Welcome, everybody. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's webinar. My name is Ed Deller, Chief Publications and Learning Officer for ASGE, and I will be one of the facilitators throughout tonight's presentation. We're very excited tonight to bring to you our program entitled EOS Around the World, Focus on New Technology and Techniques. Please note this presentation is being recorded and will be posted on GILeap, ASGE's online learning management platform. You will have ongoing access to the recording in GILeap as part of your registration. I also want to acknowledge the gracious educational programming support from Olympus for the remainder of our 2021 ASGE Thursday Night Lights program. Thank you. Before we get started, please note a number of features in tonight's platform so you are aware of the many resources available to you during and after tonight's program. Currently, you are located in the auditorium. 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Thank you for noting all these features available to you during this webinar and any time following the program. There's a URL link, the learn.asge.org. That is where our recording will be located at in a day or two. Our objective for tonight is to showcase novel and emerging technology and interventional EUS and to discuss newer techniques, innovations, and interventions in interventional EUS. Now, it is my great pleasure to introduce our two moderators, Dr. Cole and Dr. Bang. And I'm going to turn this over to Dr. Cole. Thank you very much. Thank you, Ed, very much. I am Dr. Vivek Cole at the University of Rochester Medical Center, and it's my great pleasure to co-host this event with Dr. Ji Bang from the Orlando Digestive Health Institute. I want to thank the ASGE for affording the EUS Special Interest Group to host this event. The EUS Special Interest Group is pretty much the largest SIG under the auspices of the ASGE. And Ji and I took over the stewardship from Shyam and Vanessa, who ran it for many years. So unfortunately, the last couple of years, we've had no in-person meetings, but thanks to the ASGE's opportunities through the webinar platform, we're able to present something that is spectacular tonight with our two internationally known speakers. It is my great, great pleasure to introduce Dr. Anthony Teo, who is a professor of medicine surgery and deputy director of endoscopy services at the Prince of Wales Hospital at the Chinese University of Hong Kong. Anthony needs no introduction. He's a great friend and colleague, and really at the cutting edge of interventional EUS. Anthony's going to talk to us about novel EUS devices and techniques, and following which, Dr. Latakia, who will be introduced by Dr. Bang later on, will present a different take on things in terms of where the future lies and where else we need to go. As Shyam said in one of his editorials not too far back, we have miles to go and miles to go. So we'll talk a little bit about that. So without further ado, we hand this over to Dr. Anthony Teo. And Anthony, welcome. Thank you for doing this at short notice, and I know it's an early morning for you. I look forward to your presentation. Thank you. Thank you very much, Dr. Koh. Thank you very much, Jie, and thanks, ESG, for inviting me to this great webinar. So I'll be talking about some new EUS devices and techniques. It's not necessarily the Far East perspective, but I think it's more of an international perspective. So hopefully, it could stimulate all of you in terms of what we can look forward to in the coming few years. All right, these are my disclosures. So if we look at the development of EUS guided procedures, really the first description for all these interventional procedures really dated back quite a few years. So Ken and Zohendra described the first PFC drainage almost 30 years ago, followed by a number of different EUS guided interventional procedures from Bauduc drainage to PD drainage and so on. And however, it's only in the past five, 10 years, I think, in which these techniques has really been popularized. And I think a part of the reason is that at that time, most of these procedures were still quite difficult. And really, all the endoscopists performing these procedures didn't have the right tools to do these procedures. As a result, there is a big learning curve or big difficulty in which you have to overcome. And I think at that time, most of these endoscopists were really boring devices from which we were using in other procedures like ERCP. So there was a big lag in the development of EUS devices. And it's only in the past five to 10 years that I think manufacturers have seen the opportunity to develop EUS specific devices, which are very important to the current day of EUS interventions. So the importance of EUS specific devices is it allows performance of novel procedures, not only by experts, but also by any endosonographers. These devices can reduce the difficulty procedure, reduce the risks of adverse events, shorten the procedural time, and also decrease the learning curve. So we really need the right tools to perform these two procedures and to popularize these. I think this person needs no introduction, Ken Vimuela. I think he has been pivotal to the current development of EUS interventions. In the last five to 10 years, EUS guided drainage procedures has been one of the dominant things that has been evolving. And thanks to Ken's wisdom in developing the luminal pulsing stent, we have seen a great, great development of the devices. So this is the original picture in which Ken was designing the luminal pulsing stent. The two edges of the stent is supposed to pull the two edges of lumen together, resulting in creation of either a fistula and a stemosis. And another very spectacular design is that this handle allows the endosonographer to completely control the puncturing as well as the deployment of stent. And this is a very magnificent device. So thereafter, the Axios needs no introduction because it's the first luminal pulsing stent that has become available in the market. It comes in various sizes. In the past, it was just 15 millimeters, but now the largest diameter is 20. It has the specific deployment system as well as a very important corridor-tipped design. But apart from the luminal pulsing stent, we also have seen the development of several year-specific stents, not only the Axios, but the Spexus and Nagi, and also tubular type of year-specific stents. So these stents have specific design characteristics. For the luminal pulsing stent, they are dumbbell-shaped, they have flange edges, and they are designed to be anti-migratory. Also, they have a big lumen, which allows us to use it as a portal to enter different organs, not only drainage. So this greatly increases the capability of US drainage procedures. So we don't only drain the organ, but it also allows us to intervene via placement of these stents. In terms of the tubular stents, they also have specific designs. Very often, we are creating new drainage channels. So these stents have specific designs which prevent the stents from migrating, as well as allows anchorage. As a result, in the last few years, we have seen what I would call a festival in US garden drainage procedures. We are able to drain and also access organs which were not previously possible before. For example, in the bow duct, apart from drainage, we can also use the bow duct stent to access the deep intraductal stents. For the gallbladder, apart from drainage, we can have interventions inside the gallbladder, removal of stones, or even remove polyps. We can now even drain GI organs, doing atrial loop obstruction, draining them, as well as performing gastroenteroscopy, and also gastrogastrosomy for ERCPs. So this has been very exciting for an endosarmographer. And many of these procedures have been compared to surgical procedures as well, because they are essentially creating an anastomosis between two organs, away from tumor, which greatly increases the potential