Our last talk of the day is going to be by Dr. Katari from my alma mater, the University of Rochester. She's going to talk about managing esophageal complications. Thank you. Thank you to all the audience who's still here. And thank you to the course directors, Dr. Kond and Dr. Sharma, for inviting me to speak on a topic that's very close to my heart, and I'm sure we've all faced situations. So today we're going to talk about managing esophageal complications. I will review some of the common complications that we encounter, discuss some interesting and challenging cases, and provide some tips and tricks that can probably help you in managing the next time you deal with any esophageal complication. Disclaimer, because I speak on this topic, does not mean all the complications in this talk are mine. I just wanted to lay it out there. So just like we've evolved over time, so has the world of endoscopy, from rigid scopes to flexible endoscopy to the world of wireless capsules, EOS, ARCPs. And along with that, also the endoscopic interventions have expanded from just biopsies to EMR stenting to the world of third space endoscopy and POEMs and ESDs. What has allowed us to do this is that our armamentarium has expanded to manage the complications that come with these advancing portfolios of interventions we can do. So esophageal complications, overall, they can be iatrogenic or spontaneous or based on the underlying pathology. Iatrogenic complications can further be classified based on their severity from mild to fatal based on the number of days spent in the hospital after the procedure, which is two to three days for a mild versus over 10 days or requiring surgery or ICU care being severe. And of course, fatal when the death is attributable to the procedure. This is what I call as my circle of trust in complication management, is whenever there is a complication, you want to have a multidisciplinary team caring for the patient, whether it's surgery, radiology, interventional radiology, the ancillary staff. And of course, the patient and their family are also in the part of the circle of trust, along with risk management if you anticipate any legal risks. The broad stroke do's and don'ts for any kind of complication is first to stay calm, understand that it's inherent to what we do endoscopically, anticipate it. And the one thing I want everyone to take home today is the key is to early identify it and fix it while you can or during the procedure. And that'll be the theme throughout the talk. Call for a second opinion or help if you have a senior colleague around who can come in. It's good to always ask for help when in doubt. Multidisciplinary management is key, have clear communication and learn from the event, whatever happened and if anything can be done differently. Do not ignore the patient's symptoms or discharge the patient post-procedure after symptoms. Key is to not panic and make sure you fix the underlying problem well and don't lose confidence. I mean, we all face it. The key is to make sure that you do what's best for the patient and manage it in the least invasive way. So the major complications I will be addressing in my talk are bleeding, perforation, and esophageal fistulas. Bleeding is clinically significant. Bleeding is rare for just a straightforward diagnostic EGD. It's when the interventions go higher and you're doing more invasive procedures, the risk of bleeding is higher with EMRs, ESDs, POEMs. Risk is higher when patients are on anticoagulation or if there is underlying coagulopathy. The ASG guidelines do recommend that platelet count be at least higher than 50,000 if you're anticipating biopsies or any more aggressive interventions. And some other causes of bleeding can be tumor-related bleeding or ulcerations, variceal bleeding, which I'll be discussing in the case discussions tomorrow, some interesting variceal bleeding cases. Procedure-related bleeding is divided into either immediate or what happens during the procedure. It is only considered an adverse event if you have to abort the procedure or it alters the procedure. Variceal bleeding that you can control and continue the course is not truly considered an intra-procedure bleeding event. Delayed bleeding can occur after the procedure, up to 30 days. Patients can present with hematomas, melanoma, drop in hemoglobin greater than two grams is what's defined as significant delayed bleeding. The key is your ABCs always come first. So any kind of bleeding, resuscitation is key with good IV access. Start with crystalloids. Anticipate the need for blood transfusion. And you want to transfuse if the hemoglobin is less than seven. And studies have shown better outcomes if you don't over-transfuse. Correct the underlying coagulopathy. Admit if the patient is an outpatient procedure. And as far as possible, manage the bleeding endoscopically. We have a whole host of armamentarium available to manage esophageal bleeding. Transfusion is not used as a monotherapy, but