It is my real pleasure after these wonderful presentations to now introduce a good colleague and friend, Dr. Usma Siddiqui, who is Professor of Medicine and Associate Director of the Center of Endoscopic Research on Therapeutics at the University of Chicago, and who is a nationally renowned clinical educator. Thanks, Irving, for that invitation, or that introduction, and to Vani and Prateek for the invitation to be part of this great course today. Now we spent the whole day discussing a variety of esophageal diseases, most of which are going to be evaluated by endoscopy, not only to make a diagnosis, but to provide potential therapy. And with any endoscopy, although they're rare, complications do occur, and I think it's really important to be able to recognize and manage them so you can have a successful patient outcome. And I'm hoping our case discussion today will provide a useful approach to these sometimes stressful situations. And hopefully the panel will chime in whenever needed. So this is a case where you had a patient, they have a Schottky's ring, they've been dilated in the past successfully, about once a year with symptomatic improvement. So they come back for their routine kind of follow-up endoscopy, large caliber 60 French dilators passed over a guide wire, it's in a non-fluoroscopic room, significant amount of resistance is felt when you pass the dilator, and when you pull it out, you notice there is a very large amount of blood that seems a little bit more than you've noticed in the past. So I guess the first step would be, you know, what are you going to do now, nothing and just send the patient out to recovery? Or are you going to pass the endoscope again and check your dilation site? I'll take a stab. You wouldn't be presenting this if you were going to just send the patient to recovery. Well, that would be part of more discussion on the complications, but correct. And I think, you know, when we talk about complications, your best chance, and especially when I show you what this complication is, is to recognize it as early as possible so that you can implement your management quickly, and that would result in a better outcome for the patient. So you pass the scope, and you notice this defect. I don't know if Mohan wants to describe what he's seeing. I can't see well. Is this a video? Can you play the video? Yeah, so yeah, this looks like a actually a pretty large perforation there, a couple of centimeters above the gastroesophageal junction, if I'm seeing it correctly. Yeah, it was around, I think, 35 centimeters. Yeah, and that was a Schatzkering, so I assume that was lower than the level of this perforation. Correct. And how would you describe the surrounding mucosa at this time? I mean, I really can't see well here, but just I will say this looks like maybe a 15, 2 centimeter perforation. I don't see, I mean, in terms of healthiness of the mucosa. Can you play it again, please? I mean, you're bringing up the correct key points that you want to assess, the size of the defect, the location. What does the surrounding mucosa appear to be? Is it healthy or is it friable, fibrotic, scarred? Actually the mucosa does not appear healthy, which is, as you kind of alluding to, is very important for closure. I was going to say it looked pretty healthy. Well, I guess part of it also goes into the patient's history. Supposedly the rest of the esophagus was normal, except for the Schatzkering. So then we'll go, what would be the next step? And the main question is, would you attempt endoscopic closure? Yes or no? If no, then you're going to call a surgeon and which type of surgeon given the location. And then if you attempt endoscopic closure, how would you perform that? Can I ask a question? What do we think happened here? Do we think it buckled, the Savarit buckled because there was no fluoro? Correct. I think that would be the assumption. This was a colleague's case that we were called into the room that at some point the guidewire had probably fallen back and then they pushed the catheter kind of blindly against some resistance and that's how this occurred. So it's a fresh perforation, no pathology in the esophagus, we recognize it early. I guess that could be a discussion for the panel as well. You know, if you routinely need to use fluoroscopy for these savory dilations or, you know, again, for us, we don't always use fluoroscopy. We can do it without, but you have to be kind of attuned to how you're exchanging over the guidewire to make sure that it doesn't get displaced. Yeah, I mean, there are markers on the savory wire, so you need to make sure you have at least three markers, which means 60 centimeters of wire to ensure the distal end is in the stomach. So I assume here probably it was just higher up and they did not pay attention to that. In terms of which technique to use, all can be used here, simply through the scope clips, over the scope clip or suturing. For me, this