Thank you for having me back. So I have a lot of slides, and I will try my best to keep us on time. I have no disclosures. I just want to thank Dr. Parra-Pakka for letting me use a lot of her talk. So I want to discuss complications of various endoscopic procedures. We'll keep it pretty much bread and butter, colonoscopy, endoscopy, talk mainly about risk factors, prevention of complications, and then once a complication happens, kind of like that, oh, shoot, what do I do next motion. So let's start by just defining an adverse event. It can be an injury that results from medical management rather than the patient's underlying disease. Realize that adverse events from our procedures may start even in the pre-procedure environment. So frequently, or maybe less than frequently, we have patients who call me in the middle of the night. I had a syncopal event during my bowel prep. We've had patients who've had syncopal events in our waiting room. So it may not even be related directly to the procedure. Unfortunately, serious side effects that we all really worry about are any life-threatening experiences, any untoward events that lead to hospitalizations or exacerbations of their current comorbidities. Start by informed consent. I cannot underline the importance of this, right? You are sharing the risk with your patient. Do it yourself, right? When you're new and attending, don't rely on your fellow, your APPs, nothing against you guys. I always want to make sure that I am discussing the specific risks of the procedure with my patients myself. You want to include proper procedure indication and also, you know, what are the risks of the procedure as well as the alternatives. You know, if we don't do this procedure, what are some of the other things that we can do, right? So ERCP versus MRCP, the risks and benefits of both procedures. One thing to not, don't forget to include are, you know, risks of am I missing a lesion, any splenic injury or respiratory events, which I think are easily left off of informed consent. Sedation-related complications are an important event to highlight. Fortunately, overall pretty rare. Cardiopulmonary unplanned events happen in less than 1% of the time. Risk factors include older age, sicker patient, right? These are your ASA 3, 4 patients. The type of anesthesia does matter. There have been studies in the past that show that with monitored anesthesia care, it sort of confers an increased risk of all types of complications. Are you guys mostly sedating with ModSed, anesthesia, a combination of both? Both, okay, great. And also, you know, on inpatient service, you know, the hospital team is paging you, you know, when can you scope my patient? You're like, well, they're kind of still on like 15 liters of O2. They're not actively bleeding. So maybe let's hold off for a day or two, let their respiratory issue settle out and then, you know, we'll reevaluate the patient. So let's jump right into colonoscopy and perforations. So fortunately, overall very rare, 5.8 per 100,000 colonoscopies. When you do more therapeutic colonoscopies, removal of large polyps, that can go up to 10%. When you do have a perforation, you know, morbidity is 40%, mortality is anywhere from 5% to 8%. Specific risk factors on who will perforate, IV patients are eight times risk, patients who've been on steroids, older age of patients, whether that is, you know, due to a more difficult procedure, sort of lax abdominal wall and colonic wall, you know, strength, obviously higher ASA class, just point towards a sicker patient. Female patients tend to be, you know, historically more difficult to scope. A lot of my practice is scoping, you know, tiny little women that can be challenging at times. Also with any prior abdominal surgery and diverticular disease. So procedural risk factors, right? We've all been there. Severe looping, you know, you're introducing a lot of scope into the patients. Sometimes that can lead to an incomplete procedure, right? We've all been there as well. You have most of the colonoscope, if not all the colonoscope, like hub towards the patient and you're still nowhere near the C-comb. There's one favorite line from an attending I heard once, it's like, no, you've not run out of scope, you've run out of talent, right? So I say that all the time now, I think it's quite interesting. I don't know, I mean, I don't mean any ill will, so I think it's kind of funny. Poor preps, obviously, you know, any limitations on your visualization, just I have a low threshold just to abort, you know, you're torturing everybody in the room. Specific interventions also confer a higher risk of perforations with EMR, ESD, any type of stenting that you're doing and dilations, whether it's IBD related or related to an asthmatic stricture. Right colon C-comb location has a higher risk of perforation and also it's endoscopist specific as well, right? So any person with a low volume and they've also shown that surgeons and non-GI physicians doing scopes have a higher incidence of perforations. Why do we perforate? So A, direct mechanical penetration of the tip from the bowel wall. So commonplace for this to happen is in a tortuous sigmoid colon, sometimes, you know, you kind of have to like blindly wiggle your way around a turn, right? And be careful with that, you know, really don't push too hard unless you know for sure what's on the other side of that turn, you're going to see more movement and that will come with experience. B, the bowing of the loop of the scope may cause sufficient lateral pressure to perforate the colonic wall, right? So if you are seeing that you're not getting forward motion and again, you're putting in lots and lots of scope, just be careful about what that scope is doing internally that you're not seeing, right? So you're forming a loop somewhere and just be careful that you're not putting in too much scope. And again, if you're having a hard time, don't repeat the motion. I remember as a fellow, your attending is like, what are you doing? You've done that like four different times. B, try something different, right? So just don't try to keep putting more and more scope in. Move the patient, you know, under your loop, et cetera. C is perforation can occur along any pathologic area of the colon, strictures, severe diverticular disease, tumor, if you're not going to get around a cancer, don't try to force your way through it. Barotrauma is something that is very important to recognize as well in a difficult syngmoid colon. Try to utilize less air, less CO2, and use more of like a water immersion or a water insufflation technique. And E, obviously, any direct therapeutic intervention that you're doing within the colon itself, polypectomies, any advanced resection techniques, stent insertions, and dilations. Presentations of perforation. So thankfully, you know, where downside is usually you'll know these patients are in your recovery area. They are writhing in pain, they are comfortable, they are diaphoretic. The remainder of the patients will typically present within pretty much, you know, the first 24 to 48 hours. Delayed perforations are rare. Diagnosis, usually we send these patients, you know, if it's in our surgical center, we call rescue, we send them over to the hospital and they get scanned right away. If you're in your hospital scoping, you know, go send them to the scanner to really rule out perforation and also to kind of just, you know, determine the localization of your perforation. So prevention of perforation. So this talk mostly focuses on, you know, how to prevent complications happening, right? You guys will get a lot of hands-on experience with the clips and other advanced closing techniques in our skills lab. So one, don't push against any fixed resistance, right? That kind of makes sense. Something's about to happen. If you're not going to go forward, all that pressure that you're exerting is going to bounce off somewhere else on the scope. Scope selection. We heard a little bit about this during the ergonomic talk. I tend to use a smaller scope so I'm always scoping with a PD colonoscope. Doesn't matter if you are, you know, BMI of 18 to BMI of 75. My techs, my nurses know my choice of scope is always a PD scope. We know that the force generated by a scope of a lesser diameter is always less than a scope of a bigger diameter. It's also, for me, ergonomically, way more comfortable because my wrist does hurt at the end of the day scoping with an adult colonoscope the entire day. Be careful with air insulation. Use water in difficult scopes. Have you guys seen this all yet in your scoping? Sort of that highlight, that cat scratch of barotrauma. We see this in the CECOM. Sometimes it's a surprise finding. Like I get to the CECOM and I'm like, oh, well, I didn't expect that because it was a pretty straightforward and easy scope. Safety and polypectomy. My new mantra is try to minimize hot resection as much as possible. Cold snares you should definitely use for polyps less than a centimeter in size. And depending on the polyp morphology, et cetera, you could consider using cold snares up to about two centimeters in size. Avoid the use of hot forceps. So if you are using snare cautery, you want to make sure that you're providing an adequate lift when you're trying to remove your colon, whatever lifting agent is at your institution. I recommend giving yourself a really good buffer or a cushion. Avoid the use of really large snares. I think it's easy to grab the biggest snare you can think of. But sometimes that gets in more of the muscularis propria layer. So a lot of times I'll get a snare that's just about the size of the polyp and just trying to wiggle my way around the polyp and try to maneuver the snare around the polyp rather than like getting this huge polyp and then closing it all together. Adjunct techniques including jiggling of the snare, tenting, right? So you want to just like, once you grab your tissue, pull up a little bit and then have your tech or nurse just kind of like lightly open and close the snare a little bit. Any potential like muscularis propria layer kind of just like fall back down. Underwater EMR is also a great technique where you're essentially flooding the colon with water and this way it brings the mucosal layer sort of free floating within the water and it safely separates out the muscularis propria layer for you to do your EMR just within water without having to lift. And then if you have any non-lifting polyps, you want to think about alternative methods of resection as that's evidence of submucosal invasion. So these are your full thickness resection devices that you could try to implement or refer to your advanced endoscopist for removal. All right, so after every polypectomy, you guys should be sort of just looking closely and examining your polyp base. So the best view are type 0 and type 1 lesions where you sort of see like that blue without any evidence of deeper muscularis propria involvement. When you start seeing target signs is when you're thinking about a deeper thermal injury and concern for frank perforation. One thing is don't panic when you see this. Try to finish your job, right? You went there to take out that polyp. Try to complete the polypectomy and then close and seal up your perforation with clips, suturing devices, et cetera. So perforation management, be proactive, right? Look at your resection site, recognize your complications early, stay calm. You are in charge of the atmosphere in the room. If you are yelling at your staff, sort of running around with a chicken with its head cut off, your staff is going to feel that energy as well. So it's your job just to try and just stay as calm and collected as possible. Call for help if needed. If you need to find an advanced person to say, hey, what would you do in this scenario? Go for it. I'm in a practice where, you know, my partner who's been in practice for 30 years will call me into a room and vice versa. Like we have no qualms about sort of bouncing ideas off of each other in the middle of the case. Hey, look at this polyp. How would you take this off, et cetera. Switch to CO2 if you haven't done so already. If you have access to CO2 in your endo unit, I recommend just using CO2 for all cases. And fortunately, never had to do this, but sort of this is a video of just decompression of tension pneumoperitoneum. Start these patients on broad spectrum antibiotics. And I always, always, always involve my surgical colleagues. You just never know what directions patients will turn. So surgical management is for patients with, you know, large tears, anybody who's hemodynamically unstable and any patient who comes in post-procedure obviously with a delayed perforation. Endoscopic closure is very successful. You'll have a variety of tools and toys at your disposal depending on your future practice sites. Outpatient surgical centers may just have clips and none of the more advanced over the scope clips, suturing devices, some of the other devices that you guys will be hands-on with such as the Mantis Clip or the X-TAC, just mainly due to a cost issue. So closure of defects, I would say just get comfortable using clips. That's what I use 99% of the time, right. Over the scope clips can be helpful as well, suturing device. If you find yourself with a very large defect and all you have are clips, one thing that you could use is just put clips, you know, sort of opposing your lesion and then grab an endo loop, kind of go all around the clips and kind of cinch the endo loop tight just to bring everything together. But then again, it also depends on how well-trained your staff is in using endo loops, right. I never advocate like a defect as a time to figure out, all right, what do I do? Do I open? Do I close? For endo loops. Bleeding in colonoscopy happens 2.4 per 1,000 colonoscopies associated with larger polyps and just taking off more polyps. Any clinically significant bleeding, drop in a hemoglobin, you know, patients who report that their bleeding isn't stopped should prompt a hospital admission. Risk factors are the use of cautery, the size of the polyp, you know, location in the right side of the colon, any ongoing antiplatelet or endocoagulant use. Prevention, again, I love using cold snares for smaller polyps. Adhere to guidelines for periprocedural endocoagulation. I always involve the prescribing provider for this. You don't know which patients are high risk. I don't want to be in charge of managing a bridge with, you know, low molecular weight heparin, et cetera. Try to close any mucosal defects in non-pendunculated polyps over two centimeters. Avoid using hot forceps, especially in the right colon. And then epinephrine injection prior to polypectomy. It's helpful in pendunculated polyps, but not so much in non-pendunculated polyps. I use epi mostly to shrink the polyp on my way in. So if I see a very large polyp that I know will be resecting, I inject the polyp, I inject the stock, go to the secum. By the time I come back, it's shrunk down nicely for a safer removal. So bleeding management, a lot of times, if you're just oozing a little bit after a cold snare, those will just usually stop on their own. I've started adopting the technique of just holding direct pressure with the tip of the scope in my practice. So my nurses will be like, what are you doing? I'm like, I'm holding pressure. And so it usually inevitably works as well. You can also suction the mucosa into the scope, just chit-chat with your nurses for a couple of seconds and then let go, and your bleeding generally stops. Abdominal pain is quite common. Patients will have pain, bloating, and up to everybody in recovery is gonna have some abdominal discomfort. Certainly the incidence of this generally goes down if you're using CO2. How many people are strictly using CO2 in your practice currently? All right, that's great, that's fabulous. Does anybody use air also? Okay, so in our practice, we have air in our surgical center. We've been talking about getting CO2 installed. It's important that once you're done with the procedure, you try to suck out as much air as possible. One tip that I picked up from one of my partners is that, you know those nasal trumpets that anesthesia uses? So cut one so it's about your finger length, use some lube, and just insert per rectum to patients in recovery, and usually that'll help them just decompress fairly quickly. Some patients are shy about passing gas, but this just really lets the air out. And then positioning, a lot of times the nurses will have them belly and head down on the stretcher, and you're like, oh no, this patient can't pass gas right now. Post-polypectomy syndrome is something to be aware of. It's relatively low in incidence, or relatively not reported. Associated with more hot snares, advanced resection techniques. Actually had a patient last week on service who came after their colonoscopy. Their presentation can be similar to a patient who has perforated. They come in with severe abdominal pain, peritoneal signs, fever, and just looking unwell, and management, so you're gonna scan these patients, obviously, and the injury is not a through and through mucosal injury. It is local peritonitis caused by a deep tissue burn, essentially. So management is you're gonna IV hydrate these patients, keep