it does help slow down the bleed. If it's in the middle of an EMR or something you want to feel to clear up, it can help. Thermal therapies such as coag raspers or bipolar therapy can be used. Mechanical therapies include clips, over-the-scope clips, which are now routinely available in most of the endoscopy units. Band ligations are for variceal bleeds. Pre-covered self-expanding metal stents can be used, especially in tumor bleeds. And hemostatic sprays is the new kid on the block, which can be used if you don't have a good field of view or traditional modalities don't work. It can definitely be used as a salvage mechanism. In this video by Dr. Groth, this is a post-EMR bleed. EMR was done for Barrett's nodule. And due to the scarring and fibrosis, two attempts at clipping didn't work. And here, this is where you want to make sure that you change the modality. One didn't work. Then using bipolar forceps, hemostasis could be achieved. Now the thing is you want to make sure it's adequate. You want to lavage the site, watch it for a few minutes, and make sure that you've gotten adequate hemostasis, because this is your window to make sure you fix the problem and you don't want to rush to pull the scope out. Traditional modalities, if during an ESD or POEMs, little vessels, they can be cauterized using swift spray or forced coags using the knife that you are primarily using. Larger vessels, you can use the coag grasper, again, with a soft coagulation mode to achieve hemostasis. Over the scope clips, these can be used in difficult locations. We published one of the largest reviews on the topic. And it has a high clinical success rate in managing GI bleeding. The key is to make sure that you are careful when you advance it, especially across the UES and if patient has osteophytes or anything like that. You don't want to create one problem while fixing another. So don't want to cause a tear while you're trying to fix the bleeding. It does have a high efficacy and has been shown to decrease re-bleed mortality when used as first-line therapy in GI bleeding. Hemostatic sprays, they are safe and easy, and they can help slow down a brisk bleed. And especially if, again, your standard modalities have failed, it does cover the lesion, so it can affect your following therapy. And here you can see it's being used in a G-junction tumor. I tried APC. Patient kept coming back with bleeding. With the hemostatic spray, we were able to keep his hemoglobin in check. So take-home points for bleeding. Manage the anticoagulation. Work in collaboration with your cardiology colleagues, neurology colleagues to optimize it for any invasive procedures that you're planning. Carefully select the patients. If you anticipate it to be a higher-risk procedure, consider observing the patient overnight. For EMRs, consider using blended currents rather than pure-cut currents. And control the bleeding during the procedure. Observe the area before you pull the scope out. High-dose PPI has been shown to improve ulcer healing rates and reduce the risk of delayed bleeding. Severe cases may require collaboration with your IR and rarely surgical colleagues. So coming to the most dreaded perforation, whenever, as endoscopists, we see this unintentionally, it does lead to anxiety and sleepless nights. Esophageal perforations can be iatrogenic, which a majority, over 50% of the cause of esophageal perforations are iatrogenic, whether it's dilation or ESDs, EMRs, Zenker's myotomy, difficult intubations. Thermal injury can lead to delayed perforations, and it can be spontaneous from burr house or anesthesia-related while doing an endotracheal intubation. The increase of invasiveness of the procedure does increase the risk of perforation. So overall, just for a diagnostic EGD, the risk is less. However, if it dilations, the risk can be as high as 10%. Same thing for ESDs, and the risk also increases with EMRs. The key is to identify it early. While during endoscopy, you see a defect in the muscle fibers, and you can see a target sign or subcutaneous emphysema. You know, always check for the neck for crepitus. Water-soluble contrast can be used to identify the leak, and a CT scan, of course, shows the pneumo-mediastinum. Endoscopic closure devices, endoclips, can be used to close perforations up to 10 millimeters. Over-the-scope clips can be used to close perforations up to 20 to 30 millimeters. And then the endoscopic suturing device can be used to close larger perforations. And fully-covered self-expanding metal stents can be used to divert the luminal contents and, of course, also to bridge any leaks or perforations. So when you look at the algorithm for esophageal perforations, after the initial assessment and resuscitation with imaging, endoscopy, early diagnosis is key because it has been shown to have over 90% success if it has been diagnosed and managed within the first 24 hours. And your tools for that are, as we discussed, through-the-scope clips, over-the-scope clips, endoscopic