looks easy enough through the scope clips. Amitabh or Irving, Vani, any dissenting opinions? No, I think that you go the straightforward, if you thought the mucosa was normal, especially today with the new 22 millimeter clips like Microtech, you should be able to close and you can go step by step the scope, I mean, not everybody in the community is familiar with using suturing devices, so you can start with clips. I guess if it doesn't work, people are still probably more familiar with over the scope clips. And then I think one thing that's missing is obviously esophageal stenting and securing the stent higher up, much higher up, that's where the perforation is. And of course, if you're familiar with suture, then I mean, you can go from easy to more complex. And I think there's no wrong answer, as long as you document that there is closure. Right. I agree. Obviously, the key point is you have healthy mucosa. So whichever closure technique you're familiar with, I think would be a good option. I didn't put stent on this because technically that's kind of diverting secretions versus closure. But obviously, that is a potential choice. And in this particular case, suturing was the treatment used. This is my partner, Chris Chapman, who's very facile with the suturing device. He placed a few running sutures, starting distal and moving proximally to close the defect. So once you think you've successfully closed it, at this point, the question becomes, you know, do you need any additional therapy and how are you going to manage the patient after the procedure? No, I think you need to... I'll bite. Oh, go ahead. No, go ahead. I'd say, you know, don't forget the antibiotics and nutrition. So either an oral tube or something that you put in so they can get nutrition. Irving? Yeah, no, I was going to comment. I think the... I mean, the next thing is obviously also include a chest x-ray because if you have a pleural diffusion, you need to have a pleural drain to have control of the infection in case of a spillage. And then you may want to document with a gastrograph and swallow that you had a complete closure, especially since it's iatrogenic. You want to document that everything is done, otherwise I completely, I mean, in addition, I completely agree with Amitav. Right. Just one more point, Uzma, is that, you know, if you're scoping on air, make sure you immediately switch to CO2 the moment you've seen the perforation in addition to everything else and antibiotics. And I think the integrity of the closure, if you're happy with it, or if not, then, you know, put the stent and make sure you've diverted. Yeah, no, I agree. I think, again, the points are well taken, the antibiotics, follow-up imaging, and then nutritional supplementation if needed. I'm just going to raise a question that came in through the Q&A also just that might be related. There was a question about EVAC for the sponge technique for esophageal perforations. And would any of the panel consider that, either in this case or any other settings? And how does that play into decision making? I think in this case, because you're coming in very acutely, the perforation just happened a few minutes ago. Hopefully, you don't have much spillage or leak at this point. EVAC is probably not needed. And it, you know, most of the time when it's been used in chronic fistulas or leaks where you have collections that need to be decompressed or cleaned out. You know, the way I think about these perforations, they're acute. And like you said, there's no contamination. So there's really, unless you injured a mediastinal structure, the dilator passed into the mediastinum. Actually, the dilator possibly just passed, you know, into the submucosa. I'm not sure if you perforated the muscle, could be. But in either way, if you have high confidence closure, then there's no difference between this and a controlled myotomy. So you know, and these days, if our closure is secure and you have high confidence in your closure, many of us discharge these patients home. If you don't have high confidence closure, then you admit getting esophagram. But I think we, you know, if you're comfortable with your closure and you have good experience with it, this is very controlled management of a perforation. So I don't need to do anything else. That's a great point, because obviously the hole itself is not the problem, right? It's only the subsequent leakage and infection risk. So that's a little bit subjective, I guess, in everyone's confidence in their closure and how the patient's doing clinically, if they're tachycardic, febrile, having a lot of pain. And then also, again, your need for getting follow-up imaging. But Mohan, you would send the patient home without getting, you're confident that you closed it, but would you get an esophagram and then discharge them home? So you know, with our Poland patients now, I don't get esophagrams. We used to, right? But then we learned that after you do a thousand, you don't see any leak. If you're confident, then there's no point. But you know, high confidence means mucosa is, integrity is good, and you have good mucosal to mucosal opposition, and you can look at it, you know, and assess it. If you can't assess it, or you don't have good mucosal to mucosal opposition, or the mucosa is not healthy, which means this clip can slip. You know, that's why I was trying to comment on the healthiness of the mucosa, just couldn't see it well. Same with the poem, you know, with achalasia patients, if the mucosa is edematous and scarred, then these are tough cases. These are the ones you don't want to admit and get esophagrams on. Otherwise, we really don't, and that evolution of how you treat this, of course, not everybody is doing it, but it's evolving and more and more people are doing it. I think I'm not as brave as Mohan. I think they think about poem like what Mohan is talking about correctly, is that poem is a control situation. You know how much muscle you cut, you know how deep you went. Here you already have a dilator that God knows where it went. I mean, it's completely uncontrolled. You don't know how hard they push, you don't know what they touched. I think you're probably, I mean, in my opinion, because I am not so brave, I would want to document that I have 100% closure because I don't know what exactly did you visited with that dilator. But I agree with Mohan, if it's a control problem, like when you have a post polypectomy perforation or a poem perforation, I mean, all of those things, it is a semi-control, but here you have a hole that goes who knows where. I want to pitch in on that because it was touched on something very important, which is that poem is not a complication, this is a complication. And the yardstick by which you will be judged will be totally different. And just by very nature of the current discussion, you can imagine that if this patient goes south, there will be at least three or four experts that will say that you should have gotten imaging before discharging home. Not getting imaging and watching in the hospital may be a different situation if you have a high confidence in your closure. But in complication, we're talking about simple imaging. I mean, it can only reassure you that you have done the right thing or on the side of getting imaging. That said, for poem, we probably will transition in many cases to discharge directly after the procedure. Already, we have some data on that and definitely not getting imaging in everybody. That's quite reasonable. I agree. I think medical legally, you're just, I would feel more comfortable having documented that there is closure. and also just to sort of bring it back to, I think, a choice that Uzma had, but I think it's appropriate to consider a low threshold to call a surgeon, at least if this patient's not doing so well or you had some uncertainty or didn't feel as great. I think documenting good closure and that you've at least communicated what you want to communicate in case the patient should go south up front, just to cover your bases all along, especially in the setting of a complication. I think even if you're confident in your primary closure with clips or a suture, oftentimes, again, it's a larger size perforation. We may just put a stent, because again, then you're attacking it from two fronts, primary closure plus diverting secretions. Then I would get the esophagram document, there's no leak, and then you can start feeding the patient and watch them clinically. When we're talking about the surgeon, also, I think it's important to know, again, which area of the esophagus are you talking about, proximal, cricopharyngeus area, you're going to call ENT, versus mid and distal, you'd call your thoracic surgeons. In this case, a stent was placed in addition, and then it was a fully covered stent. You have options for affixing the stent to the esophageal mucosa with suturing, and now there is a special over-the-scope clip. This is left in for about two months. I'm two months. I'm wondering, and I don't know what the other panelists think, but I think it's a little bit of over-treatment. If you thought you had good closure, and you get a gastrograft and swallow immediately after you're done, and it looks like fine, now you're committed to putting in a stent, and then going back and taking out the stent. You can always, if the gastrograft shows lack of closure, come back and do this 30 minutes later, but it sounds to me a little bit like over-treatment. I mean, you're eliminating that possibility that there would be a leak on the esophagram, and then you won't have to come back 30 minutes later. You could argue that. No. Again, you have different ways to handle it. I mean, Uzma, there are many factors, right? Your comfort level, your prior experience, and how secure is the closure, and sometimes you just want to make sure, and each person, I mean, you