Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Approach to Fistulas, Leaks, and Perforations. My name is Michael DeLutri, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our moderator, Michelle Bayliss, from Washington University in St. Louis, Missouri. I will now hand over this presentation to her. Thank you, Michael, and thank you to ASGE for organizing this Endo Hangout. I'm excited to be here to moderate this session. My name is Michelle Bayliss. I'm currently the Advanced Endoscopy Fellow at Washington University in St. Louis. Our topic for tonight, like Michael said, is the approach to fistulas, leaks, and perforations. Fortunately, with all the advances in therapeutic endoscopy, we currently have multiple tools at our disposal to manage some of these complicated pathologies in a minimally invasive way, which is fantastic for our patients. We're really excited to share some interesting and challenging cases tonight, and more importantly, to hear insights and learn from our content experts, who I have the honor of introducing. So starting with Dr. Ahmad Bazerbashi, who is Assistant Professor of Medicine and Director of Third Space Endoscopy at Washington University, where I have the privilege to train this year. We also have Dr. Alison Schulman, who is Clinical Associate Professor of Medicine and Surgery, also the Director of Endoscopy and Director of Bariatric Endoscopy at the University of Michigan, and last but not least, Dr. Christopher Chapman, who is an Assistant Professor, Director of Endoscopy, and Director of Bariatric and Metabolic Endoscopy at Rush University. Can everyone see my screen? All right, so case one, this is a 62-year-old man who presented with a history of squamous cell carcinoma of the esophagus. He had undergone chemotherapy and radiation, and he had a PEG tube in place for two and a half years for nutrition. After completing chemo and radiation, he resumed an oral diet and was requesting a PEG tube removal. So I'll direct the questions to our panel. So before performing a removal of this PEG tube, what are your thoughts about this case in terms of pre-procedure planning? Thanks, Michelle. I'll get things kicked off for us. It's my case, so I can tell you what I was thinking of this situation. You know, when this PEG tube has been put in place for over two and a half years, so this is a long indwelling device, and over that period, we know that more likely than not, there's probably some epithelialization of that tract, and it may be at increased risk for having persistent fistula. So already, I'm starting to think, is this something that we need to get prepared to close, or is this something we can just... Sometimes we can just remove PEGs, and the vast majority will close up on their own. So is this something that we really need to do an interventional procedure to close, or is this something that could be spontaneous? The other thing that I thought about in this case was the patient had radiation and chemo to a head and neck cancer, and that raises questions like, is there a stricture? Am I going to encounter a stricture? That may make it harder to get other devices down, like a Novesco clip or OTSC clip, which is larger in size, or even like the suturing devices that we sometimes use for closure. So knowing the size of your equipment and being prepared if you encounter a narrowing in someone who's had radiation or chemo can be really, really important. Great. And just to add to that as well, I think with a case like this, just as Chris mentioned, when it's this chronic, and the PEG has been indwelling for several years, you want to not only think about the actual closure of it, but also the importance of de-epithelialization. Because as Dr. Chapman mentioned, oftentimes these tracts are epithelialized, and in order to get these to close, you have to really de-epithelialize the tract. And you can do that in a whole variety of different ways, whether it be cautery, or just brush cytology, brush disruption, or a variety of other techniques. But I think that's one adjunctive method. When you think about the actual closure of these, that can be very useful as well. I think just to add that it's very important to have these dealt with early. These are quite troublesome to patients. They can impact their daily life. You get calls that they have some skin excoriation. I've seen patients with significant infection, ulceration around the area when there's consistent leaks. Some of them have stoma bags around them, which obviously just impact their ability to do their activities of daily living. So I think it's great that you're thinking ahead of the game before you get that call a few weeks later that, hey, I'm still draining. What's our next step? And this is why I think closure early is very important, especially when it's a long indwelling tube. And I think that's exactly right. So I think one of the themes that I hope we can take away is that a lot of what we focus on endoscopy is at the time intra-procedure, but our decision making really begins even before we get the scope in the patient. And in a case like this, it's just standard, OK, remove the PEG tube. But understanding is this patient at risk for not having a spontaneous closure and developing a long-term chronic fistula is really important. So people that have delayed gastric emptying for any reason are going to be at higher risk for having a persistent fistula. People that have longer lasting or longer indwelling tubes are going to have longer, higher risk for developing fistula. So already you're kind of triaging these patients in your mind before we even put the scope in the patient. So before you even start doing the intervention, think about what's the patient phenotype before you even get started. And that could help with your planning purposes. Thank you. These are all great points to keep in mind. And you sort of presented a plan A, plan B, plan C situation depending on what you run into, which is really good to think about because we see these cases quite often. So for this particular patient, the PEG tube ended up getting removed at an outside hospital. And the gastrocutaneous fistula site was closed with an over-the-scope clip. Unfortunately, two months later, the patient reported recurrent leaking at the site and is now presenting to you for evaluation. And so again, what are your thoughts now about this case in terms of pre-procedure planning, given that the patient has already kind of failed management with an over-the-scope clip? Let me just ask a quick question here to both Ali and Chris. If this was coming to you before the OTSC and you decide to do the over-the-scope clip, are you APCing the track? Are you just using suction to deploy? Are you using graspers? Are you brushing the track to improve sort of that healing and epithelialization? What's your process when, let's say you're committing to some sort of over-the-scope closure? That's a great question. So I will say 100% of the time, I'm trying to de-epithelialize that tract. And so usually the easiest thing to do is to APC, just because you have it right there. And generally, it's in most of our endoscopy units. So 100% of the time, de-epithelializing. The next question is kind of which over-the-scope clip you can use. As many of us are familiar, these come in a million different sizes and shapes. But there's three main different types. And there's the one that's more kind of atraumatic, the one that's kind of somewhat traumatic, but not fully traumatic, and then the one that's designed for fistula closure, which is the GC type. And so many endoscopy units actually don't carry all three. And so oftentimes, we're using the one that's kind of right in the middle, that's versatile for both closure of gastrocutaneous fistulas and then also the cessation of bleeding. And so we commonly are using the one that's not necessarily designed for this purpose, which I think has its downsides. The other thing to think about is the size, because depending on what scope you choose, there's different size clips that fit on the end of these scopes. And so if you're, depending on where the fistula is, in this case, it's obviously gastrocutaneous. As Chris already mentioned, there was a history of radiation, which may make it challenging to get the scope through. So you have to make sure that you're choosing the size clip and the type of clip that you want to use for closure in a case like this. And then the other thing that can be challenging with these is that, especially in fistula that have been persistent for this many years, the surrounding tissue can be really fibrotic and challenging to pull in. And so, Ahmed, you mentioned, are you using suction? Are you using the kind of tissue graspers? You know, there's, of course, the device where you can kind of pull in one side and then pull in the other and then try to close around it. Or there's the anchor where it kind of drills into the tissue and pulls it back. And I think it really depends on the characteristics of the lesion. It's good to have all of the equipment available to you, because depending on how fibrotic it is and how dense the kind of fibrous tissue is may really dictate what technique you use. And if you opt for the over-the-scope clip, you have to make sure that you really get not only suction, but some way to kind of co-act that tissue within the clip, because otherwise the clip will not be successful. Yeah, I think, I mean, those are great, great points, Allie. And I think, you know, your point starting off with deepithelialization, that is key and foundational for all fistula real closures that we're talking about. And Amadi mentioned you can do APC or, you know, using a brush, for example, to kind of rough it up. Oftentimes, I will just start off with APC, like Allie mentioned. But I think we can get in the weeds of that, because there's nuances to this a little bit. Like, well, what's your settings? What's your wattage going to be? And so the question is, so I tend to be in the stomach a little bit more aggressive. So I'm using higher wattages, usually 50 or 70 watts. If you have an Herbie, an older Herbie, or like a 5 to 7 range, if you're kind of on the newer Herbie range models. And then sometimes if I still feel like I'm not, you know, getting enough, then I will actually use a cytology brush if it's more of a tract. And so if I have more of a tract, I'll sometimes use the brush to try to make sure we get everything. I've even heard, actually, some people use silver nitrate on the outside too, actually, to kind of get the outside of the tract treated as well. But even thinking about APC, it's like, well, how much APC? Do you go into the tract? Do you shoot into it? Or do you just stay on the outside of the rim? I tend to try to ablate the whole tract if I can, and try to get as much as I can. So the more that you can get rid of that epithelialized tissue, the more you can get down to more fibrotic submucosa, or even deeper layers, I think the higher likelihood of success. So I think even how you do the APC can have a little bit of teaching points about, well, how aggressive you need to be, and how in-depth you need to be. And so I think there's some learning there. And then, as mentioned, Ali, there are multiple size clips, and even there's two companies. And we're going to go over this in more detail. So there's an over-the-scope clip made by Vesco. There's also over-scope clips made by Steris called the padlock clip, right? So these have little different features as well that you would want to keep in mind, depending on where you work, and what your group has on the shelf. And so I do think treating it is very, very key with de-epithelialization is first, and then choosing the right equipment. A lot of times, I will actually do suction to see if I can just bring it into the cap, and see how much tissue I'm really getting. And if you get a lot of tissue, then I may not resort to using accessory devices. But if I see like I'm not getting a lot of tissue, then actually what I will do is then use an adjunctive device, like the twin grasper, or the anchor, or something like that, to try to bring it in. So a lot of the pre-testing is really can help. And in actuality, I personally, and this is a personal bias, is that sometimes if you're really torqued on the scope, like with the Novesco, I feel like you can have sometimes variable release when you fire the knob, and you're not really sure if it's totally releasing. Whereas the padlock has a one-button push that deploys it, and allows, I think almost always that I've experienced, a more uniform, guaranteed firing. And so I do think if you've only experienced one, I would encourage exploring your using the padlock as well, because it has some bonus features, or some features about it that may make it a little bit easier to use. And when we go to the teaching slides, I'll go into more depth about that too. Yeah, and one other comment. I totally second everything you say. One other comment is that when you're kind of testing it with that suction, which I think many of us do as well, I am actually not kind of hubbed against the wall, because if you're pushing everything against the wall, it's hard to get anything to kind of co-act within the clip. So I actually stay a little bit away from the wall to see if the tissue will actually be kind of malleable enough to come into the clip with just suction alone. And that's why these GC tissues are harder than you think, because there's so much fibrotic tissue, and the peg has basically stuck the stomach wall fibrotically to the peritoneal wall. And so a lot of times it can be difficult to get it to completely suck in. So that is definitely one of the challenges for these cases. Just for that question we got about this epithelialization, you want to promote the best healing. So that first layer that's usually there isn't a layer that's healing well. So by brushing it, you're usually kind of removing those cells that are either friable or ulcerated, and you're promoting the underlying layers to start to heal better. And that's the same concept of using APCs. You're sort of burning that layer to allow the layers below that to start to kind of come in and hopefully fuse and heal better. Okay, great. Michelle, if you want to go to the next one. Yeah, so just for purposes of this question, I'll direct it to Dr. Vazirbhashi and Dr. Shulman, since I know what Dr. Chapman did in this case. So a patient comes to you already with an over-the-scope clip that was used as an attempt to close the fistula, and there's ongoing leaking. What are you thinking in terms of your next step here? Yeah, so do you want to start? Go ahead, Allie. Okay, I was just going to say, this is not an uncommon scenario, and these are challenging. So I think number one is the recognition that either it's the same site that you attempted to close, or you've developed some sort of kind of periclip fistula. And so that can also occur. You don't see it as much with gastrocutaneous fistula as I think you do with use of some of these cap-mounted clips per other fistula closure or leak closures. But it's good to kind of recognize where is, in fact, it leaking from. The second thing is that in order to really effectively treat it, we generally have to remove the clip that's been placed. And so this used to be a huge challenge and frustration, and we'd sit there for hours with APC and other devices trying to break these things up. Now, of course, over the last couple of years, there's been a system dedicated to removal of these. And so it's important to kind of understand how that works. It takes some time to boot it up, so you should know that ahead of time. But eventually, you can kind of break the clip at its weakest points and remove it. So the first thing that I kind of think about is where is it leaking from, and then trying to remove the closure technique that was performed so that I can offer something a little bit different. Yeah, I agree. And I think it's important to recognize that you may have sealed it, and just with time, this thing kind of moved and that fistula had opened up again. I don't think this necessarily means failure of initial therapy. You know, I've had patients where they're like, I'm not leaking for a few weeks, and then they're calling three months later that, okay, now I am, and clearly something's changed. But pretty much what Ali said, I would see what that vesicle was doing. I would probably take it out of my way because it'll probably interrupt whatever maneuver I would want to apply, and then start thinking about, you know, what else I have in my armamentarium to close it, including suturing, even including repeating a vesicle if I feel that I might get a better grasp on it too. You know, obviously keep bearing in mind that we don't know how things look like with all the radiation that they've had. That's a very important point, something to keep in mind that, you know, you may be limited with your options depending on how things look, you know, in the esophagus. All right, so back to the case. See if I can play this video here. And I'll have Dr. Chapman kind of tell us what's going on. Yeah, so this is a quick video just saying what we found when we got there. And, you know, you can see there's a prior over the scope clip in this here. And I'm threading a guide wire externally through the skin, through the site, kind of just trying to see, you know, where is the fistula? Where's the leakage coming from? Try to identify the actual size of the opening, you know, because I do think, as mentioned, some of the data shows that you may get partial closure and you may need to do just a little bit more to kind of finish it off type of situation. So knowing what's the size of the fistula and also trying to get a good idea, basically to both what Ali and Ahmad said is, how am I going to get this thing out of the way? You know, and because right now, I can't get into the depth underneath that area to do a further interventions. And so this was actually back in a time when, so as Ali alluded to, there's the DC remove, it's like a remove device that's actually you have proprietary to actually remove obesicles to break it. But I didn't have this. They used to mail it to you and you could prehead and plan and then you could be like, okay, I need to use it. But then they stopped doing that. And now you have, everyone has to help purchase their own box. And if you don't have your own box on hand, you're kind of like, well, how am I going to get this out? And so I think what I posed to Ali and Ahmad is like, yeah, we could say theoretically we would use the remove device, but what if you didn't have the remove device in your unit and you saw this endoscopic appearance, what are your options to get this out of your way to get to the underlying fistula? Yeah. And then one thing about the DC cutter to keep in mind, since I've clearly used it way too many times, it takes time to actually set it up the generator itself actually needs about 15, 20 minutes to almost sort of, you know, get ready to apply that energy to break it up. So if you're ever using it in real practice and you know that you need it, always ask your assistants to set it up, turn it on, you sort of let it get to that point where it's ready. So that way you're passing your catheter down to kind of break it up. And it's ready to do that rather than having to wait. And it's something that has clearly happened to me from experience. Yeah, go ahead. Sorry, Ali, what are your thoughts on here? Looking at this, you know, on endoscopy, you see this, what's going through your mind? Yeah, the one other thing I was going to mention is that that removal system works beautifully in a lab. You know, you press, you step on that button once and the whole clip just is disrupted, but in real life, it doesn't actually function quite that well, especially in clips that have been placed for a long period of time because you commonly get a lot of growth of tissue around it. And you have to kind of find oftentimes, like in this particular picture, it looks like you can kind of see the edges of the clip pretty well. Yeah. In oftentimes what happens is the tissue has kind of grown around the clip and you have to really find where the clip is and then make sure that you don't have tissue in between because the cautery technique or the burning technique can not work kind of quite as effectively. So just another thing to keep in mind aside from the 20 to 30 minute wait time to boot the machine up. In this situation, so I oftentimes, and I forgot to mention this earlier, but Chris, this video reminded me, in almost every one of these cases, we're passing a kind of flexible guide wire, usually the ones that we use in ERCP through the abdominal wall to see exactly where the opening is. And usually with chronic fistula, there's no severing of the tract in any way and you can easily find where it comes from. But I think that's a really important component of this because you want to make sure that you're closing the area that's still persistently open. In this, looking at this picture, this tissue around this fistula actually looks really healthy and the clip looks very exposed. And so if I didn't have the removal system, I would probably try to remove this with APC or with some other technique. Could you close kind of around it? Maybe, but I think based on what I see right here, it looks very exposed and it looks like APC wouldn't be too burdensome, but I'd be curious to see what you did. Yeah, no, these are great thoughts, right? And because as you go down again, I'm all about pre-planning, right? So thinking about what you're going to do, what you're going to counter. And so one of the things that I did for this case was the more I manipulated the wire, the more that I could see that there really wasn't that much tissue holding it on. So actually what I did is I actually used a snare and I snared it off, like I went underneath it and snared off all the tissue. So basically you snared off the clip and basically that was able to get out of the way and you had a clean slate to start with. You know, people have talked about, again, APCing over the scope clips, like you mentioned, or using cold water baths and stuff like that. I just find that it's very, very difficult to break it over the scope clip with those methods and it spends a lot of time. And so when I saw that there wasn't as much tissue that was actually grasped, it was more like kind of dangling, I made the decision to just snare it off, you know. I do want to make, sorry, one final point on the remove device using that. I almost always use it with a 2T scope because I find that if you use a Raptor Grasper to kind of lift it up and then use your three-pronged breaking device to push it on, it just allows you to get that tissue away. So anyone that's thinking about using the remove device, think about using it with a 2T scope and using the advantage of having something that can leverage the clip away from tissue. So just one little tip before I move forward. But in this situation, I snared off the Ovesco and then gave me a clean slate to begin with. I'm going to field here a very quick question. So if you have an instant clip that's so tightly adhered to the mucosa, my fear is I'll pull so much with a snare and there's so much tension that I'd make a perforation. I'm assuming instant clip, you're meaning sort of a through-the-scope instant clip from Cook. Usually, if I have those in my way, I'm pretty aggressive with just using rat-toothed forceps and taking them out. You know, very rarely do I have any issues with removing them or causing a perforation. So that's been my go-to. And then the second question is, is it very difficult taking an over-the-scope clip, especially when it's so well adhered? Did you use cold snare or did you actually apply heat, Chris, when you did your snare removal of this ODSC? Yeah, for this one, I actually used heat. I used cautery. And the reason is I just kind of wanted a cleaner cut, less bleeding. And I knew I was going to use thermal therapy on this underlying tissue anyways. So I was like, probably a little bit of burn would have been okay. And I just didn't want to deal with bleeding from some of the cold manipulation. Great. So here is, I'm trying to play this video, the rest of this case after removal of the over-the-scope clip. Yeah, so this is, you know, the beginning of the video basically showing the wire going through again that we saw in the previous slide. And you can see it kind of dangles off. And what I elected to do in this case was to do endoscopic suturing as my next method. And we already known that we were able to get the over-the-scope clip through. And so, thanks, Michelle. And so we knew about the sizing purposes. We'd be able to get a suture over-the-scope suturing device down as well. And so then you see there's a little, I've already APC here. I didn't show it in the video, but I've used thermal therapy deep into that fistula tract there. And then we're trying to think about, well, we spend a lot of time talking about suture patterns and grasping enough tissue. So what we ended up doing here is using a modified, like our incomplete figure eight suture pattern to close off this fistula tract. And so you can see that we're using a helix. So we started at kind of on the right side. Then we're going to the left. And then we'll move down and across and you'll see it. But we're using a helix to grab the tissue to try to get full thickness bites as much as possible. But even in doing so, a lot of the tissue doesn't really come that freely. And that is because it's so adhered to the wall and so fibrotic. And so you do the best you can. Sometimes with fistulas, you just take what tissue gives you and then you just have to move with it. So yeah, we're going basically alternating a four-bite running suture pattern here using the helix to try to grab full tissue. One of the things Allie and I know very well is like, if you could cutty pause the video for just a second here. If you do suturing and you're using the helix and it doesn't come towards you freely, that usually should give you pause to stop and make sure you don't have something deeper. Because that helix can grow, go through, through, through and grab alternative structures outside the gastric wall. But in this case with the fibrotic, you know, the stomach adhered to the peritoneal wall, it's probably just reflective of the fact that there are those adhesions. So that's a little bit different. But if you look actually in these videos, if you grab with the helix, you can actually feel kind of like tension almost when I'm pulling on it. And that is probably just reflective of the scar tissue. But if you're doing other suturing cases and you're using the helix and you feel that level of resistance when you withdraw the helix, that should give you significant pause to not take that bite, unscrew and maybe retry again. Go ahead, Michelle. Oh, it came backwards. You can go just maybe to the middle point of the video. Yeah. So what we ended up doing is we ended up cinching. And just to help, because this is already a refractory fistula and had been in for so long, two years, we ended up doing a double layer. So we ended up suturing on top of that first layer and just basically trying to reinforce that first suture to try to get a dual closure, to try to just really maximize the benefit or the likelihood of achieving a durable response. And here you can see another cinch coming through, driven towards where that first bite went in. And we're going to cinch it down, get that guitar string level tension, and then we'll fire the suture. And then that'll be the end of the case. And this is what it looked like at the end of the procedure. And the patient actually did have closure of the fistula after this secondary attempt. Great. That's it. I'll stop sharing here, and Dr. Chapman, I'll have you take over. Okay, great. While we're doing that, what's going through your mind is sort of an internal check. I said, I've closed this then and there. I know it's hard to do. I've seen people do two different things. I've seen methylene blue sort of squirted from the outside. Do I ever see it come into the lumen of the stomach? You know, what are you doing to kind of make sure you have that seal? Great question. Yeah, I mean, I think methylene blue can be very useful because that doesn't hide. You know, if you see methylene blue is in the stomach, you'll see it. The other thing that I commonly will do is pass that same wire that was originally within the gastric lumen again to see if it will pass through. And you can put significant kind of pressure on it to make sure that it's not passing through the wall. I think that could be helpful as well. Depending on what type of fistula you're closing. I think in this particular type of fistula, those are probably the two best methods. But of course, if you're closing fistula interluminally that are requiring fluoroscopy and other things, you can, you know, inflate balloons and inject a bunch of contrast to make sure that you're not seeing any extravasation of contrast. That can be very useful as well. Yeah, I think one thing that I also do a lot of times with these kind of gastrocutaneous fistulas, they have a little like dimple divot where the PEG tube was. And if they're supine, you can actually like do a little like a little bowl of water in that, like a little saline water. And then you insufflate the stomach to the much you can. And if you don't see any air bubbles coming out, that is one other method that we use as a surrogate to maybe that you have a durable closure as well. So if you keep them supine and add a little water in there and see no bubbles, you're usually in a good shape. But granted, over time, that may change to what you kind of hinted at. Like you may have good closure at one point and then it may change in the future. Great. So I'll go into some of the just a few aspects of the teaching slides. This was kind of a point we really wanted to hammer home. Allie and I and the model mentioned that you have to de-epithelialize the tissue before going in. And a reason why I want to show this is most often we use APC. And you want to blade at least circumferentially around the fistula to get to that kind of charred marshmallow effect. And with APC, the amount of burn you get or the amount of activity, the tissue effect you get is dependent on the duration of your activation, the power setting, as well as the distance. And so what I tend to do is, you know, use a forced APC of more high wattage of like 50 to 70 or 5 to 7. And so you really want to be more aggressive. If I was dealing with a jejunal lesion or small bowel fistula, I may be less aggressive than it is with a stomach, which usually can handle a little bit higher force of the watts. And then again, if you don't have APC, then you can use tissue brushings with a cytology brush. But sometimes that can cause more bleeding and that may affect your visibility. And so that's why APC generally is our go-to if we're going to do this type of de-epithelialization. We talked a little bit about over the scope and some of the benefits and some of the drawbacks. I kind of want to talk about that quickly just for the fellows here. It's like, remember, over the scope clefts, they are very, very strong closure, 8 or 9 newtons of force that will do this closure. But it is dependent on the amount and depth of tissue grasp. It can be used for large fibrotic ulcers and in difficult locations. And there are some disadvantages, though. You have to remove the scope and then load the device. Large cap diameter may make it difficult to intubate or get through luminal narrowings. And there's still a learning curve to assembling the device and then firing the device as well. And to be clear, we mentioned this already, there are two real brands. There are over the scope clefts made by Ovesco. The Bear Claw or Steris, which is the padlock, which is kind of this almost like spear type of pattern. And we kind of hinted at this. This is the full armamentarium of Ovesco clefts that are available to you. And it's extraordinarily complicated because there's the mini, the 11, the 12, the 14. So those are your cleft sizes. And then they come with different scope diameters that they would fit upon here. And even among that, like as Ali mentioned, there's different types of teeth. There's the type A, which is the blunt teeth, type T, which is less aggressive, the medium aggressive, which have small spikes in the GC, which is more for closure of fistulas. Be aware that the 14 millimeter clip is typically not used in upper GI tract. That's more of a colonic device as opposed to an upper, whereas the 11 and 12 are going to be your standard upper endoscope devices. But even beyond that, and things that I don't think I even knew right away, was that they actually have different versions that have different depths of caps. You may have a three millimeter depth cap, a six millimeter depth cap. And so there's just a wide variety of clips that are available and knowing this. And so one of the things I really thought was kind of challenging is, well, what scopes go with that? So if you are Olympus, this is kind of just a quick hand guide basically of what scopes fit on what caps. So this is something that if you are dealing with a certain clip that you have in stock and you're not sure does it fit, this can be a quick reference guide for you guys to understand which clips work with which scopes. And be aware also that some of these clips, in addition to the depth of the cap, have different thread lengths that are designed for upper endoscopes and then colonoscopes as well. So make sure you're grabbing the right ones off the shelf before you open it. And this can be a quick reference guide for you guys. This is one of those slides that I save in my favorites because I'm always whipping my phone out. I'm like, where is it? There it is. Because, you know, when your nurse is asking, what scope do you want? What size do you want? You're like, wait, I got to look and see what I'm choosing. So it's a great slide. Thanks for sharing it. No worries. And then Padlock, which is kind of like the forgotten stepchild of our over-the-scope clips, you know. And so it's a really good and underutilized device, you know. And they're coming in two different types of caps. There's the standard 9.5 to 11 millimeter. And then the Pro Select, which is more for the larger size of that diameter scope. So when it was back when it was US Endoscopy, they had the yellow and the white sticker. But now they've changed companies. But just know there's two different sizes for this. And there are some differences. So obvious things, bear claw shape versus the hexagonal shape. And this is, I think, one of the bigger things is the operating channel of the endoscope is occupied with the string and the over-the-scope Ovesco clip. But it's completely free in the Padlock, which is really nice if you're passing instruments to grab things. You don't have to worry about the string like getting caught or like getting spooled up and the deployment being a factor. So the fact that the Padlock has a free biopsy channel is very, very helpful. There's different