glue, especially I, and I'm not doing the gel foam, but when using glue, I'll be honest, my nursing staff hates using it. It's a sticky substance. It plugs up everything. They have, you know, we go through several vials to get the right amount. Sometimes it just doesn't, you know, and then the needle's gone actually, when, you know, one time use after that. So I think combining that with, you know, how well it works even, I've actually started just doing coiling alone as my preferential. And you do too many coils, Janak? I don't think so. I mean, you look at when radiologists, I mean, these are radiologists, you know, use coils. I mean, they will, they put as many as they need to achieve the effect needed. So at least so far, I haven't seen any issues with that. The other nice thing also, not that you need to worry about this, but not that everyone needs to worry about this, but, you know, coils are actually approved for intravascular embolization. So it does take one aspect out of using a glue, which is an off-label use. You know, we have a process in place to do that, but I think it's important for those fellows out there that, you know, when you go out into the hospital sites you work at, sort of, you know, and I'd be curious to know what the panelists have, you know, instituted at their own sites, but what is the process when you use something off-label in sort of what, you know, what committees do you go through? Do you make sure medical legally you're covered? Are you doing it by under an IRB, something like that? But coils takes that out of play somewhat. We're just delivering it in a different method, but it is approved for intravascular embolization. So, yeah, so actually, so going to your previous point, Janak, so you're basically saying that you do coils alone now, you do EOS and coil without any glue. Now there have been some preliminary studies looking at EOS plus coil alone versus EOS plus coil and glue. And some of those studies have indicated that the combination therapy actually is better. Well, there are some more studies though. Yeah, and I looked, actually, I saw that one, but if you look at the number of coils placed in both arms, it was like in the coil alone, it was just two or three. Yeah, yeah. So I think it's comparing it differently. You know, the goal again is not just the number, but to see the Doppler flow stop or minimize, if you want to call it. Those coils act in those wooly fibers that Marvin was saying, the fuzzy type stuff there, it's meant to be a thrombogenic sort of foreign body there that allows clot to form. So it's not, you know, these patients aren't, you know, I know we always follow the INR and things, but their procoagulant and anticoagulant factors are both suppressed. So they're still, we're not quite sure what they're, you know, and as we know, these serotics, they get portal vein thrombosis too. So we know that they can clot. It's just these coils sort of induce some stasis there and putting a number in there will form this area where then the clot forms, you know, at least that's the rationale. And so how long do you wait? So you've got a needle in a patient, you know, you wait a little bit of time, like a couple minutes to see if you need to put in another coil or what do you usually do? Usually the Doppler effects are pretty quick. I will say that if you were to wait a couple more minutes, you will see this whole process evolving, which is really amazing to see. But the other thing is that it does take a couple of minutes to actually get the next one sort of ready and loaded. So, you know, if you didn't want, you know, if you wanted to stop and not inject that next coil, you know, it's not like you can do this sort of rapidly, currently. So I don't know if that answers your question. Yeah, that makes sense. Cause with oil, you're sort of, that's quicker. You gotta be quick or you're right. Right. Sort of two experiences I wanted to share. One is the early experience that I had that kind of made me try more coils is that initially I had a patient with a large gastrobarics with an ulcer, with stigmata. And so I distinctly recall putting in, you know, maybe two coils and then the adjunct. And then Doppler flow went away. And I thought I'd done a good job. The patient actually re-bled 48 hours later. And my hypothesis was that I'd sort of missed my window to put in more hemostatic material. You know, I think in my mind what had happened is that I had put enough hemostatic material to set up, to start a clot formation, but in so doing had temporarily increased the pressure in the varix that it blew out the ulcer wall. And so based on that experience, I have just been like Dr. Shah has been saying, I just put as much hemostatic material into the varix as possible the first time. And these patients have not re-bled and they do well for, you know, for a while. The second thing is that the FDA approval for intravascular use for these coils, that's a very interesting point I think that you brought up. By the same token, gel foam also is FDA approved for intravascular use. And so that's been one of our reasons for using gel foam. It's also a ubiquitous hemostatic material that's available in all hospitals that surgery and interventional radiology has been using for a long time. And you can make it into a slurry very quickly and use that to deploy through a needle into an intravascular space. So, you know, that's an interesting point that you brought up about the FDA approval for coils. How does it come packaged? What does the gel foam look like? And then how do you make the slurry? It comes in all sorts of varieties. There's a form where it's already sort of, you have to pay more for this, but it's called Surgiflow. And it's a little kit that you mix with saline or saline in contrast, and you can very easily make it into a slurry. That's much more expensive. If you actually YouTube this, if you YouTube, interestingly enough, gel foam and slurry, you will come up with interventional radiologists actually taking their gel foam that looks like gauze material, and they basically cut it up into small pieces and they pack it into a syringe, and then they'll do the same thing, and it liquefies the same way. So it's a cheap hemostatic material that has been in use in interventional radiology amongst surgeons for at least several decades now. Arvind, how easily does it embolize, or when it hits the area, does it expand or it sticks to the coils? Right, so it expands to 60X, 60 times its original volume. And it provides almost like a local desiccation, if you will, to kind of help initiate the procoagulants also in that manner. So as far as we know, it doesn't necessarily stick the coils like glue does, but I think if you pack in as many coils as you and I have been using, the gel foam just sort of expands and then kind of fills the interstices, and the Doppler flow completely goes away after that. Wow. Daniel, is there a question from the fellows the fellows chat box yeah there's one question that came across about gel firm versus glue but it looks like we kind of just touched upon that well how i mean how do you decide what are you just um i mean janak hasn't used the gel foam but i think he's already googling it to figure out how to make it you know already about it it is i i mean i like call you after marvin the off label issue is is an interesting one richard what have we done at our institution i know that was a you know before everybody was doing i just feel like so many people do it now i don't know if it's as a big discussion as it used to be but you know it's it's it's it's actually a very important point i mean for the especially you know for everybody to know the fellows especially that that glue um is not fda approved in this country for use for intravascular injection um however it's it's widely used as we know in the rest of the world so if you go to you know europe go to asia go to canada it's very widely used and approved but in the u.s the fda has not approved it yet so what we've done is i mean we've been using it here for probably eight years we have a special consent form we tell you know the consent form is for glue injection we tell the patients up front it's not fda approved um but yet it's used very widely in rest of the world and it is recommended by the aasld as well as a line of treatment uh and with a special consent form with that we see you know we've been able to to do it um we obviously use a lot of medications off label as well in terms of you know pills and stuff um in the eight years that we've been doing it here at at at case i've only had one patient that's that said no that he wanted specifically fda approved therapy so we actually sent him for tips um all the other ones have said go ahead and you know do it it's kind of interesting though i guess because it's so invasive that we feel the need to say it's off label versus giving motrin for some reason that it's not necessarily labeled for so right in case important to probably remember especially if you're just first starting to use it at your institution well yeah and actually on on another note i as far as i remember i think ivppi is still not fda approved for acute um peptic ulcer bleeding we're using that i don't think we have a separate consent form for ivppi no we're using that off label ivppi drip and bolus yeah kind of interesting okay ready to move on yes thank you hey oh we got a little patient outcome here only good oh oh yeah so good outcomes patient did well and uh was re-scoped um she actually walked out of the hospital which is shocking to me um a couple days later so there's the the pre and then uh and then the post um this is uh one year later to see obliteration of the gastroenterostasis very gratifying okay richard you are up i can make this up oh okay so so this is a um all right this is a quick video but anyway this is a patient who's with esophageal variceal bleeding this patient's been banded many times um and this patient came in after a night of binge drinking uh the endoscopy showed a bleeding esophageal varix so this is not gastric varix esophageal varix we tried to suction up the um for band ligation suction up the esophageal varix but as you can see there the band fell off and you can see this this this often happens when the varices are small and you can't suck them up for band ligation so in in this oh hang on all right so so in this instance um the traditional therapy has been injecting sclerosant like ethanolamine that's been the traditional therapy and that's been approved um but in this instance this video is actually from my my colleague dr dumont john dumont when the band fell off he injected cyanacrylate into the esophageal varix i believe 0.5 ccs and it arrested the bleeding and the patient did well so you can the the point here is that glue injection can be used again it's off-label injection um instead of sclerosant for these small actively bleeding esophageal varices that you can't suck up for banding um and in our experience we don't have a lot of experience but in our experience with with this the ulcers seem to be quite shallow as opposed to the deep ulcers that you get with ethanolamine those you can get very deep ulcers with and those you can get problems with