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, Endoscopic Management of Post-Bariatric Complications. My name is Michael DeLutri, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping notes. We want to make sure that this session is interactive, so feel free to ask questions at any time by clicking on 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 it 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 GI Fellow moderator, Gretchen Evans, from the USK Keck School of Medicine. I will now hand over this presentation to her. Hi there. Welcome, everyone. Thank you for joining us tonight, and thank you, ASG, for hosting. I'm Dr. Gretchen Evans, the current Advanced Endoscopy Fellow at USC Keck, where I have the absolute privilege of learning from the amazing Dr. Jennifer Phan, our host tonight. I've obtained an MPH with a focus on obesity, and I've also just completed the Obesity Medicine Boards. Tonight, we have the pleasure of learning from three advanced endoscopists at the forefront of endobariatrics, Dr. Roberto Simónes-Linares, Director of Bariatric Endoscopy at the Cleveland Clinic and founder of Obesity Alive, a multidisciplinary case-based virtual meeting to discuss current and emergent obesity therapies on Thursdays. And we also have special guests, Dr. Rabindra Watson, one of the original pioneers in the field of bariatric endoscopy, especially on the West Coast. He is currently Director of the Metabolic Health Program at Cedars-Sinai. And our host tonight is the fantastic Dr. Jennifer Phan, who's a leader of bariatric endoscopy here at USC CAC. And I had a sneak peek at the slides, and we are definitely in for a treat, lots of learning to be had. So I have the great pleasure of being able to share this platform with such great people. And I want to be able to make this very interactive, so there's almost no, there's almost no lecture here. It's really about discussing cases, and I think when we're talking about bariatric endoscopy and bariatric complications, each person is quite unique, kind of one size may not fit all. So this is where we get to, you know, talk through our decision-making and what we think is appropriate for patients. And we may have different opinions on what is appropriate for a patient, but that's what's great about this field is, again, that there's many ways to do things well and to do things right. And so let's get started. So for the overview, this venue is to encourage a lot of questions and a lot of conversations. So please be quite aggressive at asking questions. There's no such thing as a silly question, because if you have one, that means everyone else is having one as well. The overview, well, we can't start off without talking about obesity in the United States, so we'll go through that a little bit. The question next is, what anatomy are we encountering? Is this normal or is this abnormal? Followed by what are common post-bariatric surgery complications, and I know that there are both general gastroenterologists and those that are going into endoscopy focusing on obesity. And this is meant to really understand what complications we should look first, what we should do first, what should be done by a gastroenterologist, and what can be referred to an advanced endoscopist for some more specialized therapy. And then what are some uncommon post-bariatric surgery complications that typically require multidisciplinary discussion? And so for an overview for obesity, I don't think Rabindra or Roberto have given a talk without showing these slides, so not to break from tradition. So what we see here is the rate of obesity or the prevalence of self-reported obesity in the United States in 2019. Look at the colors and look how much darker it looks in 2021, right? We see that a lot of America will self-identify as being obese, so up to 35 to 40% of Americans will self-identify as being obese. This is looking at non-Hispanic whites, and this is for our Hispanic adults. So you can see that many more will self-identify as being obese, up to 40 to 50%. And so this becomes not a problem for any individual subspecialty, but really for all subspecialties, and we know that based on kind of how the trends are going in our subspecialty alone that GI should be at the forefront of this. And so we know that the treatment of obesity is a multidisciplinary approach. I think we can go on and on about the advent of huge medications that have come on the market. All three of us here and the four of us, including Gretchen, who's learning from me now, all do bariatric endoscopic procedures as primary therapy or as secondary therapy, but here we're really talking about the patients who have undergone bariatric surgery. Now, it's important to know that as before, two to three years ago, we really had two indications for bariatric surgery, a BMI of 35 with one related obesity complication or a BMI of 40. Recently they've expanded the insurance coverage for patients with bariatric surgery to include patients with a BMI of 30 with type 2 diabetes. We know that this is the gold standard, we know that 1% of eligible patients undergo surgery, but think about where we are now and think about where you may be 20 years from now and think about 1% of the population undergoing surgery that is still millions of patients that will come under our care. So we're not talking about what we're going to see at this moment, but we need to think about what we may see now, what we may see 20 years from now and how much of the population has actually undergone some sort of surgical or endoscopic procedure. So how many bariatric surgeries are done each year? And you can see here, this graph goes from right to left, but around 200 to 250,000 procedures are done each year. If we were to take bariatric surgery in the last 40 years, you'll see that there is going to be a vogue bariatric surgery at every decade. So at one point, right, the band was super popular and at one point rheumatoid gastric bypass was super popular. And now what we see in general is that the sleep gastrectomy is really popular and takes up around 90%-ish of what patients undergo. But remember, again, these complications are not what we see right now. We are seeing complications from when lap bands were in vogue or when rheumatoid gastric bypass were in vogue. And so we need to understand kind of all of this anatomy to make sure that we can best take care of the patients. So what is this anatomy and what is normal? So you can see this is just a snippet of the surgeries that have happened in the last 20 years. There's many more of us. And this pretty much ends kind of the lecture base. And now we start to go way more into case space. So this is this and what is this anatomy and is this anatomy normal? So this is a 52 year old female history of rheumatoid gastric bypass in 2013. She lost 21% of her total body weight loss in the first two years, but since has regained weight. She's now only around 5% of total body weight loss in surgery. She comes to you with weight regain. So I asked the panelists, is this normal? And is there what anatomy is this and is this normal? So when we when patients come into us, they think they had a gastric bypass, right? We hear this all the time. I think I had a sleep. I think I had a bypass. So is this a gastric bypass? And yes, it looks like that's the gastrointestinal anastomosis. It looks horrible to me. Just to just introduce another term now. But it looks like a like a run wide gastric bypass. You see the rule in I think that the rule might be on the right, but I haven't yet probably the right and the left is just a candy cane of that rule. And it looks healthy. I don't see any marginal ulcerations. I don't see any fistulas in that area, although I haven't seen the whole pouch, especially on the left side, but it looks pretty healthy, except that like to your point, is this normal? I'll say that that gastrointestinal anastomosis is dilated and incompetent and basically, you know, probably I'll estimate somewhere around maybe 25, 30, 30 millimeters probably. Yeah. So Roberto, what is normal? Like if this was a patient that we saw at the two year mark post rheumatic gastric bypass, what would you consider to be normal for the GJs doma and for the pouch type? Yeah, that's a great question. You know, I think, I think long story short, I don't think we have very, very good data to like fixing a number, but I think let's go to actual stenosis, right? Like what will be a stenosis? Usually if you read the literature and actually in clinical practice, something that where the scope cannot pass or 10 millimeters or below, we for sure know that's a stenosis, but then somewhere between 10 and 15, maybe patients, some patients will develop some symptoms and I'll say, you know, you should assess case by case. Sometimes I'll see an anastomosis are between that range patients still completely fine. You know, they're fine. I think most people agree that over 15 millimeters is something that, you know, is already abnormal. And I think most people would agree 18, 20 millimeters, you already have an increased risk of weight regain, dumping syndrome. And I'm curious to see, Ravindra, what do you think? Correct me if I'm wrong or add anything, please. I agree. I agree. I think we're looking at, you know, somewhere between 10 and 15, 10 to 12 is ideal. The common question is, well, how big is the stoma that we're looking at right now on the screen? How do you figure that out? And they used to have this measuring device that Olympus had, right? They could lay it down and measure by the marks. But I always say when I'm teaching this is, you know, imagine a polyp and a snare, right? And you're putting a snare on the polyp when you're in there and you can imagine, okay, what snare is going to fit around this stoma, this polyp? And this looks like, yeah, maybe like you could use a 33 snare, right? To get around this one. So you could estimate like Roberto had mentioned, maybe 25, 30 millimeters is in that ballpark. And then the other question people have is, okay, well, what's a big pouch, right? We often say, oh, we had to do a pouch revision, but why? And again, variable definitions, nothing concrete. My sort of simple way of thinking about it is, you know, usually pouches at most five centimeters in length, roughly that's what they're shooting for. And the other is if you can retroflex, particularly if you're going in to tour somebody and you can take that 2T scope and retroflex, that's pretty clear the volume is going to be high. And there's other objective ways to do it, but in terms of the simple ways to think about it, think about a snare, one, like