of, reduces the chances of tumor in growth, as well as access to distant organs. The other thing that is very important is, as I mentioned, the learning curve. So this is actually a colloidal corticosteroids performed by a trainee, the first one. And I noticed that the small-sized luminal opulsins, cordial enhanced luminal opulsin stent has recently been approved in US. So I think this is very relevant to you guys, because with the cordial enhanced luminal opulsin stent, it really reduces the learning curve of the biliary drainage. So this is the bow duct, as seen from the duodenum. Usually, we would prefer to puncture it with a needle first, followed by guide wire insertion. Especially if the person is not accustomed to performing this procedure, I would strongly recommend you to insert a guide wire first. Once the guide wire has been inserted, then we would puncture it with a cordial enhanced luminal opulsin stent. And as you can see, it goes in very nicely. The bow duct is significantly smaller than the gallbladder or any pancreatic filler collections. So you need to be careful when introducing the delivery system, because the area in which you can open the stent is quite small. So after opening the distal flange, then you would need to open the proximal flange. And again, this would be via the intra-channel release method. And with this device, the trainee was able to complete the CDS in 5-10 minutes. And most importantly, this was done in a very controlled and stress-free manner. As a result, with this device, we were able to complete this trial, comparing US CDS versus ERCP with partially covered metal stents. We were happy to be able to present the short-term results in this year's ASG plenary presentation. And for your information, in the CDS group, the technical success rate was significantly higher as compared to ERCP. The reasons were either due to presence of duodenal obstruction, or basically the tumor is too bulky for ERCP cancellation. Clinical success in hospital stays were similar. Procedure time was significantly shorter, as you would imagine, because the ERCP was as you could see from the procedure just now, the bile duct is just behind the duodenum, and the procedure is very easy. In terms of the more important parameters, in terms of one-year stent dysfunction rates, many of these patients had not completed follow-up at that time. So we could not detect any significant differences. So we were just about to evaluate the one-year stent dysfunction rate soon, so hopefully we would be able to evaluate the long-term outcome as well. Another study that has been published on gallbladder, this was published in GUT last year, comparing US versus percutaneous drainage in patients which cannot receive cholecystectomy. So the results of this trial was very encouraging. We knew that the reinterventions, as well as adverse events after percutaneous gallbladder drainage were high, particularly due to the tube-related complications. So this study was able to show this, but more importantly, the recurrent acute cholecystitis rate in the USGBDR was only 2.6%. Also, in the 30-day adverse events, this was a little bit lower. So really suggesting to us that in patients which cannot receive cholecystectomy, US is definitely better than percutaneous drainage. And after this trial, we have also published a propensity score analysis comparing US versus lab coli in surgical candidates. So right now, we are doing a trial on surgical candidates on US gallbladder drainage, mainly looking at the long-term outcome. So hopefully in one or two years' time, I would be able to present to you how this procedure compares to lab coli in surgical candidates. In terms of US-guided gastroenteroscopy, we are performing the EPAS technique, which involves the balloon occluders. Definitely, you can perform this procedure without the balloon occluders. But so far, we have recruited 43 patients, and I think it's looking good in terms of the reinterventions compared to regular duodenal stents. So hopefully by the end of this year or maybe early next year, we would be able to present this trial, a randomized trial between the US-guided gastroenteroscopy versus duodenal stents. So apart from the well-known hot axios, we are also seeing new developments in devices from other companies. This is another caudary-enhanced pneumonopocene stent from Taywar. It has a very nice caudary-enhanced tip, which allows easy puncture into the organ. And but the delivery system is more like a regular system, so it will require delivery by your assistant or nurse. But in terms of puncturability, it is equally efficient. This is a gallbladder drainage, which was done by this device. Again, direct puncture. And you can see the system is actually very soft. So after the puncture, you can see my delivery system going on in. And with deployment, you can see the system actually conferring to the shape of the gallbladder. So it's very soft. And afterwards, it's basically similar to how you would perform the pneumonopocene stent opening this flange, pull back, and then deploying proximal flange in the channel and then pushing it out. So we have recently published the results of this coronary enhanced luminal pulsing stent across a variety of organs, including PFCs, gallbladder, bowel duct, gastroenteroscopy, and atrial lymphs. So again, showing a very good technical success, a clinical success rate. So definitely something for us to look forward to. Also, a few new stents in the making, luminal pulsing hepatogastrosomies. As we know, hepatogastrosomy is one of the more difficult biliary drainage procedures, and one of the most feared complications or adverse events is the risk of migration. So definitely the application of a luminal pulsing hepatogastrosomy is much welcomed, and these devices are in the making, and hopefully we would be able to present the results of the trial soon. So if you look at the past five to 10 years, really there has been a lot of development around stents, but this is not the only thing that we could do. So recently there have been a lot of interest in what other new procedures that US-guided interventions can be performing. So this is a little bit not out of the scope of EUS, but I think it's one of the related areas. So in terms of water necrosis, I'm sure we all know that drainage is just part of the procedure, but after drainage, we will need to think about what to do with all the necrotic goo in the cavity. So as we know, it's quite cumbersome to remove these necrotic material. So it's really happy that we have a device for this type of procedure. So the endorotor was initially developed for mucrosectomy, but I think we have found that it is actually a very good way to perform a necrosectomy. So as you can see, the device is here, in the tip is a rotary sort of a cutter, and you can apply suction to this device so as to suck in any dirty material or this solid material. And definitely it makes the whole procedure a lot more enjoyable because we do not need to struggle with pulling out all this sticky stuff. Of course, again, you need to be careful because the most dreaded complication from a water necrosis is bleeding. So you would need to be careful not to injure any vessels and always be humble because pseudorism can always develop in these cavities. So in Holland already, they have presented the published report of the initial experience. If trial patients undergoing a total of 27 necrosectomies, mean size was 11 centimeters, mean of two procedures, and there were no procedure related adverse events. The other area that has been gaining a lot of attention is the development of a new scope in endoscopy, the idea of endohepatology. So we know that with endoscopy, we can perform ferricyl surveillance, but recently we've been talking a lot about the US-guided liver biopsy and the benefits. Also, there has been a few studies published on the use of cordovain sampling for circulating tumor cells or DNA. And most recently, the development of US-guided