circumferential versus not circumferential. And then the deployment is very different where you have to have the pull string for the Ovesco clip, whereas the Padlock has a single button press. And in my experience of using both, I think you have a little bit increased reliability of knowing when you're firing or firing with the Padlock. And that's just my experience. If we talk about, this is going to some brief data talking about suturing now. And these are the three main studies that have been published looking at technical and clinical success using endoscopic suturing for fistulas. And you can see that these studies are 56, 40, 24 patients. And they see the technical success is always quite high. But the clinical success is significantly lower. And I think that where it gets when we're dealing fistulas, you have to set the proper expectations. And that also that clinical success is defined here. They say clinical is two weeks, four weeks. That's not very long. If you take this out to longer timeframes, and the only study to do this was I think the group from the Brigham that did this in the top study here in 2016, where they looked at 12 months and that dropped to 22%. And I think that's really what we see in clinical practice is that if you look long term, the rate of endoscopic closure is very, very low. And I think this is just this same study. And I just highlight this because they had six patients, 43 that had suturing to close, 13 were successful. But then out of the 17, they actually brought additional procedure. They were able to then capture an additional four. So this just shows try, try again when you have a fistula. Don't be afraid that if the first thing fails, that your next attempt may be successful. So definitely prepare the patient and bring them back as necessary. And there are just different features here looking at, again, peg tubes are only 2% or 3.6%. But a lot of them did have other failed attempts. And then this slide just shows that here, if you look on the right, it's what's the rate of long-term successful closure. And it drops to below 50%, you know, long-term. And so I think we need to really prepare patients for that. This is Reem Sharai's data. Go ahead, yeah. I was just going to say one other thing that is very important, not necessarily with gastrocutaneous fistula, but with fistula closure in general is the size. So we know that, you know, fistula that are less than a centimeter are much more likely to close, and specifically gastrogastric fistula. When they're less than a centimeter, we have much better closure rates than when they get larger. So between one and two, it, you know, decreases the success. And certainly over two centimeters, those ones almost never close. So something to think about as you're approaching these. I think that's exactly right, Allie, because you have to set the right expectations for your patients. So if you know you have a GG fistula that's under a centimeter, that's probably your best shot. But if you get into those bigger ones, you're probably going to have less likely to have success. And the one thing I take away from Dr. Sharai's paper that came out is they actually looked at differential success if the fistulas were acute or more chronic or like subacute chronic, and they used that 30-day cutoff. And if these are older than 30 days, they were significantly less likely to have successful closure too. So the longer that these things are there, the more likely you're going to run into trouble as well. And then this is Mike Ujiki's data from North Shore and Evanston, and it just showed some additional findings were that, again, if they had involvement of, you know, like radiation or malignancy related, they were less likely to have clinical success as well too. And so I think taking this data, just know that it's about setting the right expectations for your patients. Try, try it again. And even if you get one out of five, you know, or, you know, one out of three, that's still better than a lot of the surgical options in terms of risk of having complications and dealing with that. So those are some of the things that I think if you start thinking about, are you going to use suturing versus Ovesco? Having this data in the background is really, really important to set the right expectations for your patients. I just wanted to echo one more thing just for the fellows. If you have time and you're ever at a hands-on course, try to experience both Ovesco and Padlock. You know, I came from a place where the training was Ovesco, Ovesco was until I came faculty that, you know, I started to use Padlock. And, you know, I thought the Padlock is a great, great device. I think the fact that you have an extra hand that you can do stuff with, where your assistant is actually deploying the clip is huge when it's, you know, in a tough location where you're sort of suctioning, holding, ready to deploy the Ovesco. That's not easy. There's so many variables and it takes one wrong move for this, you know, clip to misdeploy. And so, you know, if you have time, try to experience both of these clips and kind of see what your comfort is, because it really matters. And I think, you know, you can optimize your management based on how comfortable you are with these clips. So we have a question from the audience. Someone asked, is there any benefit to cutaneous closure after all endoscopic interventions are performed? Yeah, I think the cutaneous closures are really, really intriguing. I'm assuming there was a report that I think Marvin Rio, Wasifa Bidi put out where they actually, were you in that? No, I was not. But we recently, he gave me that case just to kind of discuss at one of our, at our conference recently. It's a very cool case. Chris, do you want to go over how they sutured it? So they basically used angiocaths and basically they put two in side by side around the fistula tract. They threaded a surgical suture through it and captured with a, I think a spy bite forceps or mini forceps and brought it around and actually just tied an external knot to it. And I've done that twice now. I'm again, not, you know, massive numbers, but for Trulia Factory and they've had really good success. And so I think it's a really, I actually called Wasifa on the phone, Bidi, and I'm like, I'm like, man, this thing would work. It was great. And I was like, I was like giving major accolades. You know, we read a lot of things. It was really kind of, I'm glad you published it because I think it's something that's really underutilized and known. Yeah, we actually, we did that case with Hiro Ehara. Oh, did you? Okay. Yeah. So it was in, I think we published it in 2016. It's in Video GIE, right? Just if anybody wants to see it. It's Video GIE. It's a great video. And I think it, I want to say, yeah, I think Chris Thompson was the senior author and I was the first author. I think Hiro was there as well. And it was actually a very interesting situation because it was a patient who had had several failures. And what we were able to do is position the angiocatheters around this defect. And then we used both APC internally, but we also used some of this. I wish I could actually share the video with you because I showed it in a talk recently, but I don't have it on this computer. We use APC internally. And then externally, we used actually the instruments that the OR uses when they're closing fistula. And so it was like these long, rigid devices that basically disrupted or de-epithelialized from the abdominal wall through into the stomach. And then, as Chris mentioned, we threaded this small suture material and we grasped it with a snare, I believe. There was, I think one of the, maybe one was grasped with a snare, one was grasped with tiny biopsy forceps. And then we were able to thread it through the second angiocatheter. And then once the suture was making a full circumferential path from the abdominal wall into the gastric lumen back to the abdominal wall, we pulled out the angiocatheters and we tied the suture really tightly against the abdominal wall. And this particular patient was a patient who was not a great surgical candidate. And that was the next, that was the next step for her based on all of her kind of losses. And this worked beautifully. So it was, I think it was a very, a very good kind of, you know, we're moving more into like an endosurgical type world where we can work together and work cohesively and kind of share each other's territories. And this was the perfect example of that. Great. Let's do one more question before we jump to our next case. Scarred fibrotic tissue guys, how would you compare a vesicle versus padlock? What are you usually grabbing as your go-to and what's going through your mind? Yeah, I think that's, that's a tough, tough thing. And so if it's really scarred down and fibrotic, that's when you're definitely going to use a secondary tool to help try to get a little bit more purchase. So maybe using an anchor or the twin graspers or even like the helix with the overstitch device. And so these are things that you definitely have to be prepared for. And these are the toughest ones because a lot of times the fistula tract will be kind of like sunken in a way and you may not be able to get as much up into the thing. To be honest, like if I'm putting instruments through, I have a little bit of my personal favoritism towards keeping that channel free. Because again, you're able to pass instruments without it curling around the string and worry about misdeployment with the vesicle. And sometimes I've deployed a vesicle where it's like, you feel like you did it, then you back away and it just like, it pops off like that. Like, so, and I swear to God, I think everyone else has experienced that, you know, we just don't talk about it, you know, and it's not just me or maybe it is me. I don't know, but I do think the padlock does have that freedom. And so again, I would, I think both are going to be difficult. No matter, it's not like you're going to have like an overwhelming success with one or the other one, but I think there is keeping that channel free a little bit of advantage and I'd encourage you just to try it and explore. That's what I would say. Yeah. And I would second what Chris said earlier, which is that in very awkward retroflexed positions or tight locations, and this happens more often with fistula in the colon or other places where in the proximal stomach or fundus where you're trying to kind of retroflex, I've had variable deployment of the Avesco. So you'll turn, you'll turn, you'll turn and nothing will pop off. And so I think in those situations, it is definitely useful to think about these other, the other cat mouth eclipse. And we'll start with the second case. So this is a 48 year old female with a history of obesity, a BMI of 47, who underwent a sleeve gastrectomy two weeks prior and was transferred. She was febrile with a temp of 104, tachycardic, hypotensive, clearly very sick and was found to have a pneumoperitoneum. She subsequently underwent an exploratory laparotomy with evacuation of two liters of foul smelling, bloody intra-abdominal fluid and placement of two drains and a vacuum dressing. And then an upper GI series was performed and confirmed that this patient had a large volume leak from proximal, from the proximal sleeve. So what would be your next step? So this is my case. I know the next steps, but I'd be curious. So this is a woman, I think the useful things to think about as we think about the history are that she's only two weeks out from her sleeve. So that may change things. The fact that she is no longer necessarily as septic as she was because she underwent an exploratory laparotomy and she now has drains and other things. And so I'd be curious, how do you kind of think about your approach, both Ahmed and Chris, when you have patients who present to you with this history? Yeah, I mean, we see this and I think the two weeks makes it a bit trickier, right? These patients are fairly soon after their surgery and oftentimes the surgeons will want to go back in like they did with the, with the debridement here. But, you know, I think I'd get cross-sectional imaging, kind of see, is this a contained area? Is this just a free kind of perf? And then sort of thinking what I have in my armamentarium to fix this, you know, I'm a big fan of internal drainage, which I think augments external drainage when you have external catheters placed. So those are sort of a common go-to for me. If this is usually just something that's small that can be easily closed off, then, you know, if the surgeon wants it closed off and thinks that that will help the healing process, then, you know, that's also another option. But, but, you know, I think a lot of it depends on what you see when you go down there as well and what your cross-sectional imaging shows. Yeah, I think it's interesting, you know, I mean, I think in terms of the algorithm in my head, the first thing I think is sick or not sick. And when I see the patient come, you're getting that consult and they're 104, they're really, really toxic. I'm really glad to see that your surgeon did go in and actually do it because that is probably the right approach there to clean up, put some drains in and do what they can that way. So I think, you know, if you're the endoscopist alone, that sometimes it's hard to convince your surgeons to do that when a patient's that sick. But ultimately, I think starting off with that's really key. And I think Ahmad's point is, he mentioned internal drainage, I think drainage is really important. So you have to have nothing's going to heal if that area is wet and infected and dirty. So you have to focus on getting some kind of drainage, whether that surgical IR percutaneous or endoscopic internal. And then, then you're thinking about what are the endoscopic options here once you have good drainage, and it's relatively fresh. One thing that's interesting is this esophagram, I don't see any contrast really progressing through the sleeve at all. So is there like a kink? Is there narrowing? Is there a problem within the sleeve? Like it's too tight, it's relatively fresh. You know, I don't see anything going distally really. So you're already thinking like, well, this sleeve might have a high pressure area that's causing a big blowout this, you know, approximately, you know, along the along the staple line. And, and so you're right, and it looks like it's gonna be large, this looks like it's going to be not a small thing. I'm thinking stents here, but you know, you know, maybe dilating across an area. And if you could stent across both the area of where the high pressure zone may be, and cover the leak, that could be beneficial. I know our stents are not usually that long. But, you know, these are type of things that are crossing my head when I'm getting in. And then also thinking about whenever what you do finishing it off with what your nutrition plan, are you going to do NJ tube, TPN, all these type of things. So if you're thinking about nasal jejunal feeding at the end, make sure you also consider that that this patient is going to need some kind of nutrition support as well. And be proactive about it. I think sometimes it's often missed where, you know, you work on your drain, and then the next year, like, oh, can you now bring him back in and place an NJ tube? And so, you know, I'll usually say that at the front, you know, when I'm offering any endoscopic drainages, you know, would you like an NJ tube just for feeding purposes at index procedure, and that'll just make your life easier and help the patient with the healing process. Yeah. So I think you guys brought up many good points that we'll talk about also in the teaching. And I think the key way that we kind of approach leaks is the timing since the surgery. That's really important because there's some techniques that are much more effective early on that are not effective later on. And there's some techniques that are not safe to perform early on that are much safer to perform and much more effective later on. The other things, of course, that we want to think about, and I think you both touched on this and highlighted it, are that if there's this large kind of perigastric collection or material, it can be in the absence of effective external drainage, you can't really just close it off because you'll kind of be walling off an abscess and that patient can get very sick very quickly. So there's all sorts of different techniques, and we'll touch on a lot of these in the teaching section, but I thought this was a very impressive case, and you'll see kind of a little bit of what it looks like endoscopically shortly. So we did the upper endoscopy, and when we went in, this leak, like almost all leaks post-sleeve, occurred kind of just below the angle of his screen left, just at the top of the staple line, as Chris astutely alluded to. There was a very tight narrowing below And we think a lot of the pathophysiology of a leak is that there's a very tight stricture that is changing intraluminal ergastric pressure and kind of blowing out the staple line. And in this particular situation, this leak, everything was edematous. The leak itself was so large and the cavity was absolutely filled with material and food. And so even though they had external drainage, we didn't even feel comfortable considering like a covered metal, you know, a CEMS or a covered metal esophageal stent to help both the wall off that area and kind of co-opt against the, to prevent contents from washing through there, but also to treat the distal stricture. And only two weeks out from the original surgery is really too early to start treating the distal stricture. So we were kind of in a situation where we weren't totally sure what to do, but what we ended up doing is very safely debriding the cavity, trying to remove all of that food and different components that were in there, and then opting for internal endoscopic drainage. And so we placed several plastic pigtail stents. She actually did quite well despite presenting with this, you know, from another hospital with this crazy pneumoperitoneum and high fevers. And she was ultimately discharged and she went out on DAPOF tube feedings, which we placed at the time of the endoscopy. And I think Ahmed made a really astute point, which is our surgical team, we work very closely with our surgical team. And every time we're going to do a procedure in a patient with a leak, we are always thinking about DAPOF tube feedings because otherwise you're going to end up going back in and doing it then. Even if your interventional radiologist maybe, or your floor teams do a lot of these procedures, it's really challenging in the setting of a leak and a tight sleeve stricture to manipulate the DAPOF tube where you want it to go. And so the leak in this particular patient, which you may have seen from the endoscopic examination was basically the default pathway for passage of everything. And so we were able to kind of, we had to like wire down, we scoped with a, you know, an XP scope through the nose and advanced it deep into the jejunum. And then we were able to place the DAPOF eventually over a wire, but it was not easy in this particular situation because of the amount of edema and tortuosity in the sleeve. So unfortunately the patient did return with ongoing leakage through the abdominal incision, which was presumed to be secondary to an ongoing leak. And the patient also had to his sense of the abdominal wall and another EGD was performed. So what are the options at this point? What are your thoughts here? Yeah. I thought, I think this patient should have an ESG, should have had an ESG. No. So I think it's, I think it's, it's tough. Like this is getting, I think it's really interesting, like thinking about internal drainage within two weeks, you know, and the fact that it was a big cavity like that, because I always get worried, like, is this going to be freely into the peritoneum and when does that cavity really form? And so I think it's really an interesting thing in this case that even by two weeks, you had a well-defined cavity that even allowed you to do gentle debridement. And so how quickly it kind of walls off like that. And I think having the surgical drainage is really, really probably helpful too. But yeah. I mean, if you have this area, I would say this is interesting because you're getting a little bit, I don't know how long from the initial presentation this is, but you know, you are starting to think of like internal drainage options. Is this like endovacs targeted into that territory, you know, where you can try to get this to close off that way. And then are we still thinking maybe now it's safer to dilate and stent because it's been a little bit more time. And so it's interesting, these types of things that form cavities, if the cavities don't go anywhere, I start to question, does it really clinically matter sometimes if you have this area, if it's truly walled off, you know, that's connected to the lumen. But I do think for large ones like this, this would probably be problematic. So I'm still thinking more work needs to be done here. But this is going to be challenging. I probably start thinking about addressing the sleeve itself. If you can try to do interventions there, further debridement, and maybe thinking if it's getting more chronic, thinking about doing debridement and or endovac or maybe stenting it at this point. Yeah, those would be my options. I think I'd make a judgment call going down and seeing how things are. But I think those are probably the best options we have at hand. In addition to dealing with, you know, this most likely stricture downstream or this narrowing or angulation downstream that, you know, should hopefully relieve that pressure. Yeah, I'm just wondering, even in the back of my mind, I'm sort of thinking like, that looks so bad. Is this lady going down to bypass territory or something else like that? Is this something that we're really going to be able to fix endoscopically? I'm sure Allie Shulman finds a way, but we'll get into it. So I'll play this video. So at this point, we're now about six weeks out. And so we felt really comfortable doing a pneumatic dilation. With these dilations, you have to be very careful to make sure that the pneumatic balloon extends really between the GE junction and the pylorus. And that can be a challenge because similar to ESG, after surgical sleeves, there's foreshortening of the stomach. And the pneumatic balloon is, and you can see this crazy kink here, the pneumatic balloon is about 10 centimeters in length. And so you want to make sure that you place it, we place it both endoscopically and fluoroscopically can be helpful and adjunctive as well. But we were very aggressive about dilation. And the way that we typically dilate, depending on the clinical situation is with a, we start with a 30 millimeter balloon, and we try to get to a maximum pressure per square inch or PSI of 20 in the balloon. And so if we can't get the full PSI of 20, then what we end up doing, if we think the stricture is very tight and probably responsible for the sleeve kind of blowing out proximally, we bring the patient back every few weeks and we repeat these dilations. And so if we can get to the maximum pressure, we're repeating with a balloon of 35 millimeters, trying again to get to that maximum pressure. If we can't, then what we'll do is actually bring them back, use the same balloon size, but just try to reach the optimal