suturing, stenting, whatever it takes to manage that perforation. Of course, because you want to make sure that patient, you avoid surgery as far as possible. Of course, if patient has frank sepsis and has a BDS tenitis, you want to collaborate with your surgical colleagues. And if patient needs surgery, then they are on board with that. The ESG recent guidelines on managing endoscopic perforations recommends first-line, first-step endoscopic treatment for endoscopy-related esophageal injuries, again, through-the-scope clips for perforations less than 10 millimeters, over-the-scope clips for perforations that are greater than 10 millimeters, and stents, again, can be used for larger defects. So when you're performing closure using the through-the-scope clips, this is a long linear tear in the esophagus that was closed with the through-the-scope clips. And you can see the tear to the muscle. You want to start in a zipper fashion, always start distally, and then move approximately because you don't want to dislodge the clip by going proximal to distal. It has been reported to have over 88% clinical success in managing esophageal perforations. Over-the-scope clips allow us to have a full thickness closure. You have to change the scope, pull it out, load the over-the-scope clip, and then go down in. The pseudopolyp created can lead to luminal occlusion, and I will review your case. And it can be tough to use the twin grasper in a tangential plane in the esophagus, so be mindful of that. It has been shown to have 85% success in managing, have clinical success in managing GI perforations. So this was a case, July effect, side-viewing scope driven across the GE Junction. You can see the hole at 3 o'clock position, and it was immediately identified. We put an over-the-scope clip over it. You can see the entire perforation has been grasped into that clip. And as happy as we were, we did notice that the secretions were not making it across the side of that clip, and the whole pseudopolyp was occupying the lumen of the esophagus. So after multiple tries, we could get a really thin wire across into the distal stomach, and we said, OK, we're going to put a fully covered metal stent across. You can see the thin waste in the center of the stent, and we did anchor the stent just through the scope clips, and hoping that the stent is not going to move, and it will help patient maintain the secretions. This was a 92-year-old patient, and when lightning strikes once, it strikes again. So the stent migrated literally within 24 hours. So a nasal jejunal tube was then placed, and the patient was kept NPO, and she did well. And slowly, as the swelling settled, she was able to tolerate oral diet. We eventually did a barium swallower, and there was no leak of contrast. The perforation had closed, and we eventually pulled the stent out. And this is after a couple of months that we, again, you know, the key is to identify it in a 92-year-old patient. You want to make sure, you know, you did the least invasive thing, and she did fine. Fully covered self-expanding metal stents, as I said, can be used. And in a study of 88 patients with GI leaks, fistulas, perforations, resolution was reported in over 78% of the patients, and 84% after prolonged or repeated endoscopic treatments. However, stenting is not risk-free. One of the biggest risks is migration. As I alluded to, there are various devices available to anchor the stents, such as clips or suturing, over-the-scope clips, or StentFix is the new device by the Uvesco company. However, the data on their efficacy is still limited, and we need more studies to prove that. Here you can see the dilation in a patient with prior radiation. A tight stricture balloon dilation was performed, and post-dilation, there was a significant defect noted in the wall of the esophagus. So here you can see the defect. This cannot be closed through the scope clip or over the scope clip. So a fully covered metal stent was placed across this defect, and it was anchored to the wall using the endoscopic suturing device, again, because you want the stent to stay in place and not migrate. It doesn't make it 100% ... It doesn't take the risk away, but it does minimize the risk for migration. Endoscopic suturing, again, offers full thickness closure, but it does have a learning curve to it. Again, you have to pull the scope out and load it, and it helps in stent anchoring, perforation, fistulas, and anastomotic leak closures. This is a complete esophageal occlusion from tumor throughout the esophagus, and again, the stent had a previously placed stent that had migrated. You can see here the cancer is throughout the esophagus and had a previously placed distal stent. So we bridged it with a stent in the mid esophagus and then a stent above it just below the UES, and that stent was anchored using the overstitches below the UES, and the patient did well. And here you can see the whole esophagus was stented. So in case of perforation, stay calