So this is our next Q&A session. Eden, do you have any questions from the audience? We sure do, and we encourage folks to go ahead and keep submitting questions. Sometimes our presenters are answering them, typing in answers. So if you did place a question, you can check the answer box. And if you're just curious what kind of questions have been asked and maybe already answered, all of you in the audience are welcome to check that answer box. Our first question is, if a patient is a regular marijuana user, is there a recommended number of days to hold it before the endoscopy to allow for better sedation? Dr. Martin, did you want to answer that? You talked about sedation earlier. Yeah, sure. There isn't really going to be specific data for that particular substance. I think whatever your recommendation is in your practice, what you and your anesthesia team feel is best for other non-prescribed substances that are downers is probably appropriate. So whatever you tell your patients for alcohol is consistently what I would tell my patients for marijuana. It's good to stop those types of things, whether it's alcohol or marijuana, for a couple of days before the procedure, in my opinion, not evidence-based, because you want to avoid interactions as you would with prescription medications. That being said, I think that it's equally important to think about what the regular use of such substances might mean to what you need to do about your sedation dosing or what you might expect to have to do about your sedation, your opiate and benzodiazepine administration, or whether you might need to consult anesthesia for a MAC or a GA, for that matter, rather than moderate sedation. So that would be my short answer. Others? Yeah, John, I would agree. I think that last section you spoke on is the most important. Identify that they're chronic users, and really, if you're using traditional sedation like Aaron and I do in our group, it's fentanyl and Versed, I would really get an anesthesia professional involved. They will have a different plan of action, because even for anesthesia, these people can be very difficult to sedate. So I think it's really the anesthesia service, and recognize in that clinic visit, chronic user, I need to go a different path. We have a few questions related to consent and anesthesia, so let me go into those. Is it proper to have a nurse at the bedside sign the consents, or maybe facilitate signing the consents, including an anesthesia consent? I'll take this one. Oh, you'll take that one? Thanks, Dr. Hoffman. Yeah, because this is something I've been talking about for 20 years. The nurses in our units are extremely valuable allies. Whenever there's a question around consent, there is a gray zone patient that is competent by law, meets the letter of the law, but doesn't meet the spirit of the law, if you know what I mean, when you're describing the complex procedure. So if you have a family member, that's welcome. If you have an experienced nurse, I am a big champion of that. I think when multiple people at the bedside are in agreement that this patient understands what they're going to get involved with, I think it's the right estimation. And the second part is where there's a contentious issue at hand, where there are multiple, let's say, family members or other surrogates who are advising different things. There's a perception of difficulty. There is a higher-than-average risk of a negative outcome. I think it's extremely important to have a nursing ally. And, you know, as we all know, at least in the American medicine context, the nurses are the primary patient advocates, as stated. So I really am a big champion of that. I'm not saying this is a requirement, but I just wanted to share my sentiment from my quarter century of practice. Never found it to fail. I just want to add to what Dr. Call just said. And, you know, the main add is that it is going to be sort of institutionally dependent or institutionally variable, right, Vivek? For example, at my institution, it's absolutely permissible for physicians to have the verbal consenting discussion with the patient. And then for the anesthesia, or rather for the RN and the pre-post area to then actually obtain the physical signature from the patient. However, it is not permissible for me to lateral the actual discussion and engagement of the patient. Basically, the spirit of the consent or the process of the consent, I can't lateral that to the RN. I have to do that as the proceduralist. And I know that that's what Dr. Call means. Yes. And to actually basically just, you know, do the equivalent of what in the old days physicians or surgeons used to do is write an order saying RN to obtain consent. That is absolutely medical legally inadvisable and ethically not correct. That would be my opinion. Thanks for clarifying. Would that, Vivek? Yeah. Yeah, thanks for clarifying that point. My sentiment was to suggest that the nursing allyship, that's a well-established word now, is extremely important in delicate cases where there are gray zones. And when I do need my nursing partners to be there with me to eyeball the situation, both from a clinical perspective as well as from, you know, the read the line in between the lines, so to speak. I do trust my team to tell me it's a good idea or really not a good idea. And when I hear that from my nursing team, I put a lot of stock at it. That's what I was referring to. But as I said in my talk and as Dr. Martin has alluded very clearly, is the consent really for complex procedures falls on the endoscopist or an interventional fellow or some surrogate who is so authorized, so to speak. What are your thoughts on consents over the phone? Is that something that should be done? So if nobody else wants to take it, I'll take it first. Phone consents, the general policy is yes, it's perfectly fine as long as you have a nursing witness. Two physicians, no. Physician and trainee, no. Physician administrator, no. At least that's the policy in our institution and far and wide that I know. Physician to do it with the appropriate health care proxy or legally authorized surrogate with a nursing witness and documented signature right there next to you. That's really well put. That every word there that Dr. Call said counts. That is a first, John. No, no. Your wisdom shines through, particularly on that one. I