pressure within the balloon. And I always tell our fellows, this is a huge amount of pressure in the stomach. You know, this is like when you go to the gas station to put pressure into your tires, you're putting your tire pressure around 30 and we're putting a tire, you know, basically a tire pressure of 20 in the gastric lumen. This is impressive. So complications can occur. You really want to be careful, especially this soon after sleeve, but she was about six weeks out and we felt like we needed to address this distal stricture or that proximal leak was never going to heal. So in this particular situation, we had cleaned, the whole cavity was now very debrided. The leak site itself was smaller. What we decided to do, and I'll show you some data about all of these leaks in general and how long these can take to heal. The kind of our endoscopic armamentarium that we have is to throw in, we dilated aggressively and we threw in some pigtail stents again. And then we let this thing sit for a little longer. And at some point you'll see, I think in the next slide that we, everything, the abdominal incision continued to leak. And what we decided at that point, this was during the same kind of admission, was to place a covered metal stent. And we'll talk about this shortly in the teaching section, but the true benefit of this is that it's still relatively early in the patient's course. These do not work well when it's later on in the course, but this was the first four to six weeks of the patient's care. We couldn't get the leakage out her abdominal wall to stop. And we knew that there was this very aggressive stricture that would require aggressive dilation over time. And we thought just like Chris had mentioned initially, that if we placed a covered metal stent that we could kind of secure it to cover the leak site and also to help open up a little bit of the distal stricture, which was so kinked as you saw in that picture. One thing I will say is that these stents really should be fixed at the top, even in the absence of endoscopically somehow fixating this to the wall, whether it be with the neuro vesco devices or endoscopic suturing, or some people will even use through the scope clips in the absence of securing this, there's about a 40% migration rate. And I think I have this in my slides at the end, even in the meta-analysis that looked at what the rate of migration or risk of migration was in the setting of suturing, it's still like 15%. So when these things migrate, they can cause major problems. We've had patients come sent to us from around the state of Michigan with these stents migrating and perforating the gastric wall. There's been reported deaths, significant issues. So this is nothing to take lightly, and we are very aggressive about making sure that we kind of fix the proximal end when we can, and especially in these situations, because we're going to leave this in for a little bit. So in this particular situation, we ultimately placed a stent. And then eventually, over the course of time, she actually did quite well. And when we brought her back for her follow-up exam, at that point, she had this very large chronic appearance of this cavity, but was clinically much, much better. And so we pulled out the covered metal stent, and then in a minute, you'll see what this looked like. But this is the kind of CT scan initially, you can see a bunch of drains and this large fluid collection. And then we ended up going in, as you'll see in a minute, sorry, we can go forward a little bit if you want. Keep going. Toward the end, I think, is probably, keep going. There we go. And so if you come back just a little bit, you can see when we first go down, there is this very large perigastric cavity, and the gastric lumen to the right. So if you want to play the video from here, you can see, oh, I think we missed a little bit of what it looks like in scoping, but that's okay. So basically what we did was an endoscopic septotomy. And she's now, this is now a chronic leak. She was like 12 weeks out, 8, 10 to 12 weeks out, wasn't tolerating oral intake well, but was clinically feeling so much better. And what we ultimately decided to do is to really dehis and cut open the septum between the perigastric cavity and the gastric lumen. And in so doing, we were kind of encountering multiple staples from the staple line. We were removing those. We were also using APC. And I think this is a nice demonstration because it shows you all of the different tools in your armamentarium to manage these situations. We did consider endoscopic vacuum therapy, but I'm going to leave that part out because I think the next case may focus on that. But in this, I'm jumping to the septotomy. And here you can see we're using a insulated cutting knife. And most of the data around endoscopic septotomies include doing maybe five millimeters at a time and bringing the patient back multiple times and using a combination of APC or needle knives. In this particular case, because of the use of this insulated cutting knife, we cut through about five centimeters of tissue in one setting. And this was her follow-up CT. She's completely asymptomatic. She left the hospital a couple of days later. She was tolerating oral intake. And we've seen her in follow-up now for the last five years. She's been doing amazing. So I think these can be really useful approaches to more of the chronic leak. But again, you could never do a septotomy in an acute leak because it depends on that kind of chronic septum. Just before we jump here, in terms of your pneumatic balloon dilation, how long are you leaving, this is a question from the audience, the balloon when you're inflating? This is a great question. There is almost no data around this. And I think there's very different practice patterns depending on where you are in the world. So I personally leave the balloon up between three and five minutes. Some people will leave this up one minute. And then I've heard some of our colleagues in Brazil say that they leave these up for 20 minutes. So I think that this is variable depending on where you are. I would love to see more actual data on this because I don't know that any exists. But I tend to leave it up several minutes. What you want to see is basically an ischemic kind of component to the incisora, which is where most of these are narrowed or strictured while you're inflating it and kind of ensuring that you're between the GE junction and the pylorus. Because if you're past the pylorus or proximal to the GE junction, you will cause a perforation in one of those locations. The other thing I'll just mention, and I think we have a video about this in VideoGIE that I should be proud of, but I'm not, is that when these things perforate, they actually are not small and they're not subtle. They blow out the whole gastric wall. And so we had this happen. I think the interesting thing, we've only had very few cases in so many of these procedures that we've done because we are kind of a referral center for this. We've had a handful of these cases, and what is always interesting to me is that they tend to perforate on the opposite wall of the staple or suture line. And I've reviewed this with our surgeons who feel that it's likely because of all the kind of fibrotic tissue that holds that staple line together, the natural wall of the stomach is probably weaker at that point. And we have been able to very safely endoscopically close all of these. So if the patient is not hemodynamically compromised, tachycardic, pneumoperitoneum, which has not been my personal experience, we are very able to just go in and endoscopically suture these closed. And in the very few cases that we've had, people have done great. It seems like one of the risk factors for this is probably a tight angulation in the stomach. The sleeve stenoses don't seem to perforate as readily as potentially these, but again, we're talking of an end of just a couple. These are just anecdotal. So I'd love to hear if anyone else has had experience with these. These are very stressful. I have to say, I usually get an extra pair of pants with me to work because they can go pretty, pretty scary. That sort of second where you're deflating your balloon, because just for the audience, this is very different than a through the scope, 20 millimeter balloon. These are balloons that start at 30. They're very robust. They don't go through your scope. You're actually passing them over a wire, then you're going next to them to kind of see the damage. We don't really do them nowadays much, especially for achalasia, because poem has largely replaced a lot of these balloons, but it's good practice to know how to do them. But yeah, they could be nerve wracking, especially for sleeve stenoses. Yeah. I think just two teaching points along that thing is there are mainly two main companies that make achalasia pneumatic balloon dilations, Cook and Boston are the main ones we know of. In actuality, the Cook one's a little bit shorter. It's an eight centimeter balloon, whereas the Boston's a 10 centimeter length balloon. So sometimes when you're dealing with a foreshortened sleeve, as Allie mentioned, you may want to think about, do you need that shorter balloon? So because as Allie mentioned, you want to make sure that balloon's not going across the pylorus, not going across the junction. So take your measurements and know that in fact, the lengths of the balloons are actually different by the companies and that may come into play. The other thing when placing a stent is understanding that a lot of these stents will foreshorten over time. Right. So you want to find the most perfect location that you think it's like covering up everything right in the right and perfect spot. And then it will foreshorten in a way that may not do what's effectively you think it's doing. For example, I've had an unfortunate position of sometimes, you know, you put a stent across the angular or the high pressure zone of the sleeve and then also covering your leak. And then all of a sudden it foreshortens and now it's above the high pressure zone. And basically you're not doing anything and you still have that high pressure zone intact. And that's because the stent foreshortens. So just be aware of these things that if patients come back with symptoms or they're having more regurgitation or anything like that, or they're not healing the way you think, you know, that then keep in mind that the stents will foreshorten and the way you leave it may be different down the road. Yeah, for sure. And then just another quick question from the audience. Is there an optimal time when you would perform these dilations after surgery? You mentioned that two weeks was probably too early. What's kind of your approach? Yeah, I would never do a pneumatic dilation prior to probably six weeks. That would be the absolute earliest. Okay. Yeah, it's a great question. I think you can get away with through-the-scope dilations. And sometimes that can be partially effective earlier on, but I wouldn't do a pneumatic until at least six weeks. The one other thing I'll mention is, Chris had alluded to the two different types of pneumatic balloons. We commonly will take the, some of the wires that actually come in the system are really not stiff enough. And so we'll commonly actually take that wire out and we'll use more of a savory wire. We try to get it kind of all the way into the distal duodenum so that we know when we're advancing these over that wire that we can, that the wire has not popped back and we know we can effectively pass this safely into the gastric lumen. Now, do you find you have to use like an XP, like scope and noodle, like a noodle scope to get down? So I'm sorry, can you just use your regular endoscope? It's a