pulmonary pressure gradient measurements. So this has really been the baby of our good friend, Ken Chen. He has been in this project for, I don't know how many years. In 2016, he was able to publish a study comparing US versus a transjugular tips in pigs, and basically showing that there's an excellent correlation between US and IR methods. Thereafter, the same group, they have published the results of US-guided pulmonary pressure gradient measurement and correlating the measurements with the appearance of complications of cirrhosis. So they were able to show that in patients with high portal pressure, there were higher risk of, for example, portal hypertensive gastropathy, paroxys, and the cutoff of a high portal pressure would be around 10 millimeter mercuries. So we have also started the use of this device. This is a case of a patient with a 67-year-old lady. She came into our hospital with tyrosine anemia. EGD at that time showed two columns of OV esodioviruses with red blood sign, and banding was applied. She was subsequently worked up for cirrhosis, and the HPV, HCV were negative. Ultrasound showed sphenomegaly, and she was started on propranolol, and she was referred for follow-up EGD and portal pressure measurement. So with this procedure, you would need to be accustomed to anatomy in the liver, identifying the hepatic veins and portal veins, and also be accustomed to puncturing within the liver. So this is a technique with some learning curve. So I would show you this. Okay, let me play this first. So on US, first of all, we assess the portal keratoma. So it appears to be some coarsening in the liver parenchyma. The first thing after assessment of liver is that you would need to identify the hepatic veins. There are three hepatic veins, left, middle, and right. In this patient, it was difficult to find the origin. So I had to trace the IVC, and then from the IVC, I had to find the branch of the left hepatic vein. And from here, the left hepatic vein only measured three millimeters. So it's a tiny target. So you would need to have the techniques of puncturing tiny vessels. So right here, you can see my needle entering. The technique of puncturing these small targets is really to overshoot and then pull back into the lumen. We were using a 25-gauge needle, which comes with the pack. And you see the needle overshooting, and I was pulling back, trying to enter the vein. I felt that the needle was on the side and not really in the vein. So I pulled back my needle and tried to find another angle. And right there, I thought the angulation was good. And you can see the needle entering into the hepatic vein. So thereafter, I would need to perform the measurement. Usually, we'll perform three measurements, and the mean hepatic pressure was five millimeters mercury. The initial response of puncturing a vein is that everyone would be worried about risk of bleeding. And that's why we perform a transhepatic puncture, because the living parent climber would act as a tamponite and prevent the bleeding from these veins. This is left portal vein. You could see the size is much bigger in the left portal vein. So this is going a little bit too quickly. This is very common situation, especially in patients with cirrhosis. The liver prevents blood from going in, and it's common to see a dilated portal vein. And again, we did three measurements. And afterwards, we were able to calculate a mean of 23.33 millimercuries. Afterwards, again, with withdrawal, this was done under a Doppler ultrasound, which was turned on here. At one point, I was worried about some bleeding, maybe from here. Okay, let me get, okay. So here, it seems like there is maybe a vein or a branch along the needle track. I wasn't sure. It's very often to see all these veins in the liver when you were removing this at the needle. So as the patient breathes, it comes in and out. There are some branches, but definitely it is a little bit worrying that blood is coming from the needle tract. I advanced the needle a little bit. I changed the angle of the scope. Sometimes it can also be a vein, which is in the same angulation. So as I changed my angle of the needle track, it looked more like to me to be a adjacent vein, which is coming from sort of the same direction. So at this juncture, I think I'm not too worried about bleeding. And in fact, from previous experience, the risk of bleeding is quite low. So I slowly removed my needle and completed the procedure. So after the calculation of the two gradients, we were able to measure the portal pressure gradient as 18.33 millimercuries. This is definitely a high, anything higher than 10 is high. So 18 is very high. As you would recall, this patient, we didn't have, she didn't have any cirrhosis. I mean, hepatitis B, hepatitis infection. So liver biopsy was suggested, which could have been done in the same juncture, but she refused. So this device is really interesting because it can allow us to diagnose portal hypertension. And the important question is, now that we could do this procedure, how can we apply the knowledge? So first of all, definitely, I think we would need to correlate the risks of varicose bleeding and mortality with the portal pressure gradients. And most importantly is whether the use of beta blocker to control the portal hypertension would eventually change the outcome. So a lot of work to be done by us, but definitely very exciting. Another very interesting area is the area of US-guided tumor ablation. In the past, the only technique we could do is alcohol ablation, but recently a few new devices have came into play, including the radiofrequency ablation device, which is this needle. The microwave, which is this needle, and also OncoSeal, which is a radioactive liquid injection. So with alcohol ablation, I'm sure all of us are familiar. It has been shown by many studies to be good device or agent to inject into neuroendocrine tumors. So this study reported by Doyon Park, a good friend, showed that in 34 patients, neuroendocrine tumor, the chronic remission rate, first ablation is 55% and then increasing to 72.5% at repeated ablation. So with neuroendocrine tumors, particularly those that are functioning in patients who are at high risk for surgery, this is a good option. But recently, two energy devices have become available. The first one is the RFA and more recently, the microwave ablation. So these two energy devices have been in use in surgery for a long time, but to endoscopists, it's definitely something new. RFA works by heat energy. So heat would diffuse generated at the tip of the device, and then it would work by diffusion. So by heat conduction, it would extend a few millimeters to surrounding structures, resulting in conduction of heat and also killing of tissues. Whereas for microwave, I'm sure you have used it because at home with the microwave oven, the idea is the same. So microwave works by activating water particles. So the water particles would vibrate very quickly and as a result, generate heat and the microwave catheter that we use in U.S. works in the same principle. So in terms of the heat, it's a bit more evenly applied because it actually stimulates the particles around the catheter in a very similar way and it doesn't work by diffusion. So in terms of RFA, there are two devices available. One is the Habib wire. So I say wire because it's really a wire and the RFA needle produced by Starmet. So for me, the prerequisite of a RFA needle is that we need to have a water cooling component. So this is not available in the Habib wire but available in the Starmet needle. So with the water cooling ability, it actually maintains temperature around 60 degrees, prevents charring of the tissue, which if it happens, won't be able to conduct heat and are resulting in a more even sort of ablation zone around the catheter. So this is one of the procedures in which a patient with unrespectable pancreatic cancer receiving palliative chemo, but at the same time, we have consented the patient to have an adjuvant RFA to see if there could be any synergistic effect on the local tumor. The Starmet needle is a 19 gauge needle. It's a very sharp needle and it enters the tumor very easily. As a routine, we will perform a contrast enhanced EOS because we want to see the vascular pattern inside the tumor, as well as this acts as a way to monitor the effects of the ablation. Thereafter, we would insert a needle and then perform ablation of the tumor. So the energy setting is still in discussion in discussion because we are not sure about the optimum energy setting as well as the time of ablation. Here, I was using 50 Watts. I was using the bubbles as a way to monitor the burning of the tumor. Since the tumor is bigger than the ablation zone of the active length of the device is one centimeter. So, and the tumor was definitely bigger than one centimeter. So I was using a technique of overlapping ablation to have a complete ablation of the tumor. And after poundering a few times, I was able to ablate around more or less the center of the tumor. So you have to be careful in terms of ablation because around the needle, there's a ablative zone. If the zone is closer to the needle, it is what I would call a well-done sort of meat. And more in the periphery, it would be a, what I would call a medium rare area which there is a incomplete ablation. So the incomplete ablation is a zone where either tumor can recur or if it ablates normal tissue, it can also cause pancreatitis. So, you cannot be too aggressive when with ablating, because if the medium area, medium rare area is in the pancreatic tissue, there's a risk of pancreatitis. In patients with pancreatic cancer, I think this is not a very high risk, and here you can see I was doing a contrast after the U.S. ablation, really to confirm the absence of micro vessels inside the tumor and confirming the completeness of ablation. Hopefully I'm not going too far in terms of overtime, but I'll be done soon. So, this is the first result of U.S. guided RFA by our French friends, Mark Pate, as well as Giovannini. So, in this study, they were ablating neuroendocrine tumors, as well as pancreatic cysts. They showed that in terms for neuroendocrine tumors, those with syndicated response, 85.7%. In terms of pancreatic cystic neoplasms, those with syndicated response, around 70%. So, this is the first results of U.S. guided RFA. Definitely, we can discuss more on whether we should or should not use this procedure, but the results are here. This is the microwave device. It's very new. We are still starting to perform animal trials with this device. It's from CREO Medical. The design is very similar to any FNA needle, and this is the generator. The needle, the tip is a ceramic tip. It's actually to improve the puncturability of the needle, and the microwave catheter is actually a little bit behind the tip. So, it works in a very similar way as in any needle or ablating needle. This is in a pig, done recently. After puncturing into the liver, we were testing the puncturability of the needle, as well as the ablation inside the liver. So, right here, I'm advancing the needle. After a while, I was able to puncture into the liver parenchyma. And with the start of ablation, as with similar to RFA, you would see bubbles around the catheter. The energy setting is preset. So, really, what we need to deal with is the time. So, the longer the timing of the ablation, the bigger the size of ablation zone. And in this animal, we ablated for two minutes, and we were able to generate an ablation zone of 15 to 10 millimeters. So, animal trials are on the way, and we will compare this device to RFA. So, I know I'm running out of time, but I'll just quickly go through this last bit, which was the OncoCell. This is a radioactive liquid device, which allows you to get into an injection, and it could deliver 100 grays to a target tumor. So, it really works similar to any radiotherapy, but the benefit is a single injection, and as in contrast to regular radiotherapy, which the patient would need to come back repeatedly. So, this is the results. This is procedure, which I'm sorry I could not show today, but the results of the Panko trial, which is still ongoing, but they were able to show a local disease control of around 84%, and also around 25% of patients that were able to downstage from resection. So, for resection, and 82% were able to receive a R0 resection. So, definitely a very exciting device that allows us to inject radiotherapy. So, in conclusion, I think we are still in the boom for EOS-Guide interventions. New devices continue to come up and open up exciting opportunities, and more data are required from randomized trial to confirm the efficacy. So, thank you very much for your attention, and sorry for going over time. Thank you. Thank you so much, Dr. Teo. That was a wonderful presentation. Really eye-opening stuff. Really wonderful. So, for our next presenter is Dr. Sandeep Laktakia. I am delighted to be introducing him as part of our session today, not only is he one of the most eminent endoscopists in the world, but he's also the Director of EOS and Endoscopy at the Asian Institute of Gastroenterology, and the current President-Elect of the Society of GI Endoscopy in India, and he today will be presenting on new technology interventional EOS. So, Dr. Laktakia, thank you so much for joining us today, and we're going over to you. Thank you, Ji. Thank you, Vivek, and thank you ASG for inviting me for this meeting. It's an honor and pleasure to be there. It's very early in the morning in India. Nevertheless, it's an exciting time. So, as you see, the topic is very exciting too, what are the unmet needs and what is in the pipeline for interventional EOS. We had a wonderful talk from Anthony, and let me just move my slides. So, during this talk, I would cover some of these things and maybe skip what Anthony has already spoken on. In interventional EOS, there are several things which are going around, biliary intervention, pancreatic duct intervention, tumor ablation, direct endoscopic necrosectomy with what Anthony showed was rotavirator, and there's some graspers which have come across, and portal hypertension, how to measure the pressure, and whether it can eventually lead to tips. It will be the ultimate thing because we can see both portal vein and the hepatic vein, and we can just join them with so many wonderful stents around keeping infection under control. I think that would be the ultimate in management of endopathology. So, let's take one by one, and as was the topic suggested, in malignant disease, this is the most commonest thing. For what biliary intervention that we do is mainly for access or access as well as drainage. So, this is either roundabout or when we do drainage together, it's called either colorectal diagnostomy or hepatogastrostomy, or even antigrade stents can be placed if the wire goes across the papilla. I'll skip this video because Anthony showed something similar. LAMS is preferred in some people, but we in India still use tubular stents. One, they are cheaper than LAMS, and second, they are tubular. LAMS, once it collapses the CBD, then some, it's possible that the inner flange, which is inside the CBD, can hit the opposite wall of the bile duct and cause injury, similar to what happens in pancreatic fluid collection. So, a little concern there, but we need to see what happens in the long term when patients have these stents placed inside. I'll skip this video, and as Anthony suggested, these two stents which are available with us are cotri-enhanced LAMS, SPAXs, and Axios, which have really made a huge difference, and this has revolutionized our US interventions because with one device, which is a single catheter system, which the endoscopist himself controls, eliminates the exchanges of devices, and also reduces the time between the access and the stent deployment. So, the issue remains is of long-term patency of LAMS or a tubular stent, which is placed for colorectal diagnostics because food can enter it, as has been seen in several earlier experience. Will it be more with LAMS than tubular stents? Only time can tell, or trials comparing the both can help. As I said, there's an issue about injury of the opposite wall of the CBD with LAMS. Moving forward to hepatogastrostomy, there are several stents now which are either fully covered or partially covered, which bridge the left hepatic duct to the stomach lumen. And the issues here is that we need to choose a longer stent. If we choose a short stent with patient's respiration, these stents can migrate over a few hours or a few days. So, never let your guard down. Soon after the procedure, if you see a stent hanging about three centimeters in the stomach lumen, lo and behold, a day or two later, this stent is certainly going to migrate, especially if it's fully covered. So, that's a tendency now to use long stents, 10 centimeter or more, with at least four or five centimeters hanging in the stomach, or you have a good anchoring device which prevents internal migration. I will show one of our own experience. This is a patient who had a higher cholangiocarcinoma with a metal stent in the right hepatic duct. And he came with a disease progression and cholangiitis of the left system. So, you see a nice dilated left hepatic duct. So, as we're deploying the stents, there's a tendency to deliver in the channel of the scope, but sometimes you also have an intuitive sense that, okay, let me watch it endoscopically and you deliver it. And we thought that the stent is in good control. And suddenly we realized that the stent is actually not in the stomach at all. It's entirely in the liver and the peritoneum. Luckily, we had the guide wire inside, and this is, always proves to be a lifeline. Never remove the guide wire till the end, till 100% sure that everything is okay. This guide, we could place another stent, a fully covered one, telescoped over this guide wire so that it was overlapping with the internally migrated stent. And we could bail us out of this dreadful complication. So, these are situations which make us realize what are the unmet needs. And the reason was that the marking on the stent was not too good. And we thought that the markers were actually in the stomach area, but they were not. So, we need dedicated EOS biliary stems and not ones which are borrowed from the ERCP toolkit. These stents should always be reconstrainable. So, if you have a challenge that you have misdeployed or partially misdeployed, actually you can recapture back and redeploy it, which some of the current stents do not have the facility. But I guess in EOS, we need to have that as well. The radiopacking markers on the stent should be seen very well on x-rays. So, your fluoroscopy needs to be good, plus the stent markers should be very evident. Both the ends should be marked. And in a fully covered stent, the center should also be marked so that you know where exactly you're leaving the, it should not be a skewed placement. And for the partially covered stems, they should be marking at the junction of uncovered and the covered segment, which some of the stents do have, but they are not, they're generally very faint and not so visible on the fluoroscopy. So, another end mate need is if you have a guide wire inside, why do you use a sister storm? Just use a hot delivery system and place these stems over the wire. Hopefully in future, we'll be able to see it and discuss in one of these ASG forums. The anti-migration features also have to be very robust. They should either have flares or fins and flaps, et cetera, to prevent any internal migration, because that's a horrible complication to have. Moving forward, now the experience is expanding towards biliary disease as well, benign diseases, and for stones and strictures, especially where ERCP fails, which can happen in even an expert hands. So, here are some of the examples of where a stone disease patient, where we could not enter the bile duct for a variety of reasons. We did a coludoco-diagnostomy kind of a procedure, access the guide wire, kept looping inside the CBD, and finally it came out of the papilla. Then we used an ERCP scope to catch this guide wire and go beside it and complete the procedure. So, we need to, so this wire manipulation is a challenge for benign disease, and that's why it's not being used so common. You can also access the biliary tree from the intrapartic root, provided they are dilated, which are not so much generally in benign disease, unlike a malignant disease. And hence, anti-grade PTBD procedures are much lesser, but we can do now with the experience getting up to puncture even the thinner ducts, pass the guide wire across the papilla, and then complete procedures. You can also remove these stones by dilating the papilla and pushing them down, or at least pass a wire and do a roundabout procedure if the papilla is accessible to place a stent. But some of these procedures, unlike malignant procedures, are much more time consuming and hence can have their own adverse events. In spite of a successful procedure, we can have a little bit of perforation, as you can see it here. Fortunately, we're all using carbon dioxide, and we have learned from our colleagues in third space that this amount of CO2 does get absorbed apart from a little bit pain soon after. So, the unmet need over here is guide wire manipulation to the desired duct. The balloons that we use to push out the stone should be stiffer. The current ones are a little more softer and can buckle. And we need stents to place anti-gradely, which should be a stiffer stent, plastic stent, in a benign disease. So, what is in the pipeline? There are curd-axis needles from Medtronic called Beacon Needle, and also from one coming from Vossen Scientific. This is the one which is currently available, the rotatable needle, the Beacon Needle, which the needle is straight when it's available, but once you pull the stylet back, it takes a pre-curved, which is either 90 degree or 180 degree, depending on which direction you want to move eventually. So, this is one of our case who had a intra-diverticular papilla. This was MR, CP, and stones here. We could not enter the CBD on several occasions, and that's why when we decided to use this device, you can see the stones there, and you puncture like a simple colloidal cardiognostomy. This was a 90 degree needle, which was decided to be used in this case. It's an 18.5 G needle. So, once you puncture a dilated system, you would draw the stylet and the needle curves around. You can move in whichever direction you want to go. Here, we wanted to go across the papilla, and hence we moved the angle towards the distal end, injected contrast, and then the guide wire. And once the guide wire comes out, you do the roundabout procedure like you do it. Moving forward to EOS-guided PD interventions, which are one of the most difficult ones, and they are considered to be waterloo of EOS interventions, and they should only be attempted when no other option is feasible. This is one of a case with chronic pancreatitis having hugely dilated that looks quite juicy. The ER-CP could not allow us to enter, and that's why we decided to do an EOS-guided intervention, and lo and behold, we could place a stent easily across. So, this looks to be much easier of all the EOS PD interventions, but there can be several challenging ones. Let me show you an example of the standard grossly dilated PD. You puncture with a 19-gauge needle, with the needle directed towards the papilla so that the wire can come across if you plan to do a roundabout procedure, which is much more better than a pancreatic gastrostomy, where you also have to deliver the stent across the pancreatic parenchyma and the duct. And then, depending on where the direction of the wire is, if it comes across the papilla, it helps you, but if not, you can still place a stent. So, here we were able to get the wire out of the papilla. So, we remove the needle, pass over the wire coaxial 6-francisrotome, which is a very important device in any intervention EOS unit. I'm a little surprised it's not approved in the U.S. as yet. Luckily we had the guide wire that across the papilla with this device and then we placed a stent, not only pancreas gastrostomy, but we also placed a trans-papillary stent. So we had two stents from two different directions. So this is some of the ways that you can think of doing the procedure, but disconnected duct is a major issue if they are symptomatic. And this is a patient who had a cross dilated PD, we punctured, got the contrast in, none of the contrast went across the papilla and the guide wire went back to the tail of the pancreas. But since we had a long limb of the wire inside, we did a systatome over the wire and then placed a stent. Other case I would like to share is some of the disconnected duct, which are symptomatic and appear like a DPDS on MRCP may not actually be DPD. So we were trying to drain this thin duct in the distal body tail area. What we saw is a little bit of contrast coming back towards the head and body area. So which made us realize that this is not actually, we have some bridge available by which we can, although initial ERCP we were failing to enter, we were not injecting in full pressure, but during this EUSPD procedure, we could realize that it's possible. So some of the DPDS may not be an actual DPDS, but it would look like that. And then you can do a trans-papillary work of the guide wire comes across the papilla. So unmet need in EUSPD is a requirement of ultra sharp needles to traverse tough pancreas, especially in chronic pancreatitis patients. Pancreatic systratome, which goes over the wire is must. And dedicated stiffer pancreatic plastic stents, which are available currently in Japan only should be much more widely available to have a complete successful procedure. Next endoscopic necrosectomy and Anthony covered using rotablator, another device which helps us in removing the thick adherent debris. And this is called as OTSG, which is also from the same company of Ovesco. It's called over-the-scope grasper. There are several steps by which you prepare this assembly. It's like a cap, which is fitted at the tip of the scope. So the working channel is spared and you have now a device at the tip, which is transparent hood, which opens like a flap. And then this is tied with sticking tape on the shaft of the scope, all along the length of the scope. And this can, the tip can be controlled by the handle, which works like a, like a biopsy forceps. So the handle can open and close the tip, which is there. So the jaws can open at the tip and the control mechanism is outside the endoscope and not through the channel. So you can clean through the channel, like in a manning who is over-the-scope grasper, which basically explains already what it's good for. I'm quite certain that you're very well familiar that removal of necrotic debris following severe pancreatitis or removal of large blood clots can be quite cumbersome since there are no specific tools available. The idea or initial concept was therefore to have an extra large transparent grasping forceps that can be attached onto the tip of an endoscope without blocking the instrumentation channel, thereby still allowing flushing, suction, and if necessary, introduction of other additional instruments. The OTS-G is attached on the tip of a standard endoscope and further fixed with two tapes onto the shaft. As you can see, the instrumentation channel remains free for flushing and suction. Therefore, I also prefer to combine the OTS-G with the STEROS BioVac direct suction device. And this explains basically the concept. Now let's see it in clinical practice. Here you can see the passage of the scope with the OTS-G attached. There is no problem with visualization. Even narrow movements as anticipation of the radiotherapy can be passed. Here a large fragment of the esophageal ESG was removed. The concept is that we open the forceps, apply suction, close forceps, and thereby remove the clot. So far, most of our experience is for using the OTS-G for direct endoscopic necrosectomy as demonstrated here. Usage of certain devices may be cumbersome in these cases, but with the OTS-G, large particles can be removed to significantly speed up the process. Finally, we also apply the OTS-G for removal of foreign bodies, such as impacted food, as shown here. So you can use this device for necrosectomy, removing large clots, and also foreign body impactions. Moving forward, EVUS gastroenterostomy is a very exciting procedure, and the availability of lamps has really made it possible. There are several ways to do this. Our current preference is to use an EPAS balloon, which is not commercially available, but it makes the procedure reasonably safe compared to a freehand technique where the jejunum is filled with water using tubes passed through the nose into that area, and then by free hand you puncture that. So if somebody is not very comfortable with lamps, hot axios, then this may be a little better or a safer way to go forward. Let me show some of the steps that we do using EPAS balloon. That first is to pass a guide wire deep across the DJ flexure, and then using an overtube, and then over this guide wire we pass a balloon, which this EPAS balloon has two balloons, one at the forward balloon, and then a more proximal balloon. So these two balloons are inflated with contrast, which helps in trapping the jejunum loop, and then intervening area is then filled with contrast and a coloring agent and saline. And in real life scenario, let me share a video of using the EPAS balloon, DJ being performed. This is a trapped segment of the loop. And once you have a nicely distended jejunum loop next to the stomach, and that becomes a target organ, you can also see the tube in between, which helps you further identify. And the rest of the procedure is quite similar. I'm sure all of the audience in this forum are aware of the placement of the axial stent. The last part is done in an endoscopic vision, or you can deliver in the channel per se. And the appearance of the coloring agent, which is indigo carmine, in the stomach helps us identify that the tube has been, the stent has been nicely placed. The technical success is quite good, and so is the clinical success. But this is a very high risk and high reward procedure, and one mishap can actually deflate our egos and make us look like fools in front of somebody. There are not studies available comparing DJ with a surgical DJ. These are retrospective study, but comparative, and they have been reported as they're as effective as a surgical DJ. This was one of the earlier publications. It's equal efficacy and safety, and it's not inferior to the surgical DJ. It can also be used in benign gastric outlet obstruction as a bailout method when surgery is not possible. And this has been found to be quite effective in the early terms, and the stent remains patent for a reasonable period of time. So it's a promising treatment for treating benign GOO, and the comparative stent patency in benign GOO is at least a year or so. Malignant patients, anyway, they are in the end of life care, so there the justification is much better. But for benign disease, I think we need more studies. It is also much better than the enteral stent, which we are conventionally used to, because here we are away from the tumor area, which can ingrow into a enteral or a diurnal stent and can cause problems. So the issues with the EOS gastroenterostomy is whether we can use in GOO as a standard of care or situations where it's possible to do it and surgery is not possible, but when to remove it is another question. So these things would come up with passage of time, but there are some other issues which can come as the variations of the deuterogenostomy anatomy, which can be variable in several patients and upfront, you cannot say till the time you're doing it. And these can pose challenge. Also passing a lamps can cause be