them NPO, start IV antibiotics. Once their pain is resolved, it generally can take two to three days sometimes. That's when you can start advancing their diets, and then switching them to oral antibiotics to finish a course at home. Be aware of splenic injuries. It happens in about five per 10,000 colonoscopies, and women are more susceptible to splenic injuries. Mechanisms can be direct trauma from the scope. It can be from applying of abdominal pressure. So whenever my techs or nurses are giving pressure, I never, especially if they're a new tech, new nurse, just say don't give pressure in the left upper quadrant. These ligaments can pull and tear, especially if you're doing a reduction maneuver, so be really careful how aggressively you're reducing your scope. If you talk to the colorectal surgeons, they say that even after routine colonoscopies that the patients are undergoing surgery for other reasons, they see frequently injury to these ligaments. So it's probably more common than we realize. Obviously the worst case scenario is a splenic rupture. These patients are generally in pain. They can be hypotensive in your recovery unit, and so obviously don't need co-management with surgery. Miscellaneous complications, infections, or transient gas explosions have been reported with APC and poor bowel prep, so you want to make sure that your bowel preps are good, and then also be careful with choosing who gets a stent placement as they're associated with perforation and migrations. This is a big one, I think, missed lesions, and so especially as you're going out into practice, the missed rate for polyps over a centimeter are two to 6%, and less than one centimeter polyps, up to 26%, all right? Five to 8% of colorectal cancers are all interval cancers, meaning that they've had a colonoscopy within the last three to five years of diagnosis. Interval cancers tend to happen more often in the right colon than the left colon, so good practices are, right, have at least two looks in the right colon, or really try to retroflex in the right colon, which is why I also use a pediatric scope. I find it easier to retroflex in the right colon, and I try to do that in every single patient. Sometimes I'm doing both back and forth. Keep track of your ADR, that's super important. Once you start your own practice, if your institution keeps track of it, that's fabulous. If not, that's something that you want to track on your own. In my practice, everybody's ADRs get tracked. It gets emailed out on a quarterly basis, so we have a little friendly competition. And spend time looking at the colon, right? The more time you spend looking, the more things you will find. EGD, diagnostic EGDs, perforation rates are overall rare. Risk factors are, you know, any malignancies, EOEs with stricture. I remember this one patient I had to have an EUS, and I put down the scope, it was fine, and then when I was pulling out that linear scope, it was just like this, there was this huge tear from like the GE junction all the way up to the proximal esophagus. She had no dysphagia, nothing. So I think some of the EOE dilations are some of the more like tachycardic that I get. Sedation-related side effects, just be aware of that as well. EGD with dilation, really try to follow your rule of threes, and I think that's gonna help keep your dilation safe and minimize perforation as well, right? So that's where you assess like how narrow your stricture is or what size dilator you're starting with, and really just going up to a maximum. So let's say you're doing, you find that the stricture is 12 millimeters, you know, stop at 15 millimeters for your dilation. There's really no clear association between the type of dilator used, so if you're comfortable on balloon, wire-guided savory, there's no benefit of one over the other. Perforation management, you know, clips, suturing. I think stunting, talk with your thoracic surgeon. That's sort of your, obviously gonna be your backup. Sometimes when you deploy an esophageal stunt, the radial force can actually worsen a perforation, so it's always a conversation to have with thoracics before putting in a stunt. Foreign bodies and food impaction. This, I updated this yesterday because the CT scan was something that my partner pulled out yesterday from the proximal esophagus. So we're from Rhode Island. Shellfish is involved. Does anybody see what is going on in that CT scan? Yes, so this was a mussel shell about three-ish centimeters, and the patient was eating pasta with mussels, and I don't know, I mean, I saw the fragment once he removed it, but it was large. And so foreign bodies are those things where we get woken up in the middle of the night to go in, sort of timing from impaction to EGD is important. You wanna keep that under 24 hours. Higher risks are obviously anything that is sharp or has bone and large foreign bodies. I always discuss with anesthesia, are you guys able to call in anesthesia at night? Great, perfect, about the best plan from a sedation perspective. Briefly touch on ERCP. So the biggest, one of the bigger risks is post-ERCP pancreatitis. Overall incidence reported as high as 9.7%. Higher risk patients, that risk goes up even more. So these tend to be younger female patients with normal bilirubin, and also patients who've had prior recurrent pancreatitis. For those advanced-minded folks, safe techniques always are helpful. That's something that you'll learn in your fourth year. And also the use of pre-procedure rectal endomethysin, placement of a pancreatic duct stent, and also aggressive hydration with lactated ringers have all been shown to reduce post-ERCP complications. So for those not interventional folks, be aware that there are other complications, including post-vigtorotomy