great question. We almost exclusively use regular endoscopes, but there are situations where it can be, especially in really tight angulations or in really edematous stomachs where it can be almost impossible to pass both this large balloon and the upper endoscope past that large balloon. So fluoro can be helpful to know that you're kind of proximal to the pylorus, but we almost always do it under endoscopic visualization as well, just to confirm. And so in the few situations where we can't advance our regular scope, we will use an XP scope, but it's rare. All right, Dr. Schultz, do you want to share your teaching slide? So can you guys see this okay? Okay, perfect. So when we think about gastrointestinal defects, there's really several different types. And, you know, it's important to kind of understand what you're treating when you think about what your armamentarium is for treatment. And so there's of course acute perforations where the, you know, in this situation, this is actually a picture from the sleeve dilation that I mentioned where it kind of blew out the lesser curvature of the stomach. There's more chronic fistulas, like we discussed with Chris during that last case, which are abnormal communications between epithelialized surfaces. There's leaks where you have defects leading to a communication between different, you know, intra and extraluminal compartments. And then there's post resection, which are obviously a totally different kind of cup of tea. We're going to focus mostly, in this case focuses of course on leaks themselves. And so as you saw in this case, this is really the most feared adverse event. These have really high mortality ranging from 12 to even 50% in some studies, depending on how sick the patient is. They present with variable range, but oftentimes when people are sick, they're very sick. And so in this case, you saw the classic presentation, which is tachycardia, leukocytosis, elevated inflammatory markers, and really fulminant peritonitis or sepsis. The frequency of upper GI leaks, you can see in this kind of these numbers below, and I'm going to skip some of this just for the sake of time. But what we have been seeing is that with the increasing number of sleeve gastrectomies being performed, the incidence and the prevalence of those has really increased. So unstable patients, and I think Chris and Ahmed both mentioned this, they really go directly to the operating room. There's no role for endoscopy in someone who's unstable. But in stable patients, we really think endoscopic intervention plays a major role in the management. And usually these are performed under general anesthesia and with fluoroscopy. Commonly, as we discussed before, there are intra-abdominal collections associated with these. And if there is, those need to be adequately drained. And then also thinking about kind of antibiotics and what we discussed with enteral feeding as well. I started to mention this before, but the timing and the chronicity very much affects the management strategy. So we talk about acute or early leaks, which are really in the first six weeks, and then more late or chronic leaks, which are really six to 12 weeks or later. The size of the leak, just like fistula closure, the size of the leak really plays a major role in how to treat it. And we have a growing endoscopic armamentarium. So there's the self-expandable metal stents that you saw in this case, the endoscopic internal drainage with plastic pigtail stents. We have different septotomy devices, like you saw. There's mechanical devices, you know, like suturing and a vesco and the aponos or padlock clip. There's tissue sealants that have even been used commonly. And then also, of course, endoscopic vacuum therapy. But the one thing to really note is that distal dilation of the incisor or that area that is potentially narrowed is imperative for treatment. So we were part of an international study that really aimed to evaluate the effectiveness of endoscopic therapy for some of these leaks. And this included patients with all types of leaks that I mentioned before, but about 40% of them in this particular case were sleeve gastrectomy leaks. It was 206 patients who underwent a total of 775 endoscopic procedures. And what you can see is that the clinical success really correlates with the length of treatment with about 80.1% success overall. However, when you're starting to reach, you know, three to four or even more procedures, there's some plateau in the success rate. I love this image from, I show this in almost every talk I give about leaks, which is an image just from a random surgical article on obesity surgery from 2018. But I think this very well describes kind of the different types of leaks that we see in clinical practice. So type one leaks are tiny. They don't have a documented collection and, you know, we treat these totally differently from type two, where they're associated with some sort of intra-abdominal abscess, or even worse, type three, where you can see leaks connecting to a whole complex system. We've had gastrobronchial leaks, we've had gastropleural leaks, we've had gastropathic leaks, gastrosplenic leaks. These can go anywhere. And these really are, the management is very much individualized. Again, I mentioned this before, but I can't emphasize this enough. These really seem to occur when the intragastric pressure exceeds burst pressure. So these are often precipitated by that distal structure. And as I mentioned, again, all of these pretty much develop at the proximal staple line. Sometimes you see them in the mid-stomach, but that's rare. And usually when it's in the mid-stomach, you also have another leak in the proximal stomach. These happen mostly there because of this area of relative ischemia. This is where the surgeons will do their takedown of short gastric arteries. And it's really a zone of increased pressure, like you can see from this upper GI series. You also can see in that bottom picture kind of the common suspicion that there could be a sleeve structure or a leak with the pooling of bilious fluid. So there, I'm gonna blow through this for the sake of time, because I think we've hit a lot of the highlights of this, but there are so many different approaches. Usually diversion therapy or covered metal stents are used in acute or early leaks. And as we had just discussed, these really should span from kind of the distal esophagus across the leak site. And ideally through the distal stomach where there could be a stricture as well. Sometimes you can consider overlapping these to achieve the appropriate extension or coaptation. But the idea behind this is that it's providing an integrated flow of secretions to kind of subvert or avoid that area of a leak and let it heal. But of course, as I mentioned, you wanna fixate the proximal end. And there are stents that are specifically designed for more bariatric use that I think we'll see more and more. The reported success rates are high in early, early leaks that are treated with stents. But it's really important to think about the fact that many of these migrate. And as I mentioned, there's perforations and there's deaths reported in the literature associated with that. In a meta-analysis, as I mentioned before, the pooled migration rate, despite endoscopic suturing was 15.9%. So these really have, you have to really think about how to keep them in the esophageal lumen. Next is endoscopic internal drainage. And this really just facilitates drainage. The idea behind this is very much like a necrosectomy, where we're kind of going out into a leak, we're cleaning the whole area out, and then we're allowing stents to kind of traverse between the intragastric lumen and the perigastric cavity. And these used to be, as Amit had mentioned, used to really only be used in chronic leaks, but more and more, and there's literature to support this, we're using these in the acute setting. You have to be very careful in the acute setting because of course you're kind of entering a cavity and ignore my artwork, this is horrendous, but you're threading wires through and then you're placing these stents. But oftentimes what we're also doing is injecting a bunch of contrast to kind of fill the area and delineate it a little bit. And you don't want to do that in the very acute setting because you can really cause sepsis or peritonitis. Septotomy, as you saw in the video, this is, oops, sorry, this is really only used in late or chronic leaks. And it requires a fibrotic septum, as you saw in the video. I don't know why the image isn't showing up on the right here, I apologize for that. But you basically, as you saw, you really want to make sure that you're exposing the cavity and equalizing the pressure. So you have to make sure that you're getting all the way to the bottom of the leak site. You don't want to just stop partway down because you'll still have that change in pressure across that lumen. You want to make sure that you're fully getting to the bottom, bottom of that cavity. And then at that point, you can stop. So just some take-home points about leaks, kind of similar to what we learned about fistulas. These are really the most feared adverse event, but you should look for all the signs of a leak early if you think patients are presenting with these. The majority, as we mentioned, occur at these increased zones of pressure. And endoscopic management is usually successful with this growing armamentarium, but it does really require several procedures and persistence. The size, the chronicity, and the location are all important. And I think it's really important, I can't emphasize this enough, that these types of complications really require multidisciplinary approaches. So we review all of these with our surgeons and our interventional radiologists when we go to treat them. So thank you. Thanks, that was great. Thank you. Michelle, maybe in the interest of time, I'll share my screen and I can start quickly running through the presentation so we're not flipping through. Okay, so we have a 52-year-old gentleman who comes in with a persistent esophageal defect. He had atrial fibrillation. He underwent, at an outside facility, an ablation and pulmonary vein isolation. And four months prior, he had developed chest pains. We were seeing him kind of late into his presentation after this ablation, and he was found to have this atrial esophageal fistula and an esophageal tracheobronchial perforation. Obviously, he went for surgical repair of his fistula. The left atrial perforation was also fixed. They did a bronchial stent for a period of time and they placed a J-tube. Despite all this, he had a persistent esophageal fistula, unfortunately. This is sort of a picture representation. The yellow arrow is showing where that lumen is and this sort of defect at six o'clock that's sitting there. There's actually some pus every time you suctioned coming out of that base of that defect where that red arrow is. So we can probably all agree here that it's probably worth attempting an esophageal stent. Again, just in the interest of time and showing you some didactics about what we're gonna talk about today. He did actually have two stents placed at an outside facility, unfortunately, without much benefit. He did have a barium swallow, which you guys can see here. It shows that there's still a bit of a leak. Is the barium kind of moving around your stent? What's really happening? Why isn't the stent working properly? And so this is kind of where we got involved with this patient's care as he's failed at this point, luminal stenting. And so going through what you have here, obviously your armamentarium isn't as robust compared to the great presentation that Ali had given. But this is sort of where we thought that VAC therapy