Roberto mentioned, can you get the scope through and how close is it to the scope? And then to measure, imagine what snare you're going to pick to take out that polyp and then can you retro? And then again, as Roberto mentioned, we also have to look for a fistula and particularly on that left side, as we dip into this pouch. So that's what we'd like to see on this exam is you've got to look over there and take a look at that staple line, particularly with the older undivided gastric bypass, right? That very common fistula is along that left side. I agree. We can't do that fistula talk too early. This is like the first line. Yeah, we're covering a lot of ground already. So, you know, when we think about where my gastric bypass, and I want to make sure that we really cover this well, because we, I think we have first and second year fellows here as well, right? We need to make sure that we understand the anatomy. We talked about the GJ anastomosis, the JJ anastomosis, but when I think most of the fellows, when we think about where my gastric bypass, this is like the limit to what we think it is, but that's not what, what it really is, right? And this is exactly what Roberto and Ravindra were talking about. When we think about it in the terms of bariatric endoscopy, this is what we think about. What was originally the surgical size and how different was it from that original surgical size? Some of it may be normal. We may expect the stomach to stretch out a little bit, right? And, but how far is it from normal? So I love to reference this one here. This is the consensus statement from the obesity surgery group for so far my bariatric surgeons, that this is what they were meant to aim for when they're doing the surgery, right? So if we look here, the C length here is that pouch length, right? The length of the created pouch, the goal is three to four centimeters. So that's why when Ravindra says around five centimeters or so, that's close to what it was surgically made as in the beginning, right? Then we see the stoma length, right? The width of the gastro neurotomy was originally made as a 1.2 to 1.5 centimeters. That's a kind of a normal-ish stoma length. And that's what the, these standard principles were for the surgeons to follow. And so this is a great kind of tool when we're looking at, you know, what is normal. And I really want you guys to think and to look at this because it actually shows a version of every single bariatric surgery that has been undergone in the last 20 to 30 years. And this is what their standards are for bariatric surgery. So when we think about it from this perspective, this is what I'm thinking about. Not kind of this anatomy, but this anatomy based on kind of the length. Okay. This is a patient that actually came in to me, a 62-year-old female, history of a gastric sleeve and progressive weight loss, nausea, oral intolerance. This one, we're not going to get into much of like what's happening, but what is the anatomy and is this normal? So she told me she had a gastric sleeve. And in my mind, when they say that, I think of a sleeve gastrectomy. I'm going to let this play, but- I think this is not a sleeve gastrectomy based on the- This is not a sleeve gastrectomy, right? And also the anatomy. Yeah. So I came into a full normal stomach here, right? What is this anatomy? Right. So we dropped in through the G junction and then we went through some gastric, you know, because of a few centimeters and there's another narrowing there. So what is that? So I'm full duodenum here, right? And then I'm retroflexing and I see a full cardio fundus. And then that's my scope going through. This is not a gastric sleeve, right? And I'm going to stop kind of right here with this line right here, right? What is this anatomy? It's not a sleeve gastrectomy. And anyone in the audience, does anybody have a thought of what this anatomy is? We'll give it like five seconds. Okay. We have a possible wedge resection. What is this anatomy? It's kind of similar to a wedge resection. Similar. You're super close. All right. Ravindra, what do you think of or what comes into your mind here? So it looks like, yeah, can you replay? We can walk through. Yeah. Because it almost looks like when you look at this anatomy, you're at the distal esophagus, you drop into essentially what looks like a gastric pouch, right? But there's a staple line to the left side, then another ring. It's basically like a vertical banded gastroplasty where you have that band there, that second almost G-junction. And then when you retroflex, you can see that cut line, that staple line. And so those are the key kind of features that tell you what we're doing. I'm going to go through the next slide just so people can see what we're seeing, right? What you're talking about. Right? So Ravindra, you said we're going through the EGJ here, right? I'm putting my mouse into this pouch here, through this ring here, right? Then through a completely, you know, maintained almost stomach, right? So it's important, I think, for us to know what this anatomy is, because what if I thought this was just a stricture or stenosis or something funky, right? So without knowing that this was an implicated and actual surgical anatomy, right, I wouldn't understand really what to do here. Right? Yep. Beautiful. Go ahead, Roberto. I was going to say that outlet is very important. It looks a little stenosed, maybe tanned, or it looks a little inflamed. So I think what Ravindra was saying, like the key features, that is a pouch, right? Like it's basically a VBG pouch, and then there is an outlet, but sometimes you will see also the mesh eroding, or it's not really an anastomosis. So I call it an outlet, you know, the VBG outlet, basically, and you measure the length from that pouch to the outlet. So I just wanted to add that for the fellows. Perfect. All right. Next one. What is this anatomy? So I'm going to skip forward a little bit here. So I'm going to go through, this is a hiatal hernia, right? History of a quote-unquote gastric sleeve. Is this a sleeve gastrectomy? Right? So this looks kind of like a sleeve. It looks like a sleeve. And then... What was that? Anastomosis. And there is an anastomosis at the bulb. And is this a loop anastomosis, or just like a, let's see. Just one length. One length. Okay. All right, Roberto, what do you mean by that? What are you thinking? Well, right now, as I saw that anastomosis, you know, one of the two most common options I'll say is either this patient had a duodenal switch or a SADI. And that's what I was asking. Is there a loop anastomosis or not? Because if there is a loop anastomosis, then it's most likely a SADI, which is, you know, the single duodenal ileal anastomosis with a sleeve. That's what they call it. So it looks like only one, correct? So it's probably a duodenal switch. That would be my bet. Yeah. So, you know, this used to be in vogue because people lost a lot of weight with like the duodenal switch. And then it kind of came out of vogue. Roberto, can you talk about that a little bit? Is... Why? Am I that old? With the good old days? Yeah, I mean... No. But, you know, Roberto described it perfectly, but the simple idea of this anatomy, and I'm sure we have a diagram up, but so you have a sleeve gastrectomy and then you have this very, very long bypass. So it's very, very effective. Right? So people lose a lot of weight, but it's also, as you can imagine, very dangerous. People have malabsorptive issues, excessive weight loss, and, you know, and decades gone by, you know, liver failure, things like that. So it's sort of fallen out of vogue, especially as just a gastric sleeve alone is basically born out of this duodenal switch. Right? So they said, oh, why don't we just do the sleeve alone and not do this crazy bypass and patients still lose weight? But so we don't see it too often nowadays, but I think this is a good case example to remind us that if you see that in asthmosis, something else is going on. Right? It's not just a simple gastric sleeve. Yeah, exactly. The other thing I wanted to add is that, you know, one of the fathers of this procedure is Michel Gagné, who is, who at some point was at the Clinton Clinic, then moved to New York, and now he's in Canada. Right? So this guy, this Dr. Gagné, he invented basically this procedure and was the first surgeon to my knowledge to perform this. And that's how a sleeve gastrectomy was born because, you know, this is like 1999, you know. I'm not that old, guys, but I have some mentors who've told me these stories, right, who know Dr. Gagné, but, you know, they thought that the sleeve gastrectomy was not going to be enough. And then after this, you know, the thought was like, well, how about we just do the sleeve part, basically. But just for the fellows, it's important to know, you know, this was the first step, actually, to then just do a sleeve gastrectomy down the road in 1999, if I remember correctly. Yep, exactly right. Okay. So now we're going to switch to the next one, which are what are common post-bariatric surgery complications? How do I manage them as a general GI physician? How do I manage them as an advanced endoscopist? And I think this is important because, you know, I do think that the first line of defense of where most people are seeing these complications is within the general GI field, right? So we want to make sure that, you know, there are things that we for sure can be therapeutic on within our toolbox, and then what we need the advanced endoscopist with that extra year in order to complete. So first, we're going to go through room-wide gastric bypass complications. And so, you know, we talked about this a little bit about weight regain, but remember, when you're going through a room-wide gastric bypass, any surgical option in order to do either weight regain or for complications has a lot of different comorbidities and morbidity outcomes. And so, for example, when patients weight regain with a room-wide gastric bypass, the alternative is to do a limb lengthening conversion or switch to a duodenal switch. And we did talk about kind of the limitations of converting to a duodenal switch for promoting more weight loss, but a lot of concerns about liver steatosis and cirrhosis. And then to surgically repair room-wide gastric bypass complications is also very complicated. So for open revisions, lots of early morbidity related to leaks and infections and pain, a 2% mortality. And in trying to revise anything laparoscopically, it's technically very challenging, and up to 50% of cases that are attempted for laparoscopic revision end up kind of getting converted to an open revision. So this is where endoscopy and GI is really important in this multidisciplinary discussion for patients who have rheumatoid gastric bypass complications. We can't talk about weight regain in a rheumatoid gastric bypass without promoting a TOR. And so a TOR is a trans-outlet reduction endoscopy where, again, we take an outlet that is really wide here. This is around 3 centimeters or so. We APC in order to deepithelialize that surface area. Now it's significantly promoted that we do a purse-string suture around the outlet in order to tighten it over an 8 to 10 millimeter balloon. You can see that here. And then this is what it looks like around a month later, kind of nice and scarred down. So this, in terms of the types of bariatric endoscopy procedures to start with, this is kind of one of the ones that we think about. So we have a question here about any experience with a vescovari besides a TOR. So I've used it a couple times. I have a couple thoughts. Rabindra and Roberto, have you used the obescovari device for this? Yeah. Yeah, I haven't used it. I've been so happy with suturing. So I'll leave it to you guys to comment. Yeah, I have not used any. One of my patients have used it in, you know, lab. So I have not have any experience with my own patients. I think it has its pros and cons. But, you know, I think for the fellows, before we go into like the actual device, I'd like to make two points real quick. I think tissue opposition is one concept that you guys need to learn. And, you know, that can be achieved with multiple devices, including, you know, different type of clips, sutures, placations, et cetera. But then the gastric remodeling or that remodeling of that tissue is like it's a different step. So I think opposing the tissue is important. But, you know, the actual remodeling of that new shape, I think that's where the money is, you know. So I think many times it's like you may use something to close something. It looks great in the picture and then it will still leak. It will still not, you know, do the job. So I think suturing has sort of proven to us, you know, with, you know, data and multiple clinicians reproducing similar outcomes, I'll say that is happening, you know, that remodeling like you have in your beautiful pictures there is what you're achieving with obviously the opposition, but also the treatment of that mucosa. So mucosa to really try to, you know, remodel that. So I think for devices like over-the-scope clips, the bar is just a bigger clip like an OTSC. And basically you are closing that anastomosis in one side. I think we still need to see more data. I'm only aware of that study from Italy of, I think, seven or eight patients. I know actually the inventor of the device, Antonio, and I think obviously from that company and that produces a device. And I think at the beginning they were not doing enough of DPT allelization. They were doing just a little bit of EMR and, you know, I think that they needed more APC. So I think those results doesn't also, you know, really show the potential of this device, but I'm curious your experience, Jen, your thoughts. I think it has potential. That's long story short. We just need to see these procedures, more data like done, I think that the right way with like more APC or ESD or something that will, you know, allow the remodeling. But what are your thoughts, Jen? Yeah, I mean, I agree. No one has a lot of experience here in America in general. I would say in the beginning there was concern of kind of creating kind of unintended kind of infinity sign with like a little side hole here, you know, for like tissue or for food to kind of bypass around. I agree. I think that we need to have more data before we adopt it to the degree that we adapt TORI's because TORI's is tried and true. We have over 20 years, you know, 15 years, 20 years of data. And I would say that, again, really interested to see kind of in bigger studies, the complexity of doing that versus a TORI. Because I think for those of us that do a TORI commonly, it takes around 30 minutes or so. I would say for a general gastronomy, all those GI fellows that we have here, one option if you don't suture is APC, right? APC is really effective for a certain size outlet. So, for example, if we see an outlet around 12 to 15, you may just go from B to D with just a little bit of APC around it. And it's really important to make sure that you're not touching this small bowel mucosa because that's where a lot of pain happens if you APC the wrong side. But say for a general GI fellows that want to kind of go into this space and don't suture is that this is a possibility for the right patients here. I'd also kind of hone in on that. I'm sorry, go ahead, Gretchen. So hone in on that. Some questions I would have if I were starting my fellowship. What is the theorized mechanism of APC and how it helps here? And would you, I may have missed it, but would you point out what A, B, C and D are showing? So I'll start with A. So A is your GJ stoma that's dilated causing weight regain. B is the APCing of that stoma on the gastric side. I like to think of it as, you know, a ring, right? At least a one centimeter ring around the stoma site. C is us doing a purse-string suture and closing down the stoma around an eight millimeter balloon. And then D is what it looks like when it's all scarred down. Great. That means I got some comments. Oh yeah. I was going to answer your question, Gretchen, too. The APC is causing cicatrization or scarring and tissue remodeling as that's a more elegant word for it that Roberto had mentioned that's going to reduce the aperture of the stoma. But what I was going to mention is, you know, we should have said at the start too that all of us should be able to manage bariatric complications to some level. And really all gastroenterologists should be really leaning into bariatric endoscopy. And I think it's a part of what we do as gastroenterologists. And we need to take our head out of the colon and start thinking about obesity care and metabolic care. So all of you on this should be really, I'm sure you're all excited to be here and learn about this and you should really seek out mentors and training in these things. If you imagine, we'll talk through the rest of these cases, but again, we mentioned APC, we mentioned over-the-scope clips. These are things that you are doing now or will do very soon. Even suturing. Suturing is something that you can learn without doing an interventional fellowship. There's a lot of industry support between Apollo and now Boston. Obviously, you have attendings and mentors who are doing a lot of it. So you can learn these things and you don't have to be doing US and ERCP to do bariatric endoscopy. So don't let that discourage you. In some programs, you can achieve this in three years, in your three-year fellowship, other places you may want to do a fourth year. So don't hold yourself back in terms of learning these things. Find mentors, even if it's outside of your institution. I'd love to see more of us doing this in academia, private practice, it doesn't matter, but really this is sort of the gut is our space and metabolic disease is our space. And we should really have more of you guys getting involved in this and pushing the field forward. So again, as Jen mentioned, these tour procedures, there's tons of patients out there. I joke that it's like one of those, if you build it, they will come kind of program building things. If you say that you do it and you just put it on your generic website, the patients will find you because they're sort of a silent majority in the sense of they feel like they've kind of burned a lot of bridges. There's a lot of shame surrounding it. So you can really build a program quickly with this patient population. This is when you're building a bariatric program. This is kind of a good start because surgeons don't want to go in and do them. Jen, can I ask you a quick question just for your APC guys, what settings do you use? And I think Jen, you said an eight millimeter balloon. I use a six millimeter balloon now. I'm curious, Ravindra, what do you use and what APC settings do you guys use? Go ahead. I like it. You're aggressive with the six. I still use an eight. I use a lot of stenosis that may happen, so I still go eight. But I feel like they lose a lot just with the eight. How about you, Ravindra? Yeah, I use an eight at this point. It's funny, before Chris Thompson had shown this and recommended it, I thought it's an elegant idea. But before I would just eyeball it. And I would do it super tight. So I probably was doing more akin to what you were doing with the five, six, kind of getting it as tight as I can go without being a stenosis. But I like the idea of doing this a little more controlled. And then when I APC, even when I'm doing suturing too, I'll do 70 watts forced, kind of juice it pretty high wattage. I do the same, 70 watts, 0.8 liters and force. And I really like it brown, really not just white, but give it two, three passes, really touch it. It's like painting something and saying, you want it perfect, but one centimeter, like Jen mentioned. Okay. Awesome guys. Yeah. I haven't had the problem with stenosis so far, with six. So I think we'll see. You mentioned Chris, when I was a fellow, we were using a seven. And then at the end of my fellowship, he switched to six. And then I just started with six here and I haven't had issues. So, okay. I have a question from a panelist. For Tori, is the APC de-epithelialization only performed on the gastric side, or is it also performed on the jejunum side? You want it on the gastric side. Great question. With those settings, that jejunum, you can poke, you could poke a hole actually. So you have to be very careful not to touch that jejunum. Yeah. So usually what I'll do, and this is what I did with Gretchen, is I'll outline the demarcation first, and then I'll have you extend it out because that's a lot of wattage to undergo for jejunal injury and a lot of pain related to that. There's a question also, it says, seems kind of aggressive with APC, possible complications. So again, if you stay on the gastric side with these settings that we just talked about, very low rate of complications. It's really about understanding the demarcation between the small, what is a small bowel and what's gastric. And if there is a concern about not being able to tell, hedge more on the gastric side. You're always going to either, you can APC alone, or you're going to end up suturing that if you're doing a full Tori. And so hedge on the gastric side to prevent complications. I've not had a single one using that hedge. Also for the complications, I mean, like we've said, gastric side, that's what you need to do, but bleeding can happen and stenosis. I have not had a stenosis with TOR, suturing TOR. I've had one stenosis from, I don't know, I think this is maybe like many APCs. I think it was, I think 18 and I did the regular APC and it really closed down with one session. Well, you would not expect, you know, one session, 18 really like this was like, I should probably even report his case. It was like one millimeter after like two weeks. It was like two, you know, it's like pinpoint, like the XP will not even pass. And what I did, I really carefully dilated because you know, you could, you will, it could look very scary that is ulcerated. But in the other side, those are like, I call them expected changes post APC, right. Which is an ulcer, but that mucosa, right. But it healed really well. And I had to do, I had to go really small and I had to do like, I think, I think two more after that, let it, let it really, you know, heal. And, you know, you can't be that aggressive, but that can happen and you should be prepared to handle those complications. I've had some, some melanin after some TOR or APC, but nothing, I scoped one patient, there was nothing, nothing to treat endoscopic. It was all clean base, right? Like you use the same principles that you use for GI bleed, just put the patient, you know, I mean, they're on PPI already. If you want to even give them some Pepsi H2 blocker to kind of enhance more, but I think you should be prepared. And I don't know other thoughts, Ravindra, from your experience with STL GI bleed. I agree. I think the, and that, that's what differentiates like a sutured or a clip type of TOR versus APC. APC is all uncontrolled, right? You're just burning and then you see what happens. So that's why it's a little less elegant, but also something to remember is that, you know, when you look at, you know, how this is done and in the studies, right, there's multiple sessions. So I think, Ravindra, your case was an exception, but usually you're not going to get that dramatic of a reduction in the, in the aperture, but you can always do more. And you should talk to your patients about that, that it may, it'll take several sessions before we get there to avoid some of those issues with scarring and stenosis. All right, we're going to move on because at this point we're never going to get all the cases. Okay. We could talk forever. All right. So 34-year-old female gastric bypass pain every time she eats resulted in food avoidance. She's lost 15 pounds in the last two months. You do her endoscopy near her GJ stoma, you see this, right? A small ulcer. What is your algorithm and how you treat this? Suture it. Next case. No. I love that. Here it's like, you know, it's not uncommon. I think we see, we see, don't see as many ulcers as there actually is, right? If we were to scope a hundred patients with rheumatoid gastric bypass, many would have ulcers, but we never see them because they're not symptomatic, right? From the audience we have PPI and sucralfate. I agree. Okay. There is a study about the open capsule. Yeah. So I mentioned, yeah. So open capsule PPI, there's a study by Dr. Schulman and Dr. Thompson group in 2017. You can look it up. Basically opening the capsule, the group that took, this is a retrospective study and they show that the open capsule PPI group will heal the ulcer way faster. I can't remember exact numbers, but I think average healing is about a year in some databases, including this study was like 360 days, I think. And they went down to 120 days or something like that, like less than half. And then from, and this was in 2017 and from Cleveland Clinic, we published a similar study on retrospective on, you know, surgery and obesity related diseases journal this year. And we found the same findings. Basically the open capsule PPI healed in about half of the time, 150 days or so. But the interesting thing was when we adjusted the potency of the PPIs to, you know, Omeprazole 40 as a standard, you know, because, you know, there is variances in PPI potency, like Pantoprazole will be, you know, Omeprazole is five times stronger than Pantoprazole. So we adjusted for this and we found that the effect of open capsule disappears. So, so the benefit of open capsule disappears. So now we're, so this year also, we started early in the year, what we call a randomized control trial for this. So we're doing an RCT on open capsule versus intact capsules called Openet. And we are really recruiting a bunch of patients. We're almost done with that. And then we will see, you know, this is the way to really see with randomizing patients and see if this open capsule. So for now I'll say I go for open capsule, but we'll have more data next year. We'll see. Fantastic. So that was a small ulcer. So this is my patient, same history, right? I thought this was maybe a GJ stoma stricture and then, right? A big ulcer. Big. So it's a little bit, it's starting to have some black tissue. That's important also to recognize, you know, not bad, but it's, I'm a little concerned, you know, that it's going deeper now. Yeah. It's a deep ulceration. She's on PPIs. That initial narrowing is a narrowing related to this ulcer. It's not the GJ stoma because eventually I'll turn to the right and we'll see that it's an open stoma. And that, again, to work the algorithm too, right? You know, you see somebody with this ulcer and you have to ask first, right? You know, we assume most of these are ischemic related to the surgery, but you still have to ask about your NSAIDs, ask about your tobacco use and those kinds of things, right? To make sure that they're, and then are they actually compliant with the PPI and not taking a PRN. So she was not smoking. She was taking a little bit of NSAIDs for a hip that she had just fractured, but this is her GJ stoma. It's open, right? I don't have any problems going in there, right? And we back up, huge ulcer, and then a narrowing. So what would you do here? Other things to think about too, right? So if you see this giant ulcer, you say, you know, is there actually acid hypersecretion? Does she have a generous pouch or does she have a gastrogastric fistula? You know, these are other things to start thinking, you know, in terms of your algorithm. H. pylori, we should test H. pylori. That's also that I find pretty often that patients that have had a marginal ulcer, 10 scopes, never check H. pylori, biopsy it. But those are great thoughts. I mean, Jen, to your point, I mean, I think, like you said, the stoma is open. I mean, to the right, you could see it, but it's a pretty big size of an ulcer. I will make sure we're not missing any etiology. I'll maximize the medical therapy. I think this, you know, here trying to suture is very, very, very, you know, uncomfortable position. I think you will get a good result. You'll probably just not even be able to do a good job in that position. I don't think X-Stack will really, you know, oppose it enough. So I always, when I see these type of ulcers where it's kind of like a time bomb and anytime they can perf or come with a big bleed, I always have my surgeon partners meet the patient, plug them in. I don't, you know, they will come back to me and say, you know, have we done everything, anything else? But at least we are, you know, ready. And if this doesn't heal, I wouldn't do an endoscopy in three months. I will probably check earlier, see what's going on with this ulcer. And if it's not healing, probably we'll need some sort of surgical resection intervention for this. So this patient was, I talked to my bariatric surgeon, H. pylori negative, took her off the NSAIDs, put her on pain medications to help with the hip temporarily. So we actually decided to stent her, to do a fully covered stent with open capsule and just see if with time and just food avoiding and kind of going through what it would look like. This was her repeat endoscopy. This is that same ulcer area. This is her stoma coming on this side here in three months. Something not part of the algorithm, right? But works because of food diversion, her eating off of NSAIDs, no H. pylori, she wasn't smoking to begin with, but something that we thought of a little bit out of the box to help her. Ended up healing her almost completely. So we avoided her a surgery here. With regard to other differentials for ulcers, have any of you ever seen these types of ulcer or GJA ulcers that were actually malignant or malignancy in origin? It's rare. I think I've had one case over, I mean, so many cases, you know, like that we see for ulcers. But quick question. So was this patient on open capsule PPI before? So was it the open capsule or was it a stent? That's the thing, you know, because I have, it was an open capsule max dose of membrane. So, okay, great. I think when there is no stenosis, I do not place a stent usually. I think it's interesting that the food diversion that you're talking about now, I think you're right. I think if that was to be the case of the mechanism, it's interesting. How do you fix the stent? Do you suture it or? I always, so, you know, there's a good study actually out of Cedars-Sinai looking at stent fixation with the stent fix versus no fixation versus suturing. And it says, you know, the data showed that there was better outcomes with stent fix. So, you know, I don't, if I'm not going to suture other things, then I'll stent fix, right? Because it's a really expensive thing to open. You throw in some suture. So I preferentially stent fix, unless I'm suturing other things, then I'll suture a stent in place. Yeah, agreed. I actually, even for convenience as well, you know, for speed of use, the stent fix is so much faster. It's interesting that you're talking about this stent as the ideology of healing. Diversions, interesting thought, as you mentioned. And then the other thing is when you look at, you know, say post-operative leaks in fistulae, when you look at like porcine studies, the stent being there actually induces further granulation. And so you wonder, again, if this is some mechanism that's actually promoting the healing of this area. I agree with Roberto, though, if there was no stenosis, I probably wouldn't have opted to put a stent in just as a primary treatment of an ulcer. So this is a kind of interesting approach that you mentioned. I did, Jen, you know, I did put a stent once, a cold axios for a non-healing ulcer, but it wasn't that open. It was like, eh, you know, patient wasn't really struggling much. I think it was more pain, but it was like, I think 15, 14, and I was like, eh, not sure if I, and I did put like a 20, just like, you know, for the sake of trying not to decrease migration, and it did not heal. But I think that's the only case I remember, but never put like a fully covered, for that reason, without stenosis. I put fully covered with stenosis, but it will be interesting thing to, you know, do a study or something, you know, kind of try. It's never going to stay in place. All it's going to do, I think, without a stenosis is kind of rub along it, and that's kind of the worst thing that can happen, right, is actually increased friction. Luckily, the stenosis kind of keeps everything in place. So this is, we're not going to go through, because there's a lot more cases to cover, but for marginal ulcerations, this is kind of your snapshot on symptoms, occurrence rates, and risk factors. We talked about NSAIDs, H. pylori, ischemia, tension within the anastomosis. We talked about soluble open capsules, really important to stop smoking, NSAIDs, you want to remove kind of all foreign material within it, so if you saw suture material, stable material, you want to remove all that from the anastomosis. You can consider stenting if there is a stricture. And then this concept of mucosal flapping, right? How many of you guys do mucosal flapping for ulcers? I would say for some of mine, I do, right? And the thought is, is you flap over an ulcer to allow for kind of microvascularization and improve flow to the area in order to improve ulceration. So this is a colon anastomosis ulceration that I flapped over, and this is one month after flapping. Right? I saw you do this case. This was live. We did this together, right? Yeah, I've done it for LA Live. Yeah, right. Yeah, so this is the X-TAC, and I'm wondering how many of our general GI are comfortable with X-TAC? Because I think that this, if you don't do kind of over the scope suturing, then through the scope suturing is an important thing to learn. And you can learn it for multiple things, right? A lot of us use X-TAC in order to close EMR defects, right? Some of it is for mucosal flapping. Some of us use it to fixate stents, right? So this is a great video GIE from Andy Storm. I really propose all kind of fellows to look at this in order to understand how to use through the scope suturing. And so again, not needing to take your scope out of position, right? Here you see the handle being attached. This is the catheter with the helix device going through it. This is what your tech is doing in order to get the screws moving into the tissue. I'll kind of go forward a little bit. And so what you see here is you wanna screw the helix and this technically goes into the submucosa. There is a little bit of hope that maybe you kind of anchor it a little bit into the muscle, but it's unlikely or less likely unless you have kind of an idealized position on your screw. And then you can screw up to four different tacks into the mucosa. And then there's this proline suture that connects each of these tacks. And eventually what you do is you cinch it in place. And this is innately how you would flap over an ulcer or how you could close an EMR defect or keep a stent in place. So I use this quite a bit, especially in places I can't get the overstitch device to, especially if I can't suture or it's too tight of a location, this is a great kind of device to have. So you can see here, again, kind of four tacks coming in and it kind of cinching it in place in order to create either a closure or an apposition, mostly of the tissue over your defect. I use it a lot. Do you guys use X-TAC or Orthoscope suturing a lot in your practice? And for what reason do you use it for? I don't use it a lot, but I use it regularly, I would say. I always prefer Orthoscope suturing again, just because it's my comfort, but I just used it actually similarly for an ulcer this week and use the X-TAC that way. Exactly what you said, stick keeping the scope in position and then we can oppose the tissues. I've used it for irregular EMR defects, although some of these larger clips now actually have obviated the need for X-TAC, but I think it does a good job opposing tissue. I sometimes question how well it actually creates a seal on something. Like if I had a perforation or something like that, I don't know if I'd have 100% confidence because you're pulling together these posts, not necessarily the tissue, again, unless you mentioned ideal position. So oftentimes we'll use X-TAC to oppose things and you kind of seal it up with clips or something else like that, but it definitely has a role. Agreed. If you were trying to close something, would APC prior to closure, do you think that would help oppose tissue or close things better? Yeah, I mean, that always helps again for this remodeling concept to kind of seal what you're doing. It kind of depends what tissue and what your indication is. For example, like in an acute perforation, I don't think you need to APC the edges, right? Let's just put that together and it'll heal. It's pretty much healthy tissue, but if you really want to create that mucosal bridging infusion for something more chronic like a fistula, then I think APC has a role there. Agreed. So I think, again, this is a great opposition device, not necessarily a closure device. Yeah. I use it a lot, Jen. I use it a lot, but I prefer over stitch for more, I don't know, I think it's deeper. I think it can hold more tension between the opposition of tissue. I think we all agree on that, but I've had actually, there was like a IR drain that perforated D4 or D3, and you're like, you can't get the over stitch and X-TAC did it really nicely. I did kind of like, I have the same concerns like Ravindra mentioned. So I did one pass and then another pass without obviously a stricture in the duodenum, but it was fine. And then I also had a case, for example, double pigtails migrating inside the gallbladder after a gallbladder drainage, which is really weird, they migrate in. So, you know, I didn't want it to suture or clip that. So X-TAC did a really nice job holding, you know, kind of around the pigtails without disrupting the pigtails or putting too much tension. So I think it has a definitely a role. I usually use it if I don't need full thickness or hold a lot of tension and for convenience sometimes. And then if I cannot get there, you know, for whatever reason, over stitch cannot get there. Yeah, but it's a nice device. No, this is another indication that I don't know if you guys deal. So we do a lot of, we have a lot of tubes that we have to deal with. Like gastrostomy tube is jejunal extension and things like that. They keep flipping back and forth. Yeah, so that's sort of our frustration on our on-call service. But again, to your point about tacking down those pigtails, this is another indication where you can kind of tack down the tube at the pylorus so it's not coming back. I didn't mention the J extensions because I don't know if I want to become the king of, you know, jejunal extensions in my schedule, but we'll send you all the patients, Ravindra, from now on. Okay, fantastic. So we're going to skip kind of this just to go, GJ strictures, we kind of talked about this a little bit. We want to be able to get to some sleeve complications. So when we have a GJ anastomotic stricture, what you want to make sure is you want to balloon dilate plus minus injections. And what we know is it doesn't take one dilation depending on the GJ stricture. Some people need LAMs. And so we've talked about this, Ravindra and I specifically have talked about this, that some patients you take out a LAMs and then they re-stenose and then you got to put another one in, how long do you put one in? And we don't really know that there is no literature about this. Some of these stenoses are refractory and require either recurrent stenting and sometimes they need to go to surgery, but there is no kind of algorithm that tells us how long we need to leave a LAMs in place. Some people leave it in for six months, take it out, put in a new one because people are doing very well and so for all of you who are interested in research, that's a great research project is to see kind of developing an algorithm for lumen opposing metal stenting across a GJ stricture and how long we use them for or put them in place. You can also take a needle knife and kind of cut into the stricture in order to kind of open it up like we do for some of these rings in the esophagus and then dilate in order to really kind of break up that fibrosis. Any quick thoughts on a GJ stricture so we can move on to other cases? I would just say, you know, when you talk about LAMs, I think it gets to this like physiology concept of stenosis, like even like any kind of time we put in a LAMs or something, we're trying to make a new anastomosis, you're not really cutting, you're kind of just stretching and you don't get any real tissue remodeling, which is why things close down, like if it's a gallbladder or a pseudocyst or whatever. So that's sort of the key thing and if you want to get deep into research, that's what you have to answer. It's like, we need like an actual cut, right? To allow the tissue remodel, to keep it open. So that's why doing a strictureplasty first is a much more elegant way to do it. But that being said, I've seen it go wrong many times. It's very easy to go and go too far. You usually can put your stent in and you're okay, but it's not something to take lightly and it seems so easy when you're getting in there and you're like, oh, give me like a needle knife or something, let's do it. You had to be careful and go slowly. Just quickly, Jen. I think to your point, Ravinder, perfect. You read my mind. I was going to say, when you are dilating or whatever treatment like needle knife, I think the dilation specifically, let's say you put a balloon 15 and it goes to 15, but it didn't break the tissue. That's a problem, right? Like you need to get that rent pretty deep. And I've almost switched my practice now. If I don't see that rent for whatever reason, I'm going to needle knife. I need that rent one or two, three places. And then if I put a LAMS, I almost always give them steroids for the same reason of restenosing. And I leave it for like three, four months minimum. And if it's recurrent, I'll leave it for six months and even change it. Yeah, I agree. And then regarding that needle knife, a participant asks, what needle knife do you use? Is it the ERCP needle knife? And do you clip post stricturoplasty? Yeah, it depends what you have in terms of tools. So if you have EST knives, it's a much safer, more elegant way to do it. For example, say a hook knife or something, you can kind of grab tissue and pull back and just cut it. You can use a needle knife, but that's usually where I see it go wrong. And I've seen complications of that because it's not really controlled in the way that you would like. And again, you kind of want to go slowly and peel the onion and kind of, you want to have almost a withdrawal force as opposed to a slashing force into the stricture. But yeah, you can use a needle knife, but you have to be very, very careful. But again, to Roberto's comment too, like that's the idea. It's like, you want to get those rents and it's the elegant way. If you can do a cruciate incision, right? And then dilate, that's where you're going to get the tears. That's where you're going to get those rents. And then you can put in your steroid and your stent and that's when you get the best response. And this is what people are doing kind of more in the esophagus as well, right? Kind of these refractory structures in the esophagus. And you see a lot of it where kind of the safer way to do it is kind of take a forcep biopsy and kind of just biopsying around it if you're not used to needle knifing or you're using that anyways is to kind of biopsy to break the stricture first and then really dilating it and then doing kind of steroid injections. That's the same kind of concept that's happening here. All right. In my notes, I always write, appropriate mucosal tears we're seeing. And you don't want to close it, right? I think there's a question about closing it. Unless you've like gone awry and perforated through, you don't want to close these rents that you're making. You really want to kind of cut and you want something to oppose it, to make it open. And then you want the remodeling to happen around that kind of stunt or that you're placing. So don't close it. All right. Sleeve gastrectomy. This is your standard sleeve gastrectomy. This is what's been on the market. And this is only like a couple. So remember that if they're asked to kind of do a sleeve gastrectomy ERCP, it could be easy or it could very much not be easy. And so just make sure to know exactly what anatomy they have. So this is very common. And this is a patient that I had, 21-year-old female, she went under a sleeve gastrectomy in Mexico three weeks after nausea, vomiting, abdominal discomfort with food intake, rapid weight loss, 16% total body weight loss in three weeks. That's way too fast due to oral intolerance. Way too fast. So what we see here, right? What, and this is important, and this is important for our general GI fellows. When you go into a sleeve gastrectomy, a normal sleeve gastrectomy, there really should not be too much of a turn, a torque or an up-dial needed of your scope in order to get to the pylorus. It really should be almost a straight line. The moment that you're really torquing to go up in order to kind of create a curve, there's something happening there, right? And that's what's normal, is this straight tunnel. So here, what we're seeing here is eventually I'm gonna have to make a sharp turn, and then this is her upper GI series. So what am I seeing here, right? Clearly something not good is happening here that eventually required this. We're gonna forget that that happened just specifically for this case, but clearly there's a narrowing and something happening here. So Roberto and Rabindra, what is your algorithm of how you treat a sleeve stenosis, because this is what we're talking about, is a sleeve stenosis, and what is appropriate to do kind of initially versus what do you do kind of on your next steps? I'll let Roberto answer the question first, but I'll just say for the fellows in the audience that when you see a sleeve gastrectomy, there's only three answers. Sleeve stenosis, sleeve leak, and then reflux-associated pathology like Barrett's or esophagitis. That's it. And oftentimes altogether. When you take the boards or you're getting quizzed on rounds, those are the three answers every time. There's nothing else. That's awesome. Leak and reflux-associated pathology. Okay, go for it. Yeah, no, that's great. Well, going to your question specifically, Jen, when I see a sleeve stenosis, I try to first differentiate if there are, like you were mentioning, like it looks like in this case too, there are some of them that are completely twisted from the outside, and actually a pneumatic dilation, a tunneling, a structural atomy will not fix that. So sometimes I try to recognize that pretty early. That doesn't mean I'm going to give up. I try to set expectations and see how is this going to end up, right? Because it doesn't make sense to use pneumatic dilate 10 times and you're not going anywhere. So that's one of the things, kind of my branching point. And then in terms of dilations, I never, well, I shouldn't say never, but like almost never, or I don't think I've used a regular through-the-scope balloon and usually it's not enough. A 20 millimeter will not even touch any sleeve gastric. I've seen so far. However, a pneumatic dilator is what I usually use. And these come from 30, 35, and 40 millimeters. And I almost, I don't think I've ever used a 45, sorry, yeah, 40, not 45. So I usually start with 30. I will try to go to the, you know, to the appropriate PSI to get the 30. Then I may use the 35, but you gotta be very careful. I watch it, like you show us in the video with the scope, make sure that white mucosa is, you know, make sure I'm not overdoing it. I don't do all my cases under floral. You select the case and I can tell you which ones, but, you know, sometimes it's useful. Sometimes it's pretty comfortable without floral and efficiency, obviously, endoscopy is also important. So that's my sort of first line. I think data shows that pneumatic dilation, pretty efficient, about 70% in relieving symptoms and actually treating the stenosis. However, like I said, if I see a spot where it's not just a whole twist, I see that there is really an opportunity to do tunneling and really, really do a strict uroplasty in that sleeve, which will be very different than other strict urotomies or strict uroplasties that we treat. Especially if the patient has had a leak, you know, sometimes those patients will have a more scar tissue, usually I find, than, you know, a no leak patient. Again, I don't have data to back this up, but that's like from my training and my clinical experience now that I think is true. So that's kind of my algorithm. When to send to surgery? Well, when I see that there's no progress and it's really a twist and a twist. And one time we've actually even put an Axios to create a new- You're just ruining all my slime. So basically, you know, from Proxima's lift, bypassing the strict urotomy. Anyways, okay, I'll shut up now. And do you have any other questions? Do you want to- Let's go back a little bit because, yeah, so I agree. So through the scope balloon is a good place to start, but rarely ever going to do anything. And I want to show you why. So this is a through the scope balloon, 20 millimeters, right? Across a stricture, nothing, right? It can slip back and forth. And this is exactly what Roberto's saying. It's okay to try. Unlikely to really be effective and a permanent change in the sleeve. But look at the difference. And this is a 30 millimeter pneumatic balloon and same exact patient, right after each other, right? Same procedure. And you can see here, this is where we see that white out here, right? Where you're actually pushing against some sort of waist or turn or something and really pushing out. Now, the thing for fellows to know is, one, you can do it under fluoro, or two, I do it under both because, you know, I like to be super careful, is to have the scope looking into the balloon. There's a reason why it's a clear balloon. The center two marks here are meant to be the center of the balloon where it can take the most amount of pressure outwards, right? You're gonna center that on your stricture and what you're looking for is this white. What you need to be careful for when you're doing a pneumatic dilation is ascending white towards you, right? If there's ascending white towards you, you're a little bit concerned here that you kind of torn too much and possible perforation. So if you see that, this is why we like to do it under endoscopic visualization plus minus fluoroscopic, is that you don't wanna see this ascending white significantly towards you. That's when you know you need to stop, you need to assess, you need to take a breath before understanding what just happened there. You know, I don't typically like to stent people, but sometimes I will. I don't think that one, you know, if you put a stent through, you're gonna have to put a big stent through and most patients do not tolerate this well. There's a lot of pain, consistent pain. There's a lot of reflux that can come up, but just know that this is part of the algorithm that you'll see. I'm not the biggest fan of doing kind of a, you know, stenting all the way across. Not a lot of stents are long enough. There's a couple of stents out there that are meant specifically for this, but I mean, do you guys do stents? Because I find that patients really hate this. They want this out. Yeah, they tend to get a lot of symptoms and I think it also speaks to this idea that stents can work, but they're not really treating the underlying problem, right? Exactly. So this is like an extrinsic fibrosis and scarring issue that we really have to use the Echolasia balloon to get to. So sometimes you'll, yeah, you'll see it. It'll be an adjunct, but it's certainly not the primary treatment. Agreed. So, you know, Roberto perfectly kind of went through this. Through the scope balloon to 20, not great. Pneumatic dilation, you want to be intubated for this. You start at 30 and when he talks about maximum PSI, he's talking about going to around a 20 PSI is maximum. Of note, you should be doing the kind of the balloon inflator yourself because the first time you may not get to 20. You may have to stop at 15 because you're getting a lot of resistance. You're seeing a lot of white on the pneumatic dilator. You want to stop. This is as much as this stenosis may handle at this point safely. You can come back in two to three weeks. You can redo it up to try to go up to max or you can go up to 35 if you already went max beforehand. You can go up to 40. I rarely go up to 40. You can try stenting. And then this is where Roberto just like took, took it and went with it. So one is doing an endoscopic tunneled stricturotomy. Now this is obviously more where your advanced year, this is a tool set that you have for this is cutting