bleed, infection, especially acute cholecystitis. I actually had this happen to me for the first time. A couple months ago, a patient came in, routine, as smooth as can go ERCP, for just a small stone in the duct, and he came in 12 hours later in florid septic shock from acute cholecystitis, and was in the ICU on pressers, and I felt terrible that that had happened to him. The use of fully-coated metal stents has been reported to have an increased risk of acute cholecystitis as well. Perforations, fortunately, are overall also very rare. The ASGE has great resource online library about adverse events that can happen in various GI procedures. Then I wanna spend the rest five minutes talking about medical professional liability. So GI is the sixth most cited medical malpractice in claims, and if you look in the red box, the procedural error negligence is actually only about 25% of claims in GI related to endoscopy, all right? So it's also a delay in diagnosis and a delay in treatment, which has more reasons for litigation than actual procedural-related complications. Colonoscopy is responsible for half of the claims when it's endoscopy-related. Malpractice education begins with prevention, right? Be aware of the major GI society guidelines. Document any reasons for exceptions to those guidelines. Why am I doing this colonoscopy in three years when in theory it should be seven years for adenoma follow-up? Patient refused. We discussed that with their bleeding. I was worried about a cancer, but the patient adamantly does not want to have a colonoscopy, right? You wanna document all of that. If you think the patient is too frail for a procedure, document, document, document. Everybody has open access colonoscopy plus or minus endoscopy. I think that's great. More patients have access directly to us, but it's also the first time that you're meeting with the patient. So just be careful, especially with language barriers, making sure that you are discussing the procedure and the risks with the patient well before, hopefully they're in the procedure room, right? Once you have been served papers, never alter the medical record, right? Don't go back and try to change some things. Discussions with colleagues are discoverable. So be careful with what you discuss with colleagues. They could be subpoenaed to testify about what happened during your conversation. Be careful about what you post on social media as well, right? You guys have all seen those Facebook groups of physician community. There's like GI-based Facebook groups. Just be careful about what you post online. All of that is discoverable. Don't try to contact the plaintiff's attorney. If they're handing you a lawsuit, they've already decided that there's enough evidence to try and bring the case to trial, all right? Ensure that your entire staff is trained as well. That comes, you know, even down to the person who answers your phone and takes a message from a patient that says, hey, I had a procedure, now I'm feeling X, so that it doesn't get buried in your inbox. I tell my staff, you know, if it's something urgent and I'm not right in front of you, just shoot me a text, I wanna know about it. So common areas for GI lawsuits are procedural events, interval colon cancers, any types of bleeding, and how to really minimize your risk. You wanna build rapport with patients, right? So 80% of malpractice claims come from communication breakdown. Communication is verbal, physical, and also written. I think it is, I can't harp on this enough. You know, now I am on sort of the hospital side of things as director of endoscopy. Every time there is a complication in the endo unit, I hear about it from risk. And when they reach out to patients, patients always say, well, the doctor didn't explain the procedure to me. I didn't understand what the risks are, or this thing happened, but I never saw the doctor after the procedure. You know, it was always like their APP or someone else who came and saw me, right? Take ownership of what happened during the procedure and talk to the patient. I always offer to call their significant other family members as well. So again, full disclosure of the procedure. It's okay to say that you're sorry that the problem occurred. It can't be used as an admission of guilt. Advise your staff not to like offer any opinions on why this perforation happened, you know, why bleeding happened. Document everything and really contact your hospital or your malpractice carrier. Try not to hide from things, right? They're on your side for the most part. I would say 100% of the time, they want to make sure that you are well represented in case something happens. And finally, this is my last slide. We are the second victim, right? Second victims are healthcare providers who are involved in an unanticipated adverse patient event in a medical error or a patient related injury and have become victimized in the sense that the provider is traumatized by the event, right? So if you guys haven't had a complication yet, it happens just based on the sheer volume of procedures that you were doing. So frequently, these individuals feel personally responsible for the patient outcome. Many feel, though, they have failed the patient, second guessing their clinical skills and knowledge base. This will happen to everybody. And, you know, I think at the end, it just makes you a better physician, a better doctor. I personally, I do talk with my, you know, colleagues and coworkers. I'll text, you know, friends from fellowship and say, hey, this happened today. And for me, at least it's helpful to talk things through. All right, great. Sorry, that was a whirlwind.

endoscopic procedures

colonoscopy complications

informed consent

sedation risks

perforations

bleeding management

ERCP pancreatitis