ulcer complications from sclerosant sorry so you know what's sort of interesting i was thinking about is you know i recently had to to inject the ethanolamine i mean we just don't do it very often and i'm curious if the fellows have done it at all because we pretty much do banding but we do have these cases where there's just a hole where blood is coming out and they've been banded so many times and they're scarred and you're kind of stuck and you gotta suddenly go okay no wait what do i do next and i you know it's always scary to have a needle poking at you know esophageal varices but um it's something probably i don't know if the if there are any fellows on and you know anyone wants to put something in the chat have if any have injected um esophageal varices because i think it might be the dying art i don't know i've i've used it once uh and i think the injector we used was ethanolamine uh but just for cyanoacrylate are you adding anything to it some people do lipidol dr wong do you um add some saline to it do you change its consistency or are you just sort of taking it as is from the the valve that it comes in just curious yeah so i mean so so that's a that's an important question you know there's there's all all sorts of different recipes for um glue injection um and that's partly why it's a bit confusing as well all those different recipes uh initially folks used to dilute it with lopidol or one of these oils to dilute it but what we found at least here in our experience we do we use it undiluted um we use the um the butyl the four carbon and butyl form of cyanoacrylate which is the faster polymer uh which has faster polymerization and if you use it undiluted um there's been nice studies from um steve coldwell uh from the university of virginia that's shown that with um undiluted the butyl form the polymerization is five seconds or less i mean it's very very quick whereas with the octyl form the older form that that we used to have the polymerization is three times as long as three times longer so it's like 15 seconds and then if you were to dilute it with lipoidol you double or triple the polymerization time so you need to lay it you know even more and theoretically if you delay the polymerization too far too long you're at higher risk for systemic glue embolization so i think if you're going to inject glue i would inject it neat i would inject the butyl form which polymerizes in five seconds or less thank you very much and your needle injector do you feel one works better to inject this type of medium or you know you just have what you have and use that no no we no no so we we use a bigger needle i mean uh the standard scar therapy needle for epi injection for like a peptic ulcer is 25 gauge so we use a 23 gauge needle um we use it once for each injection because as dr char mentioned the needle clogs up so you can't reuse the needle we use a brand new needle for each injection thankfully we don't usually have to inject a lot of different places um but um we use a 23 gauge needle we use um the n butyl which is the four carbon undiluted um and we actually i mean go go on in that vein we actually um we actually don't use it i mean we actually push it with more glue now initially when i started i used to chase it with uh normal saline and then sometimes that would clog up in the actual syringe and then um i looked at a few articles and i was told that um sterile water is actually better as a chaser so then we switch from normal saline to sterile water to chase the glue with and sometimes that would clog up and that's the last thing you want is your needle in a varix and you cannot inject the glue because it's clogged up the the needle that's the last thing you want because when you pull the needle out of course it's going to start spurting at you you know um so what i've done in the last well recently in the last year or so is i've i've chased it with more glue and that works well glue is glue is very cheap it's a bargain um you know basement thing as well as just like the coils is very cheap um you can buy a packet for 50 or less a whole box and uh we chase i chase it with more glue i know but to do that you have to know the dead space of the needle that you're using the exact exact volume of dead space and then i just inject it with with more glue so i know the dead space of the needle i'm using the 23 gauge needle is one ml so if i want to inject one ml into the varix i inject a total of two mls as a rapid bolus it doesn't clog up because glue and glue doesn't clog what do you think about um intravaricyl injection versus uh perivaricyl injection do you think you think there's a difference there or does it does it matter i don't you know i am you know for okay so this you know so in the past there's been huge debates about this of your varices whether you inject a paraphernalia or intravaricily um for gastric varices um i'm not aware of such a debate um however i have not injected para paravaricily for gastric varices i've always injected into the varix and i've always used undiluted and the butyl and with a polymerization rate of five seconds um or less it's it's worked out very well all right let's go to um your next video but i think um fellows it's probably important that you um be a little familiar with injecting varices because occasionally i also had a patient i couldn't get a banding device down um so we had to inject it's a little good to do it when you're a fellow i mean i don't know how to tell you to get those cases i'm just saying all right richard yeah so yes so this is a patient um 65 year old um psoriatic patient uh comes in with um we actually use