into the mucosa, going into the submucosal space, cutting that muscle to eventually kind of opening up this stricture, the stricture that you see here, a really nice video by Ademora in Video GID. The next one is in certain cases, you can do a gastrogastric LAMs. So really what you need is kind of a pancaked stomach here where you can do a LAMs across the, from the kind of proximal stomach to the distal stomach and then do a septotomy across that in order to kind of really open that up. We've only done this in one patient because everyone else has done pretty well with just pneumatic dilation, but not all stenoses are good for this. Really, if it's just a pancake V-shaped stenosis. Any comments from you guys before we move on to the next case? No, I think that setting expectations is important just to let patients know that this may be a process. I'll take a few sessions. And then this is kind of a good rule of life also, but it's like, when you do pneumatic dilation, especially if you're not really familiar, like achalasia and things like that, using it, number one, it's actually kind of very hard to do. Like it takes a lot of force for you to do, but then the question you should ask yourself before you do anything is like, if I do this and something goes wrong, what am I going to do? Right? And so I think, I think Allie Schulman has a nice video, I think in Video GID about this, where she did a pneumatic dilation and just perforated, just big rip. But she's thinking she's ready and she's going to suture it to fix it. But anything you do, but especially with achalasia balloons, but anything you do in endoscopy, you have to think is that, why wouldn't I do this when I close the snare and this goes wrong, what am I going to do? What is my algorithm? And you're always thinking those couple of steps ahead. Agreed. Okay, next, as Ruben just said, leaks, right? So this is a patient, abdominal pain, fever, oral intolerance, had a sleeve stenosis that was relieved with the dilation, but then you find this, right? This is kind of in the fundus here. This is his upper GI series, where you can see kind of contrast coming down and boom. Do you see that there? There's a leak right there. So I would say leak is not great to deal with. These are very complicated situations. It's not common that a leak will close right away with your first intervention. I think that's something else to talk about when you talk about it with your surgeons, your IR doctors and your patient, is this may take a while depending on the type of leak and the extent of the leak. So you guys see this here. What are you guys thinking about doing? He's got a sub kind of diaphragmatic collection, right? And you can see that here as contrast kind of immediately kind of comes out into this leak space here, right? So there's a- And this is acute leak, right? This is an acute leak, what, two weeks or something, four weeks? Yeah, so that's important also because, you know, if you get a chronic leak, it's a little different. But usually, Jen, when I see leaks, a lot of times I get asked to close and I think to drain, right? So I'm like, we need to drain this. We need the cavity to mature and to, basically you need to dry it out. And, you know, I've used different strategies, but one of my sort of first lines I will say in this case, because of the anatomy and the geography of this leak, I'll say, I think I don't see a drain, I think, from IR, but I think in this case, I'll be very careful not just to put any Pigtel there, but like I will probably put at least two. And I will try, it's important to really reach the whole geography, you know, because many times when I've seen from a different place or a referral as a failure, you know, I've reviewed the flora and there's just one centimeter of Pigtel in or it's not covering the whole area. So I think that is very important. I will consider that. Now, whenever there is a leak, especially in the proximal side of the sleeve, we need to ask ourselves what happened? Was this, is there a stenosis downstream? I almost never, actually, I don't think even the last time I never dilated before draining the leak. It's very important to be obviously careful. I usually will dilate if the leak, even pretty early, after two weeks, I'll be very careful. And that might be one of the occasions where I will start with a 20 millimeter through the scope dilator. But even with a pneumatic, I may go just like, you know, eight PSI, see how it's looking and 10 PSI. And then I will almost always dilate before I put the Pigtels. As early as two weeks from Brazil, I think that the more friends and group, I think have some data that as early as two weeks is pretty safe. I know most people will feel very comfortable at four weeks or so, but it also really depends how it looks, the staple line also, you know, if it's extremely angry, super inflamed, I'll be even more cautious and even, you know, really be very cautious, but I'll dilate, I'll drain with Pigtels. I will try to put a fully covered metal stand to also, you know, divert whatever secretions are going in there. I'll fix that stand. I don't use uncovered stands. I actually don't use even partially covered. I think the fully covered with suturing or a stand fix work beautifully. And you're bringing that patient pretty soon, you know, it's not gonna be three months, six months. So I will change it. I'll always try to go actually even with the stand from the lower esophagus to like the side of stricture. In some cases, I've put even a stand to a stand just to make sure it's not every time, but that's sort of my first line. There is variations of that first line depending on the case. But Ravindra, what do you think? Yeah, no, I think you explained it perfectly. It's exactly sort of the similar thinking. And to give background, I think you're right. The first thing is like, why did this happen? It's almost always an association with some degree of stenosis. There's a high pressure zone in that proximal sleeve. And that's why that staple line breaks always at the top to your left there towards the fundus area that was resected. So you always have to treat the leak and treat the stenosis when you're treating the leak. And then there's been this evolution, right? So, you know, we used to say, oh, okay, there's an acute leak or perforation. Let's close it. Let's get an Invesco and try to put it on the area and close it off and put a stent in and it never works. It never works. And so there's been this gradual evolution over maybe the last 10 years or so now where we're saying, okay, let's just do internal drainage. And that's where you start hearing these terms like, you know, putting pigtails, doing a septotomy. You may hear people have said, described at meetings or in life cases where we're basically widening that mouth of the fistula site to allow things to drain and improve the pressure gradient. And then conceptually, this is again, shifting it the other way. And sometimes what we'll do is I do basically exactly what Roberta talks about, putting in the pigtails, opening things up, treating the stenosis. And then at some point you may end up having, when that cavity matures, you just have basically a diverticulum at the top of the sleeve. And that's fine. As long as the patient feels okay and it's sealed and it's fine, you're okay. I will say that some patients, I've had a patient like that with a little diverticulum. One is to always educate the people who are reading the CTs that this is, this outpouching is a matured cavity. Two is that some people get pleural kind of pain related to that kind of diaphragmatic pain, especially because it's a little bit of an inflammation pushing right against that area with some shoulder pain. That's also common to see. Anyways, perfect guys. So pigtail stent, exactly what Roberto said, really getting deep into that space, right? It gets better, but it's not fully gone, right? You still see a little bit of a leak here. So the next step here was to place a fully covered stent across it, and then it closes, right? So I think each leak, cannot say that enough. It's not about closure. It is not about closure. It's about drainage. Things will close with secondary intent once it's drained appropriately. And so again, occurs in 5% of patients. Upper GI series are really good. Cannot say more enough. Distal obstruction stenosis has to be evaluated. It's normal for multiple endoscopies, multiple modalities to be used. Again, promoting internal drainage. There is one, so this is a great little paper, abstract from obesity surgery, where they did modeling of this. And again, the high pressure zone in any single case is right there against the fundus, right? It's the highest pressure. It's where the tension is the most, while the strength of the staple line is at the weakest point. I have, though, been more pointing more towards right off the bat, if these are surgically very complicated patients with kind of big messes and leaks, is doing a vacuum therapy. So I'm a big proponent of this, especially Demora, we said his name multiple times, is a huge proponent of this. There's no really great vacuum that's available. So most of us kind of make our own vacuums, but this is a guy, this is a huge leak site, and there isn't kind of tunneling where you can kind of hold a pigtail in place. So this is a patient that I did definitely was not gonna go back to surgery. And so this is one after the first endovac. So I bring them after five or six days. It's just, it's too difficult to bring them back every three days, just with your endoscopy unit and scheduling. And this is after the second endovac. So if you're considering endoscopic vacuum therapy, one is you kind of need to make your own until there's another one that's kind of more widely available. But the sooner, the more acute the leak, the easier it is to vac, because you're really kind of getting more granulation tissue, more vascular to kind of to this area, and it's more likely they'll close with less sessions. The more chronic a fistula is, or more chronic the leak site is, the more hard it is to do anything like this with a fewer amount of therapies. Yeah, I'm glad you mentioned that, Jen, because we're moving very much into, we call it sponge bobbing, but basically doing vacuum sponge therapy for these types of, any type of sort of foregut postoperative leak. A lot of anastomosis leaks, a lot of esophageal leaks. Yeah, yeah, exactly. And the downside is it's torture for the patient, right? Because we are doing this every six, seven days, and so they're sitting here and going through this, they have this NG tube in place, but it