can do, as I said, I'm minimalistic in this, or do all of the above, and it's really an individualized approach, so I don't think anybody can tell you, hey, you did the right thing, and if the patient's outcome at the end was good, then thumbs up. Okay. I agree, because again, you have, nowadays, we're lucky. We have different tools and devices that are at our disposal, so again, having the perforation, it doesn't have to be this horrendous, stressful situation. You have multiple tools, and whatever you feel comfortable using, I think you should be able to do that. I mean, the key here is probably to carefully consider whatever you're doing, because obviously, there is a different ways to do it, not just to be a knee jerk, I'm suturing, I'm placing a stent, because stent can create its own problems. I mean, even sutured can migrate to the stomach, then you have to take it out. You can have another problem from the removal, so everything should be considered on a case by case basis, and here, the key is how secure you are in your closure. To me, the reasonable thing is to do esophogram, and yeah, if you have a leak, you bring the patient back, realizing that that may be unlikely, but that's a point of debate. My main message is consider everything, rather than just go through the kind of without considering also the downsides of some therapies. The only other thing I'd mention is when this happens, try to get the patient into your fluoro suite if you can. Presumably, this happened in a non-fluoro room, but if that's available, having the ability to do fluoro with your endoscope right then and there can give you a lot of information about the security of your closure, I think. Just put some contrast down after you've done your closure, and it really helps. Got it. Fantastic. Do you have one more case, Zsuzsanna? I do. We can switch to the Barrett's one if we have time. Okay. We do. Before we do, I do want to just ask one question that came in that I think Peter already had answered, but in terms of training for ESD, just as a question from the audience, do you want to share the answer? Yes. I put in the question and answer link three articles specifically dealing with that. Each of those articles is about 10 pages long, covering various intricacies, but the short of it is that we have come a long way as far as ESD training from a few enthusiasts dabbling and practicing on peaks. Now, there is more structure to it, but we are still not to where eventually we want to be, which is to be taught in the format of a standardized fellowship, the same way like we teach ERCP and ESD. But please refer to those articles. The latest one came in GIE last year and covers a lot of these details about training in ESD in the US specifically. Thank you. Okay, Uzmet, go ahead. All right. We're going to switch our complications to a patient with Barrett's. They had an outside EGD done that showed on random biopsies to have low-grade dysplasia and one area that had high-grade dysplasia. The question for the panel would be, what should you do next? Should you repeat the EGD yourself now with white light NBI? Should you just bring the patient in and plan to do a very aggressive resection of this Barrett segment? Should you ablate nodular areas? Should you just sit tight and then repeat the EGD later? I'm sorry, Uzmet. What was the segment length? Six centimeters with high-grade and low. Let me take on this to start with because it's kind of within the area of my talk. I mean, you kind of make it easy because BC and D are fairly wrong. With one comment on D, one time when I will consider to wait a little bit is if there is significant reflux associated with the initial endoscopy, it may be reasonable to put the patient on double-dose PPI and bring maybe not six months but three months after the index procedure and reevaluate. Pathologists have a hard time interpreting biopsies in the face of active esophagitis. But repeating EGD with a good exam will be probably what most of us will do at this point. And the reason is that with careful examination, you can detect most areas of nodularity. Not all of them. I mean, sometimes they're very hard to see. But taking your time, using white light, MBI, some chromoendoscopy may be helpful, particularly with acetic acid. There is some data for that, although it has not been universally accepted. And then at that time, you can do targeted biopsy. Watts brush may be considered in this situation, although you have a documented high-grade dysplasia. Of course, you've got to review the high-grade dysplasia diagnosis with a second pathologist. So my approach will be to repeat the EGD with careful examination, review the initial histology, and take it from there. Vani, would you add any advanced imaging techniques at this point? Because you had just random biopsies before. I definitely believe that high-definition white light is the foundation. Just a detailed exam and lots of time. The use of a distal attachment cap is also my favorite. And then I also do narrowband imaging. And in some cases, I do also use endomicroscopy, like Selvizio. But I would say the foundation is really taking time with a good high-definition white light exam. Sorry, this quality probably isn't that great either. But this is the endoscopic view of the Barrett segment. There's not meant to be any obvious nodularity that's being shown. And so assuming this was all flat, no obvious nodularity or irregular vascular patterns, this patient did undergo radiofrequency ablation. And then three weeks later, they complained of dysphagia. And now the question is, what should you do at this point? Reassure the patient this is normal and sit tight. Repeat the EGD. Give them supportive care with some viscous lidocaine or get an esophagram. I mean, I would comment. I think you make the right, exactly. You give us the right information on your slide. I think if it was 48 hours after the RFA, I would say viscous lidocaine and reassurance. But three weeks out to start having symptoms, that's very atypical for ablation therapy. So at least in my opinion, I would recommend an EGD. But I think your point on the previous slide is really important. It's the timing. So one thing is 48 hours, 72 hours. And one thing is three weeks later. Right. Especially in the beginning, we always counsel our patients. You know, the longer the segment we ablate, then the more chance they may have chest pain, some nausea. We give them medications to help treat it. And you don't want to scope them early on because you're just going to see a lot of inflammation and edema. And it's probably not that useful. But this patient is complaining now a couple of weeks out. So you probably do want to investigate it. And I'm assuming we would all go with an EGD. And here you see they do have a stricture that's developed. And now how would you treat this post-RFA stricture? Gentle balloon dilation and see what kind of response you get with the tissue. Gentle versus aggressive balloon dilation. Yeah. Probably most of you could probably go with the savory also, but it's a focal short stricture. Probably balloon dilation should be enough at this point. Unless anyone else. I remember back to, you know, worth voice. One of the pioneers was maybe the first esophagologist who used to stress the difference between stenosis and stricture. One being fibrotic, the other possibly being inflammatory. And I think the appearance here suggests and the timing suggests that much of this is inflammatory with that exudate. And all you're trying to do is get them relief and allow that to heal. And go back and do more aggressive dilation later if needed. But give it a little bit of a chance and now that you know what's going on. So Amitabh, are you going to dilate at all in that case? I think there's a reason why Vanny said gentle. It depends on if my scope got through without much and it might be able to get through with that. I might just stop with putting the scope through. Right, I agree. I would want to minimize the inflammation as much as we can because, you know, the risk of tears are easier in acute inflammation. So gentle is in capitals. I think since the patient is symptomatic, I would opt for the gentle dilation as well. And obviously make sure they're taking their PPI twice a day. But the point is very well taken that this is likely not fibrotic. So either you wait it out or you gently dilate and it should respond pretty well. Okay, so in this case we did, I'm going to say this was gentle balloon dilation and the patient did well. Came back for surveillance EGD in three months. This was based on high grade originally, but the more recent biopsies just showed low grade dysplasia. The stricture resolved and treated again with RFA. And now a week later, he has hematemesis. I guess we forgot to ask you if the patient was on any antiplatelet agents and stuff like that. Well, that's a good point. I don't believe he was. Because it's bad luck. This is an extraordinarily unusual situation that from a dilation you would get seven or whatever days later. No, then he got ablated again. He dilated, re-scoped, ablated again. But I agree, bleeding with RFA is very rare. And bleeding like this is even more rare. I think it almost looks like a Mallory Weiss tear or something like that. It was a little bit higher up, but it looks like there is a vessel that happened to get exposed there. Okay, in the last minute, what would our panel do? This did not work. And then a coag grasper was used and treated the vessel successfully. I was going to say, coag graspers are great for these. Great. Thank you so much. I'm going to have to wrap up our case discussion there. Uzma, thank you and thank you to our panel.

endoscopy complications

Schatzki's ring

esophageal perforation

endoscopic closure techniques

Barrett's esophagus management

advanced imaging techniques

post-RFA stricture