SPEAKER 1: So the patient presented to the emergency department five weeks ago with severe abdominal pain. The workup revealed acute pancreatitis. They come back now with continued abdominal pain. CAT scan imaging shows a six-centimeter collection at the tail the pancreas.

OK, so they're referred to you for therapy. So if you wouldn't mind assessing the patient, seeing if there's a reason to intervene, we can proceed.

All right, so as you assess the patient, you want to confirm that there is no vessels in the way. So it looks like there's a vessel here you want to stay clear of. OK. So advancing the scope gets you clear of that. I think if you torque, you might find a little bit larger dimension to work with.

There you go. I like that better. So I've got the wet gauze. Activate the hydrophilic coating by pulling the catheter through the gauze. You can pass that down the channel.

SPEAKER 2: Oh, wow. The light glass helps.

SPEAKER 1: Yeah, it does. It's pretty dramatic. So you'll grab it with two fingers. A little bit higher so yeah.

And now you can use one of those spare fingers not doing anything to tighten. It'll allow me to attach the active cable we've got on the Erbe 300. We have an Auto Cut setting at 100 watts of effect number five. There is no coag.

So again, line up your target. This looks excellent. Of course, the device will come from the top right and pushed to the bottom left. So to begin, your elevator lever is going to be all the way open. You can lock your wheels if you like to facilitate this.

And then begin by unlocking the catheter lock. And with a large black hub, advanced the catheter tip until we see it on the Echo-Screen. See, it's very echogenic. They've got a nice pathway. Allow me to measure the tissue thickness.

So I want to go from the tissue here inside the collection directly to the tip of the catheter-- 3.8 millimeters. It's within our 10-millimeter guidelines, so you're in good condition to advance the catheter.

So what you'll do is using the yellow pedal, you'll first step on the pedal. And a moment later, you'll advance the catheter smoothly letting the cautery do the work. So proceed. Off the pedal.

We see evidence of the catheter tip inside the collection on the EUS screen. And then you can' stop the energy delivery. And then advance the catheter as deeply as you can.

You've got the tip here all the way to the wall there. The deeper, the better. Remember that the stent will foreshorten. You need at least 3 and 1/2 centimeters inside the target.

Lock the catheter. With your thumb, peel the yellow safety clip down. And the deployment of the first flange done by unlocking here, thumb on top, two fingers underneath, pull until it stops. It has that automatic stop built in to prevent accidental deployment of the stent inside the collection.

Now, using the Echo image, maintaining this view, we've got a view of the catheter coming through the tissue. And then the angle where the shaft of the catheter meets the flange of the stent. If you use the handle to reposition this, you want to move that angle right here to the puncture site.

Now, as you put traction on this, this puncture site can move. And usually moves towards the mouth of the working channel. So I'm going to mag in so we've got an excellent view of that. So slide that open.

And with your thumb, push upward slowly. And you'll watch as the first flange approaches the inner wall. Slow down and stop. You notice now that that angle is right at the puncture site. You see the first flange is opposed to the tissue below the transducer. Lock the catheter.

You are ready to deploy the second flange. You'll accomplish that by unlocking here. And again, thumb on top, two fingers underneath.

I'm going to sabotage you. I want you to see what it looks like when that's not locked. You notice how it's moving away? That's enough motion for you to recognize that something is amiss.

You'll come back down to this portion, push it upward to bring the stent back where you had it originally, lock the catheter, and finish the deployment. Again, by traveling it slowly the first centimeter, you have time to recognize that that error and correct it before it's a disaster. So you notice there's no motion of the stent.

So now, the second flange is released, and it's inside the scope. What I'd like you to do now is physically take a step back and then bring the scope with you. So now, you're going to use your left hand to put tension on insertion tube while simultaneously using your right hand to push the catheter downward and expel the stent from the working channel. So slide that open.

Now, with your left hand, you're going to tip towards you, so you're putting traction. If you look at the insertion tube, you're at about 43 centimeters. So you'll tip towards you with your hand, and it's atttraction.

SPEAKER 2: Oh, I see it.

SPEAKER 1: So it's a simultaneous exchange. As you're pushing down, you're pulling back-- go slow. We can see the second flange is starting to open right underneath the transducer. This is absolutely perfect.

The second flange is now free. You can see very clearly on the EUS screen pull your scope back another centimeter, and it will be completely free of the scope. Voila.