This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. This is an option for patients where we do this EUS guided fistula that we create, which is between the gastric pouch and the excluded stomach. And we basically put aluminum posing metal stent, which as you guys have seen, is being used for all kinds of things, gallbladder drainage, drainage even into the liver, gastro jejunostomies and things like that. So this is a pretty nice slick approach to create a fistula where we can then go down and do a standard ERCP. It tends to be not that technically challenging if you've placed these for pancreatic fluid collection drainage. So it's kind of a slick little thing. So I'm just going to show you a video, I think. So this is just a picture of the anatomy here. So having the gallbladder and that's not correct. This would be in patients who don't have a gallbladder in. So you're basically going down with the EUS scope into this pouch and under EUS guidance, this is the fluid filled remnant stomach. Sometimes it's not that fluid filled, so you can take an FNA needle and inject it into the remnant stomach and inject fluid into the stomach. So you can fill it up so you can allow the stent to, the space to be seen. So here you can see we're injecting fluid into the remnant stomach to distend it up a little bit more. So here it looks like your basic pancreatic fluid collection. And then once we do that, you can put a wire across, you can do it with wire or without wire under fluoroscopy. You can also put contrast in where you can see the rugal folds, although sometimes that's a little hard because you need a lot of contrast to fill up the stomach since it's such a large space. In any case, in this video, they were having trouble getting the stent into the stomach. So instead they decided to go in with the old tome and make a hole and then introduce the luminoposing stent. So here it is with the first flange deployed, and then you pull back your stent and then deploy the second flange, which you'll be able to see endoscopically here is the second flange being deployed. And then you're going to pull this device out. And because it's not free peritoneum and it's just a staple line generally, and there's scar tissue in between, you can go in single step, do the dilation now and do the ERCP at that same time. So here they are dilating the luminoposing stent. You can see it under fluoro, you put contrast into that balloon and dilate it up to, there are now 20 millimeter diameter stents, there's 15 and 20, but 20 is easier because the scope will easily go through. And then there's the wire that's from the dilation and the initial lambs. And then you can see there's the lambs here with the two arrows. And then basically you just go down and do your standard ERCP. Now depending upon what you end up doing, we typically just leave the lambs in and bring the patient back in a month and we can remove it and then try to close it. You can also try and close it at the time. So it depends upon what you do and whether you're going to need to do a repeat intervention.

EUS guided fistula

gastric pouch

excluded stomach

aluminum posing metal stent

ERCP procedure