would be a great option for this patient. And I think it's important to mention VAC because I think we're slowly maybe starting to adopt this here in the US. I still think there's room to kind of do more work. I know people in Brazil do this on a routine basis for a lot of their leaks now. And it's sort of something that we're slowly getting into and definitely got me out of my comfort zone doing this. The concept of VAC therapy is really kind of similar to treating an abdominal wound, kind of what the surgeons do. You're applying this negative pressure through a sponge to induce healing of a defect. Looking through reviews, it's kind of interesting how that works. There's increased blood flow to the area from this negative pressure. There's a cytokine mediated sort of response. There's less edema. You're removing all these microorganisms, this debris, and then you're approximating edges. All that contributes to the closing of the defect. And it hasn't been around for that long. In fact, one of the very first few ones were done for rectal perforations actually. But looking at data and a lot of the big data that's out there, you can have pretty good success rates that nears 100% and varies between 80 to 10%. There's been some proficiency in learning curve studies showing that if you do about 10 of these, you should be pretty comfortable doing them. And then the biggest issue, and we can talk about the limitations, is the number of treatments you need. This isn't a one and done deal, unfortunately. This is why I think it's a bit of a limitation and sort of something that is really resource consuming. Biggest issues, complication-wise, dislocation of the device, mild bleeding, aspiration pneumonia, and stricture, especially if you're working in the esophagus, is a big one as a late complication. This is the patient that we were managing. This is here a video representation. Again, knowing what tools and instruments you're using, it's probably one of the hardest part. This isn't something readily available to you. You have to take your shopping cart, go down to the OR and kind of be nice to the OR nurse charge and be like, can I take this, this, and this? For them to be like, what exactly are you doing? But usually an NG tube, you need a grasper, you're gonna have to have this sponge or the cell phone. That's the sponge they use for their abdominal wounds. Have a good type of suture that you can suture this onto the tip of your NG tube. And then either use the actual vac console that they use for suction, or you can use wall suction, which is completely also fine to use. And so the way you approach this is you're kind of building everything. You're creating this vac sponge. The first thing is to place the NG tube. Remember, it has to go through the nose. Here, we're passing it through the nose and actually grasping it from the back of the mouth so it's coming through the patient's nose, out through their mouth, because that's how you're gonna attach your sponge. So you guys can see it there coming out of the patient's mouth. The next step here is we're just gonna put a suture loop at the tip so that way you can grasp it and gives you a little bit sort of more control as to where you want to put it within your cavity. So we're just using Kelly clamps here. And then you're sizing it. This is kind of difficult, is how big a big sponge won't really work too well and a small sponge won't let it heal. We punch a hole through it, usually with scissors. I'm just kind of going through it by making a hole and then I'm grabbing my NG tube and then I'm passing the sponge over the tip. And you don't want to cover all those holes. You want some to actually remove the secretions. And then the last thing is I'm taking a suture and this is having my fellow wrap around it really hard until they're making a nice sponge at the tip. And the goal is to try to advance this sponge with the NG tube into your defect. And then you're gonna repeat this multiple times during the patient's hospitalization. Usually just grasp it, take it out. You cut the tip and you take it out through the nose. This is day zero of the esophageal fistula. This is how usually it looks like. This is the first exchange. This is I think the second exchange. And this is sort of the tail end where you really want to see this very nice granulation tissue. And this is their final esophagogram at about 21 days or so. So I think three to four exchanges. So a very good option for your patient, which is one that we have to probably be a little bit more comfortable using. This is again, four exchanges in total and you guys can see that that area of leak has improved. There's a little bit of a defect or cavity there, but that's not communicating and nothing that you should be worried about. And this is kind of what you want to see is absence of pus. You can pass a guide wire if you want. You can do a poor man's esophagogram by injecting contrast through your endoscopy and then confirm that there's nothing there that's concerning. I don't read a lot of cardiology papers, but this is actually a great one on the risk of injury to the esophagus after ablation. And that's why a lot of times these patients have a probe down their esophagus to see how much heat is there, but the damage can vary from just simple sort of burn injury to full thickness defects. And the one thing that they mentioned is esophageal stents work very poorly for these patients. And so they are an option, but just know that the success rate is quite limited, unfortunately. In terms of data, I won't go through much into detail, but there's a lot of data. There's Borhoff data and using endoscopic back therapy. There's a great paper from the ASMBS, Swords or Surgery for Obesity and Related Diseases about the use of VAC therapy for bariatric related leaks, which works quite well in a very high technical success rates. And then there's been tons of meta-analyses using this in patients and it tends to work quite well. So it's something that's important to keep in mind. I think the biggest issue is this isn't easy to do. And I've done this a few times and now I've become the VAC guy, unfortunately, and I don't know if it's a good thing or a bad thing to be honest to be that person because you're getting called and you know you're with this patient for a while. These patients are usually in-house because it's not easy for them to go home with a sponge and an NG tube through them. You need general anesthesia. It's quite resource consuming. We don't have good VAC systems. Some companies are coming out with stents that have a sponge at the tip, but this is all us kind of coming up with things to make sure that it works some way or another. The procedure isn't very easy. Having to put the sponge and going down, it's quite difficult. And there's just a lot that needs to be done to kind of refine this technique, but one that's I think good to have in certain cases when you need it. I think for example, Alice's case may have kind of responded. I find VAC therapy difficult to do beyond the GE junction to be honest. It's just, it's hard to fit your sponge into the stomach sometimes. It just wants to fall with gravity. But sometimes you can argue this is something I can use for sleeve leaks if they're quite proximal. I am going to leave it there since we have just about a few more minutes left. We're happy to answer any other questions. I want to get your guys' thoughts about VAC therapy. You know, what you've seen in your practice, what limitations you have also seen. Yeah, Amit, that was great. I'd be curious from this particular case, you showed beautiful images of the healing kind of over the course of time. And I think of course you've highlighted all the maybe potential limitations of it, just purely that you have to keep patients in house for a while, obviously worth it when you are healing these major leaks, but that you have to constantly be repeating the procedures, you know, over and over again, and then the negative pressure and everything else. How often were you doing these exchanges? How long did it take you for this particular patient with this massive defect to close in this situation? Yeah, so we brought him down roughly every five to six days. I think it's pretty tricky because our schedules were very consistent. It was hard to have other colleagues agree to do some of these exchanges. So I had some people do one or two, but he had a total of four before we said, you know, it looks pretty good. We actually then followed up with him two months later. And, you know, other than a bit of dysphagia, which I think is happening from some stenosis in that area, he actually was feeling quite well. He had his tube out and he was actually tolerating oral intake, which was pretty nice to see. Amazing. Yeah, and you know, these usually come in boluses because we then got three after that within the next month. And then, you know, you don't hear about them at all. Until they come again in a year or so. Okay, do we have any questions at all? Is it difficult, this is a question from the audience. Is it difficult to secure the position of the sponge in the esophagus? Will it drop into the mediastinal cavity? Yeah, you know, I've seen cases of back therapy where it's, you know, not as a superficial defect as the one we have here. And no, they're actually putting these deep in. And I think the esophagus is pretty easy to work with because, you know, it's just one kind of long structure. Your sponge is sitting with gravity sort of where you want it to be. So in this particular case, it wasn't. The only thing is the lumen was probably almost fully occluded, but that's why the suction helps because some of his secretions that, you know, he probably can't swallow down are kind of coming out with your suction. So you'll see that. The one thing that is as difficult is if you're using the actual VAC console that they use for wounds, those things tend to alarm a lot and you always have to troubleshoot them. So, you know, with our first exchange, we used it and the nurse was like, I just can't do this. Every two minutes, this thing is going off. So we switched to wall suction and that actually works quite well. It's usually medium wall suction, or if you can gauge how much, it's about 100 to 150. Okay. Okay. I think we went through pretty much everything under the umbrella of fistulas defect. So I wanted to thank you guys. Michelle, thank you very much for moderating. I thought, you know, I learned a lot to be honest, just listening to Chris and Allie go over sort of what they do in their practice. So I wanted to thank everybody and all of our participants for joining. I hope we were able to teach you guys new things and thanks again for joining and I'll give it over to Michael here. Thank you. I appreciate that. Thank you to our Advanced GI Fellow moderator and to our content experts for tonight's amazing presentation. Before we close out, I want to let the audience know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of 2024 ASGE events. We may even have a couple of 2025 events out there. Our next Endo Hangout session, Surveillance and Inflammatory Bowel Disease will take place on Thursday, November 7th from 7 to 8.30 p.m. Central Time. Registration is open. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to sign up. In closing, thank you again to our presenters for this excellent webinar and thank you to our audience for making the session interactive. We hope this information has been useful to you. And with that, have a wonderful night.

therapeutic endoscopy

fistulas

leaks

perforations

PEG tube

gastrocutaneous fistula

over-the-scope clips

post-sleeve gastrectomy

endoscopic vacuum therapy

methylene blue

pneumatic dilation

multidisciplinary approach