that this is the free hand technique of um of glue injection so we're using a diagnostic egd scope we're using a free hand there's no eus um it's very easy and but we use the an endoscopic doppler ultrasound probe which is not eus it's a through the scope probe it's about the probe it's a single use it's about the same price as an endoclip so not that expensive about the same price and i've been using this for a while for a long time and um it it gives me an extra sense of security that there's no flow in the varic you're trying to look for venus doppler flow in the varic before and after treatment um traditionally uh what folks have done is that they've they've probed it and to see whether it's soft or hard they've probed it to see whether it's soft or hard and and that to me is is very subjective it depends on how how hard you press it's like you know gauging cheeses you know is it is it soft cheese or semi-firm cheese or or hard cheese i mean who knows you know and depends on because the problem is that if it's soft the recommendation is to inject more glue right so what what you call it is important if you're calling it soft you know and you don't want to inject too much glue because you have your risk of systemic gluonabilization so the beauty of the doppler probe the endoscopic through the scope doppler probe is that it allows me to inject the minimum volume of glue necessary to decrease the blood flow in that particular varic i mean the beauty of the doppler probe which our fellows are big fans of they doppler everything um is that you don't have to be able to do eus you know to do this i mean you're not injecting coils but you know we found it pretty successful i don't know richard's our our biggest gluer um and i think i think i mean that raises the that goes to the point of you know i mean from what with the panelists are talking about with you know um us with coils or us with coils and glue versus the freehand non-eus egd technique um i would say that i think if you're in a institution like where dr ruiz or dr char is um where you have us available you know 24 hours a day at 3 a.m and at night you know and that you can wheel it up to the icu then it's doable i think if you're outside of these um these really great academic institutions in the community yeah you have we have a hard enough time finding endoscopers um in enough endoscopers to stage you know or to fna pancreatic masses you know let alone come in for food i think on a practical standpoint i think you know i think if you're in a center like whether to ruin charis um uh us guided glue injection and coil um certainly has theoretical advantages but i think in the wider community in the wider world um it's going to be difficult it's going to be a big challenge to get enough endoscopers to be able to do what you guys do with a 19 gauge needle through a therapeutic us scope what um when you guys are injecting glue i mean the big thing that i i remember richard when he started doing it was this concern that we would glue the scope and obviously gluing in a standard upper scope is one thing gluing a linear us scope is another so i'm just curious marvin and um jenna you know whether are there any things that you guys do every time before you bring the needle back or whatever so you don't damage the scope i mean i i can say you know we sort of extrapolated what before i was doing eus i i did do for a short time the endoscopic uh glue but probably similar precautions i mean i actually don't pull pull my instrument back through the scope once i think i'm done i leave i you know whether it was before using scleral needles i left it outside my scope channel or if it were an us scope i'll leave my sheet outside pull the scope out and then we make sure that you know that then our nurses will wipe down the area using even mineral oil if it's sticky still there to kind of to get it off before we um uh pull that instrument through the instrument channel um i do think you got to take some precautions because there is a concern of that and it's an expensive uh scope i also wonder you know for for those doing the endoscopic alone versions with advent of this promise of you know disposable scopes of various types coming out i wonder if that might change practice as well in in using that rather than a dedicated upper endoscope the the you know the one thing that that we that we've been doing here also is that i mean you know we've been so where i learned the free hand injection um folks used to inject um put silica oil in the channel of the endoscope but as we know that's very difficult to clean you know you know silica silicon oil so what i've done is i've we've actually flushed it with olive oil so we actually use um olive oil we flush the channel in the dual denim with olive oil thinking hoping that it'll actually decrease the rate of glue adherence to the scope um the other thing that we've also done is just before we inject we also take the suction off the endoscope we take the suction completely off because all of us are so used to sucking just instinctively that sometimes when you suck you suck the glue back into into the lens and it and it obviously sticks to it so we've actually taken the suction off we inject olive oil in the channel of the endoscope and um we leave the needle out as well and so i think with all that we've managed to decrease our our instance of of you know problems like that i would say for us we we are not masters of glue therapy like dr huang so uh we we have made every mistake with glue that that you can think of and it has been written about um very expensive uh uh complications of the