tenting, and this can lead to a misdeployment of the stent that we have not actually punctured the general loop and only punctured the stomach, and this can cause problems. So if once you realize it, you can quickly pull back and close the gastric defect. So several combination combinations are possible, but if you punctured both the stomach and the jejunum, then it needs a surgical intervention. Short of that, if it's only a gastric, then it can still be closed. Moving forward, radiofrequency ablation of tumor, Anthony showed there are several devices which have been there, that wire device and the USRA, which is a needle type device. Another one which was there for some time, has been withdrawn recently, is a hybrid from Irby because of the study. It's a very long device, and it's a tumor which are quite large, at least three centimeters or so. This is how it looks like. And the complication which can associated with this is pancreatitis, GI bleed and perforation. So we prevent pancreatitis by either using a pancreatic stent placed by ERCP upfront before the intended USRFA, especially if the tumor is very close to the pancreatic duct. And often almost we use endometriosis suppository as well. So this is how it works. This is the tumor and the PD stent is there inside. These cartoons show that. You go deeper down towards the deepest most part of the tumor and then keep pulling back one by one area. So it's different zones of the tumor which get ablated. You can do in one axis or you can do in several other axes as well. Let me show an example. This is a pancreatic neuroendocrine tumor, which is where we're using currently with a stent inside. You see that almost at the edge of the tumor, the duct is present, and that's why stent was placed upfront. And just like Anthony showed, we do the ablation using 30 watts. So this wattage needs to be set up front and has to be now more acceptance has to be made at what wattage is correct for which tumor. So you can go in different direction just like an FNA and keep fanning and burn. And the last slide. So in this area, the issues and unmet needs in USRFA is a safety. Yes, it is quite safe. And it's now been experience of several centers world over. It has been used as a treatment for PNET and both functional and non-functional. And I believe now it should come in the treatment algorithm of PNETs, although it's currently not there because of its pure safety. Like surgery, which has higher risk of adverse events, I think USRFA is much, much safer. For PDAC, whether we can use it or not, it's still a debatable area. We need to have a uniformity in the wattage that we use, contrast, and as Anthony showed that you can select the device length according to tumor size, very small, tiny tumors. This device of USRA is available in five millimeter, seven millimeters, 10, 15, and 20. So larger tumors you can use. So that entire length of the electrode should be within the tumor boundaries. The current bipolar devices, which are now coming available, may be safer, but we need to have a proper device or we withdrew it because of the sheer size, the larger size of the device was preventing us to use it in a smaller ones and microwave, which Anthony mentioned. So thank you very much for your kind attention. So I was touching upon each and every procedure and giving a little brief summary of that. Thank you. Nadeep, that was really an amazing spinoff on Anthony's earlier presentation. It's very difficult to juxtapose in this field, at this level, two very interesting viewpoints. Anthony showed us where we are and where we are going. And you showed us where the issues are and what the unmet needs are, which is exactly what the vision was for tonight's programming. Now, because we are a little bit behind, I'm going to actually rush through the new device exposition that GBang and I put together here. So this is essentially an attempt to showcase two devices that are not yet out there commercially available most anywhere. And hopefully we can have a discussion around it. A new VUS FNA solution, this is basically to suggest that the FNA needle process is cumbersome with the repeated access required, single passes and then multiple passes per session and the difficulties in certain lesions where you access them. So this is an attempt at creating an FNA needle that has multiple access points. So there is a central needle which is delivered through this handle here and then a release of four additional needles from the side into the same lesion at the same session. So you get five FNA samples from essentially one pass, if you will. So this is the one pass InstaFan needle. It's a brief video here, we'll see if this plays. Here we go, so this is basically a schematic to show the lesion, how the initial central needle is deployed and then with the actuation of the secondary handle, you have the four additional passes for a total of five passes. So key benefits here is basically reduces time, reduces overall procedure complexity envisioned, at least that's the concept and it potentially gets different aspects of a tumor, especially if there's a lot of desmoplasia in place and gets the job done relatively quickly. The needles are intended to be flexible and get the samples without too much effort. So obviously this type of a concept is somewhat disruptive compared to what we have now and over and above the diagnostic components, there's also potential for converting these needles into ablation treatments and delivery of therapeutics and so forth. So more to come on that, we'll have a discussion time permitting on this topic as well. The next device and there's actually this needle had an abstract at DDW 2020, where basically a proof of concept was shown in a porcine model and that was presented 2020. So here is, most of you may be aware of or heard about endosound, this is a concept where you can convert basically any endoscope, gastroscope ostensibly to an EUS scope with the use of this patented disposable device and technology. And essentially the idea here is to disseminate EUS technology and capabilities across a broader platform and given the capital intensive nature of the current EUS platforms out there. So this is a video demonstrating how the assembly is put together. This is not an unfamiliar platform here with the device head at the head of the scope. And then you have a transducer with a disposable housing, which is how this is assembled. And this gets connected to a beam former. So you have a standard gastroscope that then now becomes an echo endoscope, so to speak. So I'm just gonna see if I can move this forward. So this is the key part here is that you have the capability of making this, using this as a forward viewing or as an angulated linear echo endoscope. So that's the additional advantage. And of course the biopsy channel can be used to deliver the needle. The EUS images are comparable to the linear echo endoscope and the confirmation and the orientation is very similar. As you can see this slide. The transducer assembly is interesting. It's got a reusable, cleanable transducer right here and a disposable housing that is of course one time use. And that's how it comes. The beam former right here connected to a operating system. And then of course animal lab was performed with this device and you can see the celiac takeoff here with the standard equipment, the traditional platform and this is the endosome platform. And again, the comparison and the echo texture and the imaging is very similar, at least in this lab. And this video here demonstrates the endoscopic view entering the porcine esophagus and then how the system looks endoluminally. So very familiar views here. All right. Try to forward this here. And this is the video showing a pancreatic examination in the animal lab. Very similar to our experience with the curvilinear echo endoscope with the traditional platform. Just moving this along in the interest of time. This is a liver biopsy being performed using this novel device. And very similar again to our experience in the animal lab with the standard platform. And then of course the view of the needle which is all important as the needle exits the endoscope you can see it right here. So not too complicated, at least as presented here. So, and then the Doppler capabilities are very similar as well. And this is the outcome of the animal lab with a bunch of folks at varying levels of expertise ranging from KOL level to novices and the output was described as fairly acceptable. So I'll stop there. And gee, I know we have to do some questions and we have just about enough time to get that going. A lot of the questions have been asked and answered on the chat menu because our panelists have been very good about answering the questions but I'll just call out some of the questions in case people are not reading the comment sections. And basically one of the questions was what to do for patients with benign gastric outlet obstruction? When you do an US guided gastroenterostomy whether you keep the stents in place indefinitely or if not, then how long for and when you would choose to exchange the stent, if at all. Sandeep, Anthony, either of you please. I think Anthony can answer it better, he's a surgeon. But these stents can be kept for a long time. Personally, we have seen that one patient had a stent for two years and I recently reviewed a paper from Takao who had a stent for five years and the stent being patent still. Having said that, we have removed some of the stents and the anastomosis remains open but it can stenose with passage of time and one patient required a replacement with another Axios. Anthony, your take on that. So for benign conditions, of course we need to balance the condition of the patient how long the disease will continue to cause the stricture and also whether the young patient is young, low risk for surgery versus a older patient which may have multiple comorbidities with high risk of surgery. So for young patients, of course I think we would still prefer a bypass laparoscopic gastroenterostomy. There are some situations that, for example in the patients with a lymphoma causing a duodenal obstruction and we've performed a gastroenterostomy and the patient came back with a complete responded tumor. And then we would need to consider a long-term gastroenterostomy. As Sandeep has suggested, we can place the stents for a long time but if you put it for a long time you need to be aware that the silicone does tend to come off and it becomes a uncovered scent and efforts to remove an uncovered scent may be very difficult. So for us, we tend to be on the safer side. If we need to keep it for a long period of time we would place it for one year in exchange after a year. If we remove it, I think it tends to close down. Then you need to balance the risks of a need for recurrent intervention versus the chance of a permanent fistula. I think it depends on the age of the patient as Anthony mentioned, and also the chronicity of the disease process at hand. I think, so that's the answer there. But I think, I still feel that I think the relative simplicity of a duodenal stent needs to be kept in mind. And a lot of these patients who end up with duodenal stents don't have unfortunately a very long lifespan to live. The time is short. So Sandeep and Anthony, any comments on the new technology that we showcased tonight? Rose, Collins, concerns? I think that both look very exciting. There's a multi-pronged FNA. Only fear is that we are seeing an EOS only one plane and these can go in different planes. So there can be a risk of injury to the neighboring vital organ. That's a very good point. Anthony, any comments? Well, I think to be a technology that can replace a regular FNA, I think we need to overcome the deficiencies of FNA first. Nowadays, we are seeing all these FNB needles and it does allow us to get a very nice white core even with a single pass. That's true, I think, yeah. I think the issue becomes is that, you need a lesion of a sizable nature to accommodate five needles at the same time. That's one. Secondly, I think there's a wide variation in the diagnostic yield of FNA between someone like you and someone who's relatively early in their experience. And then of course the desmoplastic and other post-radiation factors in the lesion may also count. So there may be value here. We'll see where this goes. Any comments on the universal endoscopic, endosound technology, which converts every scope to an EOS scope? That's phenomenal, actually. That's out of the box thinking. Yeah. Yeah. Anthony, do you have anything to add? Yeah, ISAC have shown me a video before as well. Yeah. I think to gain usage in the wider scale, therefore there, we need to overcome a few hurdles, costs and also the quality of the EOS. So yeah, I think for a regular EOS scope is really expensive. And I think only in major centers that could afford the device, you could purchase it. So if it can come with a really cheap cost and if it allows you to plug into any ultrasound units, definitely be attractive and it fits in the regular scope. And of course the puncturing abilities as well as interventional abilities. So if you can perform drainage procedures with a device, definitely very attractive as well. Yeah. I think, and also for difficult to access areas, right? We still have issues in luminal anatomy where we cannot get with EOS. So I think those are all good comments. Very little time is left now at this point. The presentations were amazing. You guys have answered a lot of the questions already and also given some excellent pointers like longer for hepatic gastrostomies, pancreatic stents before you do ablation, the concept around wattage, when to remove these stents, all of those caveats hopefully have been very useful and this will be an enduring recording on GI leap. So people can go back to all your pointers and pearls and take heed from that. So at this point, I wanna formally thank both of you for your excellent presentations. The hour and change went by pretty quickly. Ji, thank you for your co-hosting tonight as well. And at this point, I would like to turn it back to Ed Dellert so he can close out the event tonight and thanks again, everybody. Ji. Thank you. Thank you, Dr. Cal and everybody on the faculty. You did a fantastic job and I deeply wanna extend ASGE's appreciations for your dedication to the field and especially your presentation during odd time zones around the globe. So thank you. All of your presentations and discussions were fantastic. In closing, I would also wanna thank the participants tonight. Before you log off, we would greatly appreciate your feedback on tonight's event by going to the network lounge in the platform and completing our evaluation. I promise you, it only takes about a minute or two to fill that out and your input is greatly appreciated. This does conclude our presentation. And just as a reminder, you can access our recording of this webinar by logging into GILeap by going to learn.asge.org. Just as also another reminder, you do not have to be an ASGE member to access this content as our goal to provide all of this information from our Thursday night webinar topics as an open source resource to all gastroenterologists globally so that they can improve their practices with the latest information. Finally, I just wanna remind everyone that next Thursday we will be doing our global spotlight webinar on August 26th at 8 a.m. Central on the topic of indications and patient selection for colonic stenting by Dr. Mauro Flo from Brazil. And we're looking forward to his presentation as well. So once again, thank you all for your participation and have a wonderful evening. Good night.

EOS Around the World

Interventional Endoscopic Ultrasonography

EUS Devices

Stent Design Characteristics

EUS-Guided Drainage Procedures

EUS Interventions

Biliary and Pancreatic Duct Intervention

Tumor Ablation

Direct Endoscopic Necrosectomy

Portal Hypertension

LAMS

Advancements in Managing Endopathology