works, it works very well. I bring them also every five days, like Jen, and it's a lot of work, and you got to set those expectations at the beginning, because otherwise it can be a little tricky, you know, they have to know. And then the other thing is for septotomy, I'm also moving towards just APC septotomy, like I love APC septotomy, and, you know, even in the acute leaks, later on in the second, third session, I may start just septotomy and opening, like Ravindra was saying, it's important to open it, because, and I explain to patients that that cavity is kind of like the sunroom in your house, and it's going to kind of join the living room now, and they sometimes, they freak out because they think their stomach is going to be bigger again, and I tell them it's just going to be like a little tiny sunroom, you know, but no closure is more drainage like you guys, like we all said, guys, so, awesome. So I have a bunch of videos for less complicate, less common complications, but I might actually skip over to training, because we're, between the four of us can talk for two hours, apparently. So this is a case of a GG fistula, biliary refluxing across the fistula with significant weight regain. What we know here is from GG fistulas and rheumatoid gastric bypass, it's very dependent on the size of the GG fistula, whether it can be actually closed endoscopically or not. This is a patient that was actually sent to me from surgery because they tried to close the fistula surgically and couldn't. So what here is, this is way bigger than one centimeter, this GG fistula, and so the decision was made to kind of ESG the excluded stomach in order to promote weight loss, and also to help with some of the huge amounts of biliary reflux that was coming through. My goodness, this is a candy cane syndrome that I had, where every time she ate, it would sit in her stomach, she would regurgitate up, and what a candy cane syndrome means is, look at this kind of long blind limb and food kind of going, has equal opportunity to go either or both ways. And you can see that this is her upper GI series that shows what looks like contrast really kind of pooling in that area. Kind of a couple of ways to treat this, one is to kind of suture down, I'll actually just play this video down here, where you can kind of suture down and bring in that blind limb to kind of create a tunnel there or to cut the septum in between where that candy cane kind of area is right here in order to create this into one continuous pouch in order to go down. Next case is also to say that sometimes there are times when it's appropriate for surgery and when it's appropriate to ask our surgeons to get involved. So this is a vertical band gastroplasty with lots of dysphagia. And what you can see that I kind of went through really quickly is there's actually a gastric fistula right on that left side here. So as you kind of retroflex and you've already seen a vertical band gastroplasty, what you see as we pull in in retroflexion is this here, which is a GG fistula. The question from my gastroenterologist is like, should we close this? The real answer is like, not really, it's a mature tract into a gastric space, the suture line, the surgery line is healthy appearing beyond this fistula. But what she really needs is to take down this band that's there because it's way too tight. And that's something that we ask our surgeons to get involved in because this is a surgical revision that needs to happen. And the last one is in a patient that I actually just scoped today with really bad reflux, right? She has clearly LA grade C, a large hiatal hernia and her anatomy here is not asleep, but a duodenal switch. And she really wanted an endoscopic option for her really bad reflux. And so she wanted a TIF is what she came to me for. And what I told her was, we need to look at your anatomy to see if you're even a candidate for that. One, we know she's not a candidate for a straight TIF because of this large hiatal hernia that she has, but two, in patients with a sleeve gastrectomy anatomy, whatever that they may have, we need to see if there's actually enough tissue here to actually create a proper wrap for a TIF. So her surgeon did a good job. This is a really high up sleeve. There's not a lot to wrap here. So this is something we talk about in a multidisciplinary conference in order to discuss whether she actually should just go for a Roux-en-Gastre bypass given the amount of reflux that she's having. So I'm gonna end there because I do wanna talk for two minutes about training. There are multiple papers that are out in order to say what we should do in terms of competency and how we should treat patients who have bariatric surgery complications. It is so key that Roberto, Ravindra, and myself, we all have multidisciplinary approaches to a lot of these complications. These are not singular decisions that we made. You need to understand the physiology and the anatomy to even do the therapy. Without that understanding of anatomy or physiology, the therapy may not be appropriate, such as leaks. Closing a leak is not appropriate because the physiology is drainage and pressure. For some patients, you need expertise in interventional endoscopy for fluoroscopy, for stenting. You need a screening people for other comorbidities. So like our big ulcer patient, NSAIDs, H. pylori, smoking, those are all important understanding how to really fix a patient's issue. And then you should consider endoscopy in almost every complication as part of a multidisciplinary decision. The ESGE has a great position statement paper talking about recommendations on who should be doing endoscopy and in what patients. So we don't have time to go through these, but please read them. And the most important thing is it has to be multidisciplinary and you have to have an understanding of physiology. A lot of gastroenterologists can do these procedures if they understand the physiology. Some may need more techniques such as suturing, but really look at this paper and see kind of what's appropriate for you. And I'll end with this thought is that really obesity is a GI field, whether we treat it endoscopically or medically. And a lot of us are publishing papers. Roberto talked about his paper with open PPIs. I have a paper getting submitted right now about GLP-1s. We are not just doing the endoscopy. We're a part of the medication, the complications, the primary obesity management, secondary obesity management. This is all part of GI now. I'm part of a big field within it. So with that, I'll leave it for questions for anyone that is still with us. And then we'll also have kind of closing remarks from the panelists, but I really appreciate everyone's time and input. It's been really fun and very clearly we could have talked for another hour. That was beautiful, Jen. Amazing. What amazing slides, fun cases, a lot of learning. Guys, I wish I would have had this when I was a fellow. This is like a lot of tips and tricks. It's like a bolus of so many amazing cases and amazing expert panelists here. I cannot agree more with you, Jen, real quick. I think GIs, we have to step up, treat obesity. We have a huge advantage. We are clinicians. We have an intramedicine background. We know how to treat hypertension and long-term chronic diseases, but we know how to scope. And we love our partners in endocrinology, obesity medicine, but we have a huge advantage, right? It's not that we're better. We're just in a different position and we can do medications, endoscopy. Surgeons are surgeons. They are in the OR. They are not clinicians, right? They have no background. We have different roles, but in my opinion, GIs, we have wearing diapers and basically going to treat metabolic diseases. Now we can even treat diabetes with endoscopy. So just for you guys, fellows right now, I think this is an amazing field to get in. In my hospital, we're training. I have a first-year fellow training, doing ESGs and TORs with me, a second-year fellow. So you don't need to go into advanced endoscopy. I mean, if you do wanna do advanced endoscopy, that's great, but don't feel that you have to do advanced endoscopy to do bariatric metabolic endoscopy. And then the medical part, you know, in your own hospitals, there is obesity medicine, endocrinology. There's a lot of people doing medications that you could learn or mentors elsewhere as well, you know, that I think reading those papers are key, but I know we're short of time, so I'm gonna turn it to my panelists, but I just wanted to give my two cents on that and congrats, Jen, amazing presentation. Honored to be here. Thank you so much. I just wanted to make a plug again. We're at PAC. Dr. Watson is at Cedars-Sinai. Dr. Simon-Lenares is at Cleveland Clinic. So feel free to reach out to us with any questions. I'm sure that they can maybe write in the chat, kind of our emails, that way you can reach out to us for any questions or to get a little bit more training with us. We're always happy to help. And there's a lot of us around the country that do this. So with the last couple of minutes, I'll actually kick it back to our ASGE counterparts in order to close out the session. But again, thank you again to Gretchen, to Rabindra, and to Roberta for being on the panel with me. So before we close up, I would like to thank our GI fellow moderator and panelists for their insightful input. And thank you to our content expert, Jennifer Pham, for her leadership in tonight's excellent case-based presentation. Thank you so much. I want to let the audience know to make sure to check out our upcoming ASGE educational events. Visit the ASGE website for the complete lineup of the 2024 ASGE events and to register. The next Endo Hangout session will be Advanced Endoscopy Fellowship, and that'll take place next year on January 11th 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 are offering interactive sessions that fit your educational needs. As a final reminder, ASGE membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and make sure you sign up. In closing, thank you again to our content expert, our panelists, and our GI fellow moderator. This was an excellent presentation, and we thank the audience for making this session interactive. We hope this information has been useful to you, and with that, I will conclude our presentation. Have a wonderful night.

endoscopic management

post-bariatric complications

weight regain

ulcers

trans-outlet reduction endoscopy

open capsule PPIs

stenting

bariatric endoscopy training

gastroenterologists

obesity

multidisciplinary approach

sleeve gastrectomy stenosis

gastrointestinal fistula