1/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts"> Some tips for a safer, faster, and easier EUS-gastroenterostomy (EUS-GE)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✴️" title="Strahlen-Stern" aria-label="Emoji: Strahlen-Stern">an interventional EUS procedure used for malignant gastric outlet obstructionhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✴️" title="Strahlen-Stern" aria-label="Emoji: Strahlen-Stern">

#EUS #AdvancedEndo #GITwitter

(All media posted with permission)

2/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Patient selection is key
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen">If life expectancy is < 3 months, we believe risks of EUS-GE outweigh benefits https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">choose duodenal stent
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> If > 3 months, go for EUS-GJ

@BilalMohammadMD @NickMcDonaldMD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895656/">https://www.ncbi.nlm.nih.gov/pmc/artic...

3/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Study pre-procedural imaging carefully
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> You want to see a distended stomach with D3/D4 coursing immediately inferior to and adjacent to gastric body

In this CT slice, the IR placed GJ tube is a nice guide as to how D3/D4 courses in relation to the stomach

4/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Place the pigtail of your naso-biliary drain at the ligament of Treitz
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> This is your ideal puncture site to maximize your window for deep insertion of LAMS catheter (which will minimize AEs)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen">Connect NB drain to water pump and infuse saline, contrast, and methylene blue

5/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Use fluoro to guide EUS-scope to ligament of Treitz
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> On EUS, this is where you will find your best window with a long "runway" to hub your LAMS catheter and ensure complete opening of the distal flange (4.7cm here!)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> Continue to infuse fluid up until moment you puncture

6/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts"> Use a 15mm, not a 20mm LAMS
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen">Anecdotal experience suggests that patients with a 15mm stent do just as well and can tolerate a near regular diet
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen">The outer flange diameter of 24mm vs 29mm gives you a larger margin of error to fully open distal flange in a tight space

7/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Always puncture freehand, never over a wire
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> Slow and steady (not like an FNA), let the cautery do the work
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen"> Deploy distal flange only when catheter within a thumbs length of being hubbed
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✔️" title="Fettes Häkchen" aria-label="Emoji: Fettes Häkchen">Deploy proximal flange in scopehttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">big wheel away https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">unlock catheterhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">push LAMS out

8/9
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👉" title="Rückhand Zeigefinger nach rechts" aria-label="Emoji: Rückhand Zeigefinger nach rechts">Hold your breath, and wait for the methylene blue

Congratulationshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="‼️" title="Doppeltes Ausrufezeichen" aria-label="Emoji: Doppeltes Ausrufezeichen"> https://abs.twimg.com/emoji/v2/... draggable="false" alt="👏" title="Applaus-Zeichen" aria-label="Emoji: Applaus-Zeichen">

9/9
Of course, EUS-GE should only be performed in expert hands where surgical backup is readily available

Anticipate problems and how to troubleshoot. This is a great video by Shayan Irani highlighting various rescue maneuvers ( http://learn.asge.org"> http://learn.asge.org  https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> 2018 DDW Videos)