think every word there counted. Now, does this apply for a landline or as equally as it would to say a Zoom or some kind of medical, you know, like visit where you could see the person's face? Yeah, that's an interesting question. You know, hasn't come up yet in our clinical practice, but we are in the post pandemic era. I suspect it will be okay for Zoom as well. But you know the construct we are talking about here is that we have a bi-week at four o'clock on Friday, and patient is not in a position to provide consent so I get on the phone with his wife or spouse. They're likely to be doing a Zoom call, you know, even in the foreseeable future for that particular clinical scenario. But if that's the way it is, then that's fine too, I guess. Eden, if there's time, maybe the question about the APP obtaining consent for endoscopists might be a nice follow up. Oh, let's go right into that then. So can the APP obtain the consent for the endoscopist, whether it's a nurse practitioner or a physician's assistant? Sarah, you want to take that? I know you have a lot of expertise in that discussion. I think on an ambulatory setting, it's unusual. Inpatient, however, we do train our APPs to take consent. This is always verified by the endoscopist when the patient comes down. But we put our APPs through an actual formal training on how do you get informed consent. What does informed consent mean? We do refer to the ASGE guideline on informed consent during that. And then we have one of our faculty members sign them off as they've been appropriately trained in order to do that. And that's been a really important thing for us because we want to make sure that it comes back to you're hitting all the key areas. The patient has the information they need. You're doing shared decision making with the patient. And it truly is the patient going back to ask any questions. I think the value of that, again, particularly inpatient, is that the APP can make the phone calls with the family. They can do these group Zooms or FaceTimes or conference calls, whatever may need to be done to make sure everybody's on the same page. And this was particularly important during the COVID pandemic for us when they weren't able to have visitors and you wanted to make sure the family was involved in the discussion and that the patient felt comfortable and was asking the right questions. And so, yes, APPs can take consent. I think best practice, however, is that the endoscopist is still kind of double checking everything, if you will. Let's try and sneak in one more question before we go to break. And Dr. Shields, I think we'll start with you. What about EDGE procedures? Do you think this is offered at the same rate as regular ERCP for indications or are people more reticent to offer EDGE due to higher risk? The general question is how to perform ERCP in people who have altered anatomy. And so, you know, it's fairly common, although not performed as often now, Roux-en-Y gastric bypass are typically the patients that provide the biggest obstacle to performing an ERCP. And it's just because the anatomy has been changed such that a regular duodenoscope won't access the papilla. So your options are either to use a very long scope and try to come in kind of the back door. And that's one option. You can do a deep enteroscopy or a double balloon enteroscopy to get there. It's a very technically challenging procedure. You can have a surgeon create a basically open the abdomen and give you a conduit directly into the stomach. And that's a procedure that's performed some places as well. Or you can perform this EDGE procedure, which is basically an EUS guided stent placement that reconnects the gastric pouch to the native stomach so that you can then easily perform ERCP. When we encounter patients like this in our practice, we're sending them to people like Dr. Call and Dr. Martin because they do all of these other things. So I'll let Dr. Call tackle the second part of that as to how often EDGE actually comes up. Yeah, it's interesting, you know, in the American context, it does come up. You know, the Roux-en-Y gastric bypass is the typical poster child for which it was developed. Be mindful, though, that there's a lot of other gastric, obesity surgery that has taken place over the last three decades that is not Roux-en-Y gastric bypass. The first question when you're dealing with post-surgical anatomy is to really get the op report and understand what was done, because it may not have been a Roux-en-Y gastric bypass. That's number one. Number two is that there are literally three options right now available for the Roux-en-Y gastric bypass patient. Very quickly, a patient who has an indwelling gallbladder. The laparoscopic assisted transgastric ERCP is probably the most efficient combined procedure with the surgeon. If the gallbladder has been removed already, then you have two choices. You can go double balloon ERCP, which the original data published from the Mayo Clinic is in the 60% success rate. Our experience in the last 15 years has been higher than that, but that's based on volume and experience and refinement of devices. You can go double balloon ERCP or the EOS directed transgastric ERCP, for which you really need very good level, high level EOS expertise, and you most certainly need surgical backup because for all the good stories that you hear, there are also potential outcomes that can be catastrophic in the moment, and certainly in the week or two afterwards. And in many cases, EDGE ends up being a two-stage procedure, because if you use a smaller lumen opposing stent, you really shouldn't be doing ERCP in the same day. But if you use a larger lumen opposing stent, then you can do it the same day. So it's a very nuanced thing. The clinic will offer the patient all the options depending on the construct that I described. So I think for a patient who has an indwelling gallbladder who needs a cholecystectomy, I have a very low threshold of just going to the OR and tackling both problems at one time, with a dedicated ERCP scope. Thank you, Dr. Shields and Kahl. And Jill, it looks like we've come to our afternoon break. I think we should stay on time and reconvene at three, you think, in 10 minutes? I think that's a great idea. We'll see you all in 10 minutes.

sedation

marijuana use

endoscopy procedures

consent process

ERCP