glue and so that's kind of part of the impetus for moving away from from blue at our institution quite honestly so that's funny that's interesting i'll be next time try and try and try the olive oil and try and remove this i'll try it on but it has to be medical grade see now olive oil in the cabinet so yeah yeah olive oil is also very cheap very bargain price yeah extra virgin extra virgin no he has extra virgin in the list of things he needs for his glue injection it's extra virgin kosher so before so do you put anything down the needle anybody before you do the glue do you prime it with anything or no i well how let me just get back to the screen here a minute okay no i i don't you know i i used to prime it i don't prime it now at the beginning i used to prime it now i don't i i basically put the put the so the so the key thing is for the fellows to know is suck up your glue at the last minute i mean because glue polymerizes so you want to the hardest part is getting your angle right so get the angle right to to the varix if this is the freehand technique now i'm talking about the egd technique so after you flush the olive oil in the in the duodenum down the accessory channel in the duodenum bring it back um get your location and your angle correct and make sure you're you know ideally you you want to puncture the varix perpendicularly at at 90 degrees you you don't want to puncture it tangentially because you might get actually get into the wall and not actually into the into the varix so you want to do it do it 90 degrees um and then at the last minute tell the nurse to suck up whatever volume you need of of um of the glue um and then your your angle is right i tell the nurse to hook it on express a drop at the tip as soon as the drop comes out i i you know you do a straight puncture you do a rapid bolus and of course and before that you take off the suction of the of the endoscope so you're not sucking it back um and that works out well and and then i you know i also use that endoscopic double ozone probe before i inject and also two minutes after i inject because what i found is um the consistency it stays kind of soft for a while the the hardness of the varix when it polymerizes actually takes some time so if you were to probe it immediately after you inject glue it could still be soft but yet there could be no flow there could be no flow in the varix but yet it could still be soft if you're probing it too quickly after injection it takes a while for that firmness to to develop and and after you uh inject and you want to remove the needle are you doing a slow pull are you doing a quick pull i know sometimes there's concern you could de-roof the varix if you know you're sitting in there with the needle the needle could get uh you know glued in as some people say or is there any specific technique no well no i i i well you know i do worry about the needle getting glued in um that those there have been case reports of that we've never had that happen i that's why i just pull it out as soon as i can i pull out quickly because i don't want to get stuck um but again leave the needle out take the suction off and um expect some immediate back bleeding which is which which is actually good some immediate back bleeding is good because it means that the needle is actually in the varix you want some immediate back bleeding which which if you observe it will stop in the next and go slower in the next uh 30 seconds and then you know i i wait two minutes and then i put the doctor ultrasound probe down again and listen for the signal and what i'm looking for is not a complete absence of signal i'm looking for a decrease in the signal so it doesn't have to be completely gone but just a decrease of the signal is good enough and if if it isn't decreased or there are some you know i might inject more at a different location as well based on the doppler um you know signal all right i think this is you right oh well no this is mine i think oh there's yeah yeah so this this this is my last video so actually this is actually for the fellows so this is a patient who's um who's who's 70 year old who came in through the er um history of cirrhosis uh came in with a melanoma some dropping dropping hemoglobin uh was sent from the er because of worries of uh of variceal bleeding to the icu the the the patient arrives you know he's he's fine patient arrives sits in the ICU for a few hours. Then suddenly becomes a tachycardic hypotensive and almost codes, and you are called the fellow is called to come in. The patient is intubated because because then he actually starts vomiting blood. He's so he's vomiting blood, and he's also passing blood rectum is hypotensive tachycardic on presses now and intubated. The fellow the first year fellow goes down and sees what there is actually work. Actually he go back to the previous video and sees this. So question for the fellows, what would you do. This is again at 3am in the morning when most of these things happen. Except in Boston. Except in Boston what happens during the daytime. Looks like a gusher any any fellow response questions responses. One of our fellows is on Richard we'll see if he has an answer. I don't see anything. I don't think we have a therapy video of this do we, is that the next. No, we don't. So, no, no, no we don't this was this took long enough to videotape this. So, yeah, so basically so this is a patient with, with, you know, with cirrhosis. Clearly you can see here a huge gush on the top there when the restriction the cardio, a huge gush of blood. That's clearly coming from a gastric barracks. The patient has has this object viruses but they were not bleeding. This is, I mean for us that by default a gastric barracks. Some, you know, a peptic also would not bleed like that, nor neither with a dual voice bleed like that. So it's clearly a gastric barracks. So the key thing here. And the main treatment here actually what we did is put a put a balloon temper not down blue put a big motif down to stop the bleeding, the patient was on to process hypotensive was basically bleeding out. So this is an ideal time to put a big motif down. And, you know, and we can discuss about a big motif so they could be potentially life saving it's one of the things that as a fellow, you need to learn, it's very important to learn these. Unfortunately these bleeding cases come, they're very highly unsociable. They come in unsociable hours, usually at 3am in the morning, at a weekend, except in Boston. Or you could just call Marvin he'll come. I did that once and I got a lot of bad looks for my patient intubated and had it like look like metastatic something and they just wanted an FAA and I got a lot of heat they're like, um, do not bring that level of. All right, I think this is Dr. Shaw's. Yeah, I think this is well, this just, it's an example of a bleeding barracks, I think I caught Dr. Wong's case, 30 minutes prior before it cooled all that but again just to you know this just kind of shows that it can be a scary sight and pretty aggressive in terms of the volume of bleeding. Typically gastric varices are thought to have a much more voluminous bleeding than esophageal varices or other even upper GI sources of bleed. Historically they've been more, they're usually under more portal pressure, even to get to that stage too so we can go on to the next. So, this is just an example, you know, just, and again, I'll, I have to be honest, this video is probably over 12 years ago so this is when I was first starting to think about doing this. I, I don't do a lot of endoscopic injection anymore, just because I have the benefit of the US, but, you know, I certainly defer to Dr. Wong on his tips for those who want to do this now what to do. This also is a good example of back bleeding there you saw a little of that. Yeah, and then you can see what happens over time but this, this, you know, two things can happen sometimes it can just sit there as a thrombus and you'll see it without flow down the road but often we've noticed that over time, these cast like complexes, whether it's glue alone or, or coils plus glue or maybe coils alone but over time they'll start extruding back into the lumen, and then pass and then it'll just be a nice scar down the road. So that that's just an example of the endoscopic version. We don't, I don't know if they, we can skip this let's let's stick to the upload it okay well so, so this is this is a nice example just showing what I think are the benefits of the US guided, you know, we started. I was with Ken been more in his group in California when we started sort of thinking about us guided options it was actually in a case where there was a pool of blood in the fundus and sort of difficult to see but we knew was a gastric merits. And this isn't that same case but but again that's where for us that concept of it, you know, us you can see through the blood. And you can target it with the Doppler. And that's where, at least to me it made sense that I was no longer limited by the endoscopic view but I can rely on a sonographic view to to guide what I do. And, yeah, that was a case of using a needle puncturing in similar to what Marvin does with the coils which now, now I also do where I go as to the farthest point I can, and then bring the needle back. This will kind of show that too but we try to get the needle to the most to a more distant site, and then bring it to a closer site on the way back. So are you continually injecting as you're pulling the needle back or in this case yes. Yeah. And we're watching it you can almost tell it's, you know, it's polymerizing there and you can see it sort of take shape. So you're doing so when you're doing coil and glue. You're putting in the coils first so you're starting distally and packing it right. And then, so then your needles not that deep you go back down to where the coils were and then start the glue again. Similarly, if I do glue I do that. So I'll push it back in and start the glue again, you know, there's there's little tips and tricks to do this I know this is probably beyond the point of this but you want to make sure you're not introducing any air into the channel so there's there's a lot of like sort of, you know, your team has to be solid in assisting you in doing this. We sort of have a dedicated team who kind of knows and we watch them and work with them to develop but they've got to have the right techniques down. So you don't, you know, yourself produce any complications in that patient. But, and again with their, I'll be honest, in the last year, year and a half I have not done any us coil plus glue I've just stuck to coils alone. And, you know, a lot of it really stemmed from just the difficulty our support staff who are very good at this, even had with the, with the glue, and we'd go through, you know, two, three US needles before we're done with the case now, essentially needle I can pack all the entire barracks, even re punctured another site if I need to an adjacent one, and really fill everything up with the coils. I'm really intrigued by gel foam though so I'm planning to reach out to Marvin to get some tips and tricks on that. Anytime. The gel foam. The advantages that well it sounds like you can't ruin a scope with gel foam, I'm assuming. Right. Yeah, we have yet to ruin it. I'm surprised they'll give you glue anymore. So the concept is to that's reabsorbed but after the cloud has already formed is that the idea is yeah so it's it's it's biological material it's it's foreseen observable gelatin sponge, forcing derived and it resorbs after we think about the were from six to 12 weeks is what from from from animal data. But, you know, by that time, it's the, the, the gel foam plus the coil combination has already done its thing, and hopefully the barracks, it's already on its way to being obliterated at that point so could I could I ask the group to if there's, especially Dr. Wong to prior to you doing glue injection and even Marvin when you were doing blue, were you doing any precautionary test for the patient so I know because I know you know my biggest concern obviously and I think everyone's biggest concern with with glue is is embolism. And in fact, I know there's been a good study from Europe, where, where a group certainly, they would routinely check cat scans after, and they would mix their glue with lepidol so it would show up. The actual the rate of asymptomatic embolism is almost 50%. Now I'll grant that that most are, you know, most of these patients will not be symptomatic, but at least our practice we usually get a Doppler bubble study. Just, you know, I don't mind and I tell the patient. Look, this does embolize but fortunately symptomatic is very low, but if they have an intracardiac shunt. Those are people I definitely avoid glue injection. So I think that's, yeah. Dr. Shah that's a very, that's a very important point. The one thing to know about some of these initial studies from Europe is that some of them were using the longer acting octal glue the eight carbon glue, and they will also, they will also actually mixing it in that's in the study that you're talking about that's from Spain, they were mixing it with with with lepidol, and they were doing routine CT scans of the chest on every patient, and they found a high rate you're correct, of over 40% I think over 40% of asymptomatic PS, based on CT scanning. So I would say that these are all asymptomatic I mean i think i think symptomatic they may have had like one or something I mean, you know, so I think the problem there is the CT scan is too sensitive, but for picking up these things I'm not trying to. I'm not trying to belittle asymptomatic PS I think that's important but nonetheless they were asymptomatic. And you have to balance that with the risk of mortality from gastric virus still bleeding, which can approach 20%, you know, Jeff I mean from gastric virus still bleeding the mortality rate can approach 20%. So, I mean, yes, I mean you're balancing that with a, with a risk of asymptomatic home ramblers from the glue. And I think now with the foster acting fossil polymerizing glue, the rate of PS would be less. But I think it's just a too sensitive to follow these patients with CT scans that's the thing. My take is, I will say that I'm also worried about complications like everybody else's, but I, for me to concern has reached the point where I actually use floral, in addition to us. After I've packed it in with the coils, I will inject the contrast on occasion. This very sealography if you will. And I'm surprised even when I think that I have really packed it in, I will see contrast runoff. At that point and so it makes me you know hesitant to add that second agent. I mean for me it's a gel foam so if it were to embolize I think theoretically it might be a little bit less, less of an issue than Sam accurately, but, but, you know, I think, I think the concern about complications. That's a real one. One thing I would say is that, you know, the, you know, the largest series to date has been a study from China. Back in 2010 published in the clinical gastro clinical gastroenterology and hepatology from China is a two center retrospective study, where they just EGD glue injection. They use butyl mixed with love portal one to one ratio. They had about 750 752 patients. And in that large series, they only had point 7% they had five patients that had embolization one p. And one stroke, and three splenic influx, and all of them were not fatal, but the rate of embolization in that 752 patient series was only point 7%. So I think the rate of symptomatic and, you know, embolization is low, that's what I'm trying to say. So Marvin when you inject contrast and you see someone off you put more coils in or what do you do. Yeah. And if you still see it do you just don't glue or you get sometimes I'll see persistent runoff, and then I won't add that second agent. And I would take it Marvin that you're not getting a CT scan of the chest and those patients. Afterwards, no, no, no, no, I mean not unless it's not unless it's symptomatic. One of the nice things about the coil is that they, they stay where you leave them. I mean, for the most theoretically. We can see the coils on on Floro, we see that they're just like, you know, they set up nicely locally, and we see them on the US so that's that's one of the nice things that's mechanical kind of hemostatic agent that just stays in place. Right. And I have a question to the panelists here guys. And I think with all the videos we've seen we know the sources coming from one particular place. What are you guys doing when you go down and you know you see juicy big varices in the esophagus, really big robust varices in the stomach, a pool of blood, but you're really not sure is what's bleeding is this the esophageal varices What sort of what's your strategy then are usually dropping in the US to see really what things look like you do combination therapy where you're potentially gluing and bending. Really, what's your thought process when you go in and you know you have two potential sources and you're unclear about what's happening, especially that if you put bands on the esophageal varices then you may not be able to go down later on if it's the gastric gases that are bleeding because now you have these big band ulcers and whatnot so be really helpful for us to know kind of what strategies you guys do for these kind of two, two types of varices at one time. Well, I'd say in my, in my practice, I mean I really look for stigmata of recent hemorrhage. I mean I'm looking for the Redwell signs the white nipple sign the fibrin clot the erosion, something that tells me, is it the gastric varic is it the esophageal varice that's bleeding, and most of the time, if you look carefully enough you can actually see stigmata, and I would treat whatever you think is leading at that point based based on the stigmata recent hemorrhage. That's great. Thanks. All right, so this is a little bonus Marvin bonus out of the upper GI tract to the lower because I thought it was a super fat video to Marvin. Thank you. Yeah. So, this is a video just to illustrate that this us technique can be used for other sort of topically located varices. So this is a patient who had bleeding rectal varices the stations coming in every month with lower GI bleed from from these varices, and obviously a challenging case surgery, not very good surgical options interventional radiology options are interventional radiology options are very limited here also given the location. So, we said that we would give it a shot with with with our us technique. So this is linear us view of varices. And you can see these dense network of these anechoic structures in the submucosa of the rectum starry night, if you will. And it's not like the gastric varices that we're showing you before it's not this, you know, single localized dense cluster dense nest, it's really really diffuse in what we decided to do was try to look for feeder vessel. So if you look at 11 o'clock, you'll see that black band that's the muscle layer and you'll see momentarily, you'll see the vessel, go through the muscle layer. And we kind of studied it carefully and thought that was at least one of the perforating vessels. The, the individual vessels are very small on the order of two to four millimeters so we injected this with a 22 gauge needle and deployed a coil, very small coil. You'll see that here. And what we've since learned is that, you know, it's not the end of the world, if some of these coils actually end up in the 70 coastal space, or even if it actually comes out into the woman, you sort of a tail. It's really not the end of the world, as long as you can get some of this material into the vessel. It's almost like the question that I was asking Dr long you introvert seal versus carrier seal injection. I don't want this introvert seal but it's okay to have it sort of carry various deal. And then the rest of this video is going to show you what happens to the Doppler flow, and none of this is set up and you'll, you'll appreciate hopefully sort of immediate cessation Doppler flow in that region. But the whole network sort of tends to go down, which is remarkable to us because we have never done this before for rectal varices. And so here, the Doppler window is actually overlaid the entire be mode image here. And so you're seeing sort of a faint Doppler flow with movement of the scope. And then you can see in the individual vessels it's almost like this buzzing beehive. And so it's almost like the flow is slowing down and almost becoming sludge like. And this was remarkable to see in real time. And then five minutes the whole, the whole network goes down. That was it was just one one coil that we injected. We try to be kind of, you know, judicious about where we want to place it because this whole system was so large and so. Yeah, that's basically it. So here's a perforating vessel. And then, yes, sort of more of the same for the rest of the video. So if we fast forward it, we can show you the, the images at the very very end. Patient clinically did very well did not really bleed for at least a six month follow up period. These are the pre treatment images and then this is the post treatment image so you can see like the rectal varices have sort of really flattened out and are hopefully on their way to obliteration. And then we had a radial us view at one month and again there was no flow in that area so. So this, you know, all this to say that this technique can be considered for for these, you know, challenging topic variceal bleeding cases also. Great video. Thanks Marvin. Well I think we're kind of out of time I hope the fellows enjoyed this I learned a lot. I want to just thank the panelists and Ahmad and Daniel for joining us as well and moderating. I think this is a great educational endeavor and I want to thank you all for your time. And I think we're going to hand it back over to Brett Peterson, who I think is still here. Thank you so much. This has really been a wonderful session, both challenging cases and great discussion so thanks to Drs fo Wong Shaw, Ryu, Basler Bashi, and Alice, thank you. Thank you for giving us part of your afternoon and the good discussion.

esophageal variceal bleeding

gastric variceal bleeding

coil-based therapy

glue or gel foam

packing coils

cyanoacrylate injection

sclerotherapy alternative

glue injection

cirrhosis

balloon tamponade

treatment strategies

ultrasound techniques