All right. We've got a 56-year-old admitted for his first episode of pancreatitis, okay? MRCP at an outside hospital shows the following. So you can see the gallbladder. And what's that? This is pancreatic parenchyma. Dilated duct. Yeah, dilated duct. You know what I say about dilated ducts. I hate dilated ducts because I always worry about malignancy. So again, dilated duct. Obstructive pancreatitis. It could be. It could be obstructive. It could be pancreatitis. And again, this kind of alludes to what Amitabh said earlier. Sometimes chronic obstruction can look like chronic pancreatitis-like changes as well. And so I was worried about here because right here is where the duct kind of cut off. And then you don't see any duct for the rest of the pancreas. It's very, very different in caliber. So we did it in the U.S. And what you can see is you can see a dilated duct here and then a mass. So again, I'm going to play that again. It's a dilated duct here. See that? And then it leads up to this. And so anybody probably want to stick it, right? So the question is, what would you use? Would you use an FNA or FNB? Now, I want to tell you there is really no right answer, okay? Myriad, we're going to start off with FNA needles and go to FNB. There are a myriad of FNA needles. They're all very good. 22, 25-gauge, and 19-gauge. And you're going to get more time tomorrow to FNA at the stations on live on the PIG model. So in your proctorship, too, use different types of needles. They have different types of sheaths. The flexibility is a little different on each of these FNA needles. Sometimes when you're in the unscented process, I like to use, because you're more torqued, I like to use the more flexible sheath. So play with them and, you know, sort of decide what works for you. And so which needle is the best? It's really your preference. And which gauge should I use? Well, if you look at the data, this is Sachinwani. He looked at all the studies up to that point using 22 versus 25-gauge needles. If you looked at the studies, you can see in the two randomized controlled trials, they saw different outcomes. In this study by Siddiqui et al., the sensitivity was less in the 22-gauge needle than it was for the 25. And in the other study, it was equivalent. So the bottom line is use the needle that you're comfortable with. And if it doesn't work, change the gauge of the needle or change from FNA to FNB or vice versa. Whether to use a stylet or not, you guys played with the stylets today? Yeah. So I use a stylet, and the whole purpose of the stylet is that once you put everything through the scope and you fasten it on, you push the stylet in to kind of exude the mucosa, and then you can sort of take it out. But some people won't use the stylet at all. And again, the data really shows it doesn't matter for the majority of studies. One study did show it's a little bit more bloody with the stylet. So again, use a technique, adopt a technique, and get comfortable with it. There's no earth-shattering way of doing this. And then whether you use suction or not, you know how you took the syringe, you used negative pressure? There are studies that favor suction, and there are studies that favor no suction. And there are studies that say it's equivalent. If you use suction, the specimen tends to be a little bit bloodier, and you'll figure this out with time and experience. I tend to use the following. So I tend to do capillary, and it's not good or bad. Put the needle in the lesion, and then, again, you're pushing the stylet to get the tissue out. And as I'm going back and forth, my nurse, Terry, is pulling the stylet back. It's creating negative pressure. And then you don't pull the stylet all the way out. Then you take the needle out and then push the stylet back in, and the material will come out. So again, these are different techniques. Now, what is the advantage of, you know, why did the core biopsies come out? Why did the, you know, FMB needle come out? Well, the potential advantages are that you can look at you're getting a piece of tissue, so you can look at architecture. In which cases would you consider that? Lymphoma. Lymphoma, I heard. GIST. GIST. Liver. Liver. Very good. Autoimmune, right? So those are the cases. Also gives you more tissue. You can talk to pathologists in some institutions and talk to them. They like it for immunohistochemistry. They like it for genomics, for pancreatic cancer. So find out what your folks like, and that also will influence what you do. There are many different types of biopsy needles now. You know, Procor was the first one on the market, and now we've got multiple different types. They come in different gauges, 25, 22, 19. And so use them in your proctorship site and, again, get used to one or two and use them accordingly. So if you look at the same study, when they looked at FNB using this Procor needle, which is the very first biopsy needle, some of the studies showed no significance when they compared, when they looked at FNB specimens and FNA, in terms of FNA. There are studies that showed yes, FNB was better. And then there was a study that, actually that was ours, that said we actually got more yield with an FNA needle. Why that is, I don't know. I've got to say that the new iterations of the core biopsies are much better than they used to be. So this is another study where they compared histologic core specimens with FNA needles and solid masses of the pancreas. It was 58 patients, and they randomly assigned them to FNA or FNB. And after three passes, crossover was allowed. And they looked at the proportion of histologic core and diagnostic accuracy. They didn't see much of a difference. So this is not to have you leave here and say, oh, nothing I do matters. It does matter. It's just important to get used to using something. If it doesn't work, change the way you do it. Except in lymphoma, GIST, and autoimmune pancreatitis, I think you have very good grounds for using an FNB needle. So this is another study, again, looking at pro-core versus FNA needles. And what they saw here was that there was no difference between FNA and core in diagnostic core specimen accuracy or acquisition. So again, this is not to frustrate anyone. This is just to say, and these are all pancreatic masses, that we just don't have enough data to say one way or the other. Now, do we need somebody at the bedside? It's nice to have it. And the reason being is we do know that it decreases the number of passes you need. Based on this study by Satchinwani, he found that the number of passes needed actually significantly decreased. But there was really no significant change in the amount of FNA time significantly decreased. But there was no change in FNA diagnosis, cellularity, the amount of blood. The one thing I would suggest is if you don't have an on-site cytopathologist, you may want to take, especially in the pancreas, a few more passes than you would if you did not have somebody at the bedside. So we're back to this case. You can see, again, we've got the mass. So we FNA it, and it does come back adenocarcinoma. So we chose to use an FNA needle in this case. I've got to say, our pathologists and our cytologists are now wanting FNBs for pancreatic masses just because of the tissue yield and all of the genomics that they're doing it on. So, again, it's a two-way conversation with the pathologists. This is a 40-year-old female with early satiety who underwent an EGD. And you're in the stomach, obviously. And you see this. What does it look like? Yeah, it could be a varic. So it could be some epithelial lesion. It could be extrinsic compression, right? Varices travel through the submucosa, stromal tumor. So I just don't know. So doing EUS. And what is that we're looking at? Yeah, so this is the transducer, and this is the liver here. And when we play the video, I want you guys to tell me what you're seeing. It's very large, right? It's almost like the larger the lesion, sometimes you can miss it. Do you guys see that? So I'm going to play that again. So look at it. So look at how even it is. But do you see that? Yeah, it's isoechoic. Exactly. These are the hard ones, right? But it's just not right. It feels round. It looks round. And so we did an FNA, literally did an FNA. Again, you can see it here, how round. And it's better defined here. You can almost see it better. And the FNA was actually non-diagnostic. I'm like, oh, they see hepatocytes. So what did I say to do when you get it's not working? What do you do? Change it, yes. We did. We did an FNB. We did a 19-gauge. You know, the thing is, you can use a 19-gauge needle here. I find pancreatic head and uncinnate process very tough to use 19-gauge needles. And why is that? Stiffens the scope tip. So if you're torqued, it's very hard to get that needle down. And don't force it, because you can actually tear through the channel. What I do is I'll come back to the stomach, put it in, lock it, and then go into the duodenum. So that's one trick that you can do. And so the core showed normal hepatocytes. But I felt better, because it was big core tissue. It was a hepatic adenoma. And apparently, they can't tell. It looks like normal hepatocytes. But I did feel a lot better. And this is an example of if you don't know what it is, if you don't feel like you've got good cells, try something else. One more case, 58-year-old with acute onset of abdominal pain. And the CT reveals this. This is the stomach here, obviously liver. And you can see this lesion in its tissue. And this is the EUS. This is the linear. You can see. What's that? Why do you say that? Do you see this? What's that? Moscularis. And do you see how it's spreading out and kind of giving birth to this? So it's a gist, right? I mean, I'm like, oh, it's got to be a gist. The other weird thing about it, though, and I show this to you because it's interesting, is the gist had ruptured. And there was peritoneal fluid. I've never seen that. Rarely do we see that. See that? This wall is ruptured. See how the wall goes away and there's this fluid? So anyway, that was interesting. So we decided we would go ahead. And what would you use in this case? A B, yeah. So that's what we did. We used an F and B needle. And we got a beautiful core. It was C-kit positive. And we were able to tell the surgeons, you know, it is a gist. And, you know, one can argue, well, the patient probably needed surgery, but it wasn't a free perforation of the lumen. It was a perforation of the actual outside of the tumor, which, again, I've not seen before. But we were able to get it with the core. So a little algorithm that I kind of use, you know, again, if it's a solid pancreatic mass, you have rows, then you can do either one. You can do F and A or F and B, talk to your cytopathologist, say what is it that works best. If there is no rows, you can do B. But if you do A, do a few more passes to make sure you have enough tissue for a diagnosis. And then if it's a non-pancreatic mass and you need special stains or immunohistochemistry or genomics, then do F and B. If not, nothing wrong with F and A. And remember, F and B needles are more expensive than F and A needles. So never, you know, again, there's a plus and minus to everything. So with that, we've finished it.

pancreatitis

MRCP

FNB

lymphoma

GIST