EUS & ERCP Master

The biliary "variant" framework undersells how individualized biliary anatomy actually is. Unlike vertebral count or hepatic arterial trunks, bile ducts develop via stochastic branching morphogenesis. Every cholangiogram is one of a kind. Thank you for coming to my TED talk.

Si haces EUS-gastroenterostomía en estenosis duodenal infranqueable: ocluye el píloro con balón para distender el asa yeyunal. Facilita colocar el LAMS. Detalle técnico que marca la diferencia. 🔗 doi.org/10.1055/a-2852… #EUS #Gastroenterostomía #TipEndoscopia

Dos casos de coledocolitiasis diagnosticados por ultraaonografía endoscópica , luego de resultado de resonancia negativo y persistencia de sospecha diagnóstica .

EUS-guided transpapillary vs transluminal biliary stenting: randomized comparison of long-term stent patency Find the article at: doi.org/10.1055/a-2721… Vinay Dhir et al.@ESGE_news @docdhir

28/F with 2.4 cm cyst in head of pancreas. EUS shows a nodule within cyst which takes up contrast. Biopsy shows abundant mucin and columnar epithelium. MPD is not dilated. Surgery or observe? #GITwitter

Como que tremendo nódulo mural ??

Chong et al compare "Contrast-enhanced endoscopic ultrasound versus conventional endoscopic ultrasound–guided fine-needle biopsy with macroscopic on-site evaluation for solid pancreatic lesions: a multicenter randomized trial." giejournal.org/article/S0016-… #GITwitter

Nice video from a freehand EUS guided gastrojejunostomy in the setting of malignant outlet obstruction. We did a NAJA assisted EUS GJ this week (first EVER in the state of Colorado!). Suspect NAJA will be preferred way to do these. #gitwitter #surgery @bsc_endoscopy @KristenHaeck

Drenaje transgástrico con stent de doble aposición, por colección pancreática posterior a pancreatectomía distal

🦓PanNETs @BJSurgery Commission: G3 PanNENs 🔬G3 NET vs NEC is EVERYTHING 🧬Molecular profile (MEN1, DAXX, ATRX) can help risk-stratify 🔪Surgery only for highly selected localized G3 NETs ⚠️Recurrence expected: systemic therapy 1st 🔗tinyurl.com/58zu6dzr @spartelli

🦓PanNETs @BJS_Surgery Commission: surgery in NF PanNETs >2 cm? >40% recur within 5 yrs‼️ 🔬Need to define "borderline resectable" biologically, not just technically 💊Preop therapy 🔑 to test biology & downstage 🔗tinyurl.com/58zu6dzr @spartelli

PanNETs @BJSurgery Commission: operate on small NF PanNETs ≤2 cm? ⏱️With typical features - observation safe 📊PANDORA & ASPEN: rare progression, no survival compromise 🔪Surgery for atypical features (MPD⬆️, heterogeneity, ⬆️nodes) 🔗tinyurl.com/58zu6dzr @spartelli

EUS liver examination: Portal pressure measurements 1. Targets are portal V, Hep V from the stomach (see prior tweets on identification). 2. Use 25G FNA needle, heparin flushed, 3 measurements. 3. We prefer umbilical portion of PV, middle hepatic vein for measurement.

Continuing our liver journey: After identifying Middle Hepatic vein (prior tweet), pull back, clockwise torque--> 1. Right hepatic vein branching from the IVC 2. Segments 1, 7, 8 are identified All the targets for portal pressure measurements are visualized (more soon!)

EUS exam of left liver continues along left portal vein 1. From umbilical portion of PV-> Clockwise torque 2. Reach Ligament Teres: Hyper echoic, connects PV to IVC 3. Push in, visualize middle hepatic vein: "Elephant Trunk" With this entire left lobe is examined!

Eight Couinaud liver segments are difficult to remember. Try my technique, let me know if it helps! Basically they are similar to the numbers on the clock 🕝 with "6" being the lowest segment and on the right My handdrawn figure to help understand (or to amuse) better

Identification of liver segments on EUS relies on vascular anatomy: Portal vein & Hepatic vein. To recognize them: -Perpendicular to one other ie. if PV is appearing longitudinal, HV will be circular -Flow on doppler -Crucial for identification of liver segments

1st station of EUS liver examination: GEJ: remember the clock! Our movements are clockwise. 1. Identify the left hepatic vein, P2,3 above it. 2. Follow P2-P3 to the umbilical portion of portal vein 3. Identify ligamentum teres We just examined three segments of the liver!

BLEEDING FROM GASTRIC VARICES => Acute phase: pre-emptive TIPS ↓ rebleeding risk vs. SOC => Acute phase: EUS-guided obliteration ↓ rate of rebleeding /re-interventions => Definitive: p-TIPS preferred, BRTO and EUS-guided treatment according to anatomy and expertise #BavenoVIII

Sphincterotomy necessary to prevent pancreatitis before placing metal stents ? SPHINX trial: 10.1136/gutjnl-2024-332695 🏅PEP: Sphx group had 17% vs no sphx had 21% 🏅 No superiority found 🏅Trial terminated prematurely due to the results