We will move on to the Jean and Lynn Overholt lecture. For those of you that know Jean and Lynn Overholt, they're now, I believe, around their 62nd year of marriage, living in Knoxville. And Dr. Overholt is renowned in his work that helped develop the flexible endoscope dating well back into the 70s and 80s. The Jean and Lynn Overholt lecture today, titled Innovation in Pancreatic Mobiliary Endoscopy, will be given by Dr. Greg Haber. Greg is no stranger to the vast majority of you. He's worked in the area of therapeutic endoscopy for several decades. He had received his initial training medical degree in University of Toronto, subsequently did work in bile acid metabolism in England, and returned to Toronto, where he worked at the Wellesley Hospital and St. Michael's Hospital before going to Lenox Hill in 2004 to 2016. Presently, he's at NYU Langone Medical Centre, which he moved to in 2016. In 2018, he was honoured with the title Professor of Medicine and Biochemistry and Molecular Pharmacology by NYU Langone Health. Dr. Haber is well known to many of you in the area of therapeutic endoscopy. He's an icon, not only to therapeutic endoscopists around the world, but particularly dear to my heart as he spent the majority of his career in Canada. We still consider him an honorary Canadian. He has published extensively and trained people throughout the world, and has had a very key impact in therapeutic endoscopy. I can think of no one better to give the Lynn and Jean Overholt lecture on innovation in pancreatic biliary endoscopy than Dr. Haber. Greg, thank you. Listen, I'm really honoured to be asked to give this lecture, and I want to particularly thank Klaus Mergener, yourself, Rob, of course, and Jason for inviting me. I first met Jean actually through one of my great mentors, Norm Markon, who was really the father of therapeutics in Canada. Norm had the insight to invite Jean to our international therapeutic endoscopy course early on when we started in the 80s. Jean was just an amazing teacher. You've already alluded to some of his career achievements. He really was the youngest recipient of the Schindler Award in 1975, based on his work as a medical resident and a GI fellow at the University of Michigan, where it is purportedly performed the very first flexible sigmoidoscopy. From there, that was just the beginning of Jean's illustrious career. He was president of the American Society of Gastrointestinal Endoscopy, president of the American Association of Ambulatory Surgery Centers. He was really a leader in laser diagnostics and therapy. He was the father of photodynamic therapy, just to mention a few of his accomplishments. Jean was always a gentleman. I like to refer to him as a gentle giant. He taught, but he was never overbearing. He always had the interest of the patient as foremost in his mind. One of the quotations which shows up often with Jean is that, you always do the right thing, and the right thing is what's best for the patient. Really I am grateful to be asked to speak with this endowed lecture, and it's an honor to represent Jean's philosophy. Innovation is a tough topic in pancreatic ambulatory endoscopy. There's so much going on. Our speakers today have addressed a lot of it already, so I've chosen a couple of areas that were not in the program that I think have been instrumental in advancing our treatment of pancreatic ambulatory disease. The areas I've chosen are the complementary roles of EUS and ERCP, the recent emergence of RFA for ablation, especially of neuroendocrine tumors, functioning and non-functioning, and lastly, a little bit of a teaser. I've been involved recently in an effort to use holography to enhance our abilities to stent and go where we want to when we are dealing with complex strictures, malignant and benign. Let's go to the EUS-ERCP aspect of the talk. I want to talk about options for failed cannulation, alternative access, gallbladder drainage, gastrojejunostomy. I'm going to do this mainly with illustrative videos. This was the charge of our course directors, and I hope it will serve to educate our audience. First of all, this was a case I'd like to show was a patient with obstructive jaundice. As you can see here, there was a very dilated bile duct within her diverticulum. As is always the case, it's usually the bottom right, sometimes the bottom left where we'll find the papillary orifice, but in spite of trying very hard and even clipping the folds outside the diverticulum, we could not enter into this dilated bile duct. Fortunately, a dilated bile duct is ideal for a rendezvous. With the scope and the duodenal cap, it was quite easy to identify the duct, to fill it with contrast, and then to advance a guide wire down the duct and through the papilla in the so-called rendezvous maneuver. We can see we're directing this wire. It actually is circling inside that diverticulum, but then we grab the wire and we bring it outside the mouth. Now, we have access into the duct from the duodenum and outside through the papilla. We have complete control of that duct, and following the wire now rather than going over the wire, because if you go over the wire, you're going to end up coming out into the duodenal cap quickly. We just use the wire as a guide for our sphincterotomy and our sphincterotoma, I should say, and then we could advance into that duct and we are able to perform the sphincterotomy and the therapy necessary for this particular case. This is the rendezvous technique, which can be used transduodenal, of course, transgastric as well. Moving on, I think one of the most difficult marriages of EUS and ERCP has been that of the gastrohepatic access for hepatical gastrostomies, as well as for antigrade stent placement, and I'd like to illustrate that here with transpapillary stent placement. In this particular patient, we're performing ERCP. This patient had a Heiler tumor, and every time we advanced multiple different wires and using multiple ramps and other techniques, we could not get the wire to cross the stricture into the grossly dilated left hepatic duct system, the right hepatic duct was completely occluded by tumor. Faced with the inability to get a stent into the patient that way, of course, we then went to EUS-guided advancement of the wire, and again, three or four or five centimeters below the GE junction, you'll find segment three of the liver, and then with puncture, we can fill up that left side of the liver, then advance a wire, which you can see going well down into the duodenum, around to the ligament of trites, and this part of the procedure is the toughest. We have the wire, but we have a thick gastric wall, we have a muscularis propria, we have a liver capsule, which is not so difficult, but trying to get through, and I'll talk a little bit about the different methods, but in this case, dilated catheters sufficed, we were able to puncture, and then we were able, in an antegrade fashion, to advance stent of fully covered stent down across that dilated left hepatic duct system and down into the duodenum. So this worked very well and was excellent for palliative relief. So the tips for gastro-hepatic access, you should go from, of course, the upper left down to the lower right, so we have the right direction for the wire going towards the hilum, and then, of course, we like to choose a duct which is a minimum of five millimeters in diameter to give us the ability to advance the wire in the stent. And then, this is the most difficult area, which is, how do you open up that track? In Europe and Asia, they're very accustomed to using the six French cystostome, which we do not have in North America, so we have tried very sharp-tipped catheters, like the 345, 543, wire-guided needle knife, or even in the center here, you can see, bending the needle knife over the catheter to advance through to try to mimic the cystostome. But none of these work that well. They're often off-axis, where you make the puncture through the stomach, but don't go towards the opening into the liver or to the liver capsule, so they can be fraught with problems with bleeding, et cetera. So my advice with what we have in North America is simply this. It's the one time to splurge in my mind, which is to use the tip of the hot axios without ever deploying the axios stem. It's a little bit of an expensive way to go, but it's the most guaranteed, secure way, with the least complications, to cross especially the wall of the stomach going into the liver. So that's what I recommend. I would also say that the worst complication of this access is bile leakage, and this occurs also with choledochoduodenostomies. And the toxicity of bile, I just want to say, of all the complications I've encountered in a long career of therapeutic endoscopy, bile leak induced by iatrogenic manipulations is one of the worst. It kind of sneaks up on you. It's not too bad in the first day or two, but it can lead to a multi-organ system failure and worse. So when we're dealing with hepatical gastrostomy, the real trick is to choose a stent which has complete covering in that bridge between the liver and the stomach, and also to have at least five to six centimeters of stent within the stomach to allow for the motion of the stomach with digestion to ensure you don't lose stent access. So what I do, we have a number of different stents. I won't go into all of the designs. Most of these are not available in North America. I use an uncovered stent to begin with, a wall flex, totally uncovered, to secure the stent in the liver and then in the stomach. And then inside that stent, I put a fully covered stent, and that seems to work well. These are expensive options, but we have to look at what's right for the patient. And that is, you know, complication free. So these are some tips that I can give you. EUS guided choledocal duodenostomy. Direct access is often necessary when we cannot get into the duodenum. And you can see here, as we inject dye with a needle. We'll pause there for a second you can see we have a pancreatic cancer, including the bile duct obstructive jaundice, and then of course encasement of the duodenum as well, which is preventing us from draining this. What's ideal about this case is, if we have a duct which is one centimeter or greater, it certainly makes it easier on the endoscopist. And in this case, we have a needle puncture to start with, contrast of course, and a stiff wire and O35 stiff wire. And what we do first is we're taking a balloon to dilate up the tract, a four millimeter balloon, which is just inside the tip of the scope here. And once we've opened that up, we're working with limited real estate here within the duodenal cap. So we're going to advance a fully covered stent with anti migration barbs. The greatest concern of his bile leakage. And so we're securing the stent inside the duct upstream, and then we bring it out down into there's sorry the balloon dilation skipped over and coming back into the duodenum after we balloon dilate that that And I think you'll see in a moment the anti migration barbs. The trick here is of course since you're dealing with limited room within that duodenal cap. This the rest of the video is placing a duodenal stent for the duodenal obstruction but what I wanted to say is you must release your stent for the koolaidoku duodenostomy into the linear echo endoscope. And the way you release the endoscopic side of this or the luminal side of the stent is you pull the scope back and let it emerge from the linear echo endoscope so it stays within the lumen. So, a very important trick to remember. If you look at this ease of access I mean there's really with no problem, getting a needle into a bile duct from the duodenal cap. It's a, it's a chip shot as they say. But the question is, is it better than the RCP. There were three randomized controlled trials published a couple of years ago to from Korea one from Orlando, with our group down there with Rob Oz's group. We could hear that in the Korean experience reintervention with the RCP and complications were higher, but not so with the American experience it was the opposite. So I think what we can say is that we don't really have a final answer in spite of these RCTs, but there's no question that if you're having difficulty, and you have a dilated bile duct greater than 10 millimeters. Certainly, access with us is an acceptable alternative. What about cold assisted gastrostomy. Look at gallbladder drainage and patients who are not suitable for surgery, 46 year old man muscular dystrophy was not able to undergo surgery was a severe respiratory problems. We had two probable previous colitis gastrostomy tubes placed radiologically, and we're looking for a definitive solution. Fortunately 95% of gallbladders on CT series are within a centimeter of the interim, or the duodenal cap. So again with direct axios puncture. into the gallbladder, we are able to. We put a guide wire in to maintain access. And here we're using a 15 millimeter stent. Again, releasing the stent in the scope, pulling the scope back, and that allows for opening up and then followed by dilation generally we leave the wire in. We like to dilate up to 12 to 15 millimeters. You can see here all done with the linear echo and the scope of course will open this up. And this will allow for drainage of the infected gallbladder. And then usually after we've opened this up. We do leave a double pigtailed stent in place. You can see here the opening into the interim you can see how critical it was for this patient with muscular dystrophy. There were multiple stones. We started to clean out some of these stones. I've now followed this patient for approximately three years. The stent actually migrated out after two years but there was a fistula, and he has not run into any more problems. You'll see here a wire going in for placement, initially of a double pigtailed plastic stent. So, another important tool for EUS. So this is a prospective randomized controlled trial 45 and 45 having percutaneous drainage of gallbladder versus EUS guided LAMs, and pretty much equivalent in the outcomes in terms of clinical and technical success, but the failstay and reintervention were much higher in the percutaneous group. So this would favor EUS guided drainage of the gallbladder. And of course it's a relatively simple compared to some of the other approaches, provided we're within a centimeter. Now the toughest, I would say procedure that we have with EUS guided drainage is gastrogynectomy. Now we've gotten this down to a technique which we think it works. This was a patient, as you can see, who had a duodenal stent placed previously, which is now completely has tumor in growth. So we're putting a wire, and then a catheter down through the occluded duodenal stent to allow for advancement of a, this is a six French tube designated as a nasal biliary tube in this case, we're using it to inject contrast and methylene blue about a liter's worth into the area of the ligament of trites. This will of course distend the jejunum patient on the left lateral side so that jejunum of the ligament stays filled up with fluid, we give glucagon to minimize contractility, and then we try to do a direct puncture. So with needle first the jejunum will often move away from the wall of the stomach. So we try to go direct access puncture. Once we're in, we do advance a wire often for protection in case we have maldeployment of the axios. And then of course, release the axios, pull it back up towards the stomach to try to pull the wall of the jejunum up against the wall of the stomach. And once again release the internal part of the axios in the stent, pardon me, in the scope, and then gradually release it for access. And then we inject our fluid through our nasal jejunal tube in this case to see it coming back to the stomach. Once we're happy we're in a good position, we'll dilate this up to about, usually we use a 15 or a 20 millimeter axios in this case, we'll dilate it up. And then as you see here we get it wide open and I must say that these stents work amazingly well for gastric emptying, something I didn't anticipate, and they've been very effective in select situations. So I'm going to move on to something I find quite exciting, which is trying to address the problem of selective cannulation of ducts and selective wire and stenting of ducts. So this is a typical hyler cancer. When you end up with a type two or three, three A or B, with a tertiary branch duct secluded or secondary branch ducts. If you have the patient on the semi prone the typical position, you can't separate the right and left ducts we move them supine, the so called Brussels position, championed by Michelle in the early days Kramer. We can see now we separate the right and the left and we then can blindly wire into the left side. So this is kind of the, the way that we've been tethered with for selective dilation I would say for the previous for my entire career. So what's happening in neuroradiology which is fascinating, and a company that I've been working with over the last few months we're trying to adapt this to cannulation of the in the bile duct. So if you look at. This is a system where you have sort of a lens system where you can see on the holographic image of the, whatever this the duct system you're looking at this case it's the vascular network in the brain that the neuroradiologist wants to look at, he can see that through a holographic lens. And then on the 2d image of the fluoroscopic image. So I'll show you how this works. We'll turn on this video, you can actually move these images around as you're working. And then if you take a pointer. You can point to areas of the vascular, the vascular network, where you want to go, and that will be translated to precisely the spot on the 2d image, which will show you where you have to go with your intervention. So it's a way that we can now try to apply this to er CP, where we use the Mr. I Mr CP image to get a construction a 3d construction of the billiard tree. And once we have that we can again put that in front and marry that to what we're doing in the bile duct so as we, the orange on the image represents the wire going but it's, it's corresponds to the wire that's going up the 2d image on your fluoroscopic image in your room. So you see here on the left is where the holographic system, where we can control the billiary tree move it around any which way we want to. Once we advance a wire up the duct, we can see on the 3d image, which duct we're going into, as it corresponds to the 2d image of the of the fluoroscopic image so this is an area which I think is a game changer I think there's no question that we're probably 10 years behind my son who plays video games doing this stuff all the time, but I think this will have a huge impact for effective drainage in this, when we have complex anatomy. On that note, I'd like to certainly say that, and on this call by Dennis Wheatley that imagination plus innovation equals realization. And I'm very thankful to gene overhaul Bergen overhaul for being inspiration. Thanks to the ASG for giving me this great honor. I much appreciate it.

pancreatic biliary endoscopy

EUS and ERCP

radiofrequency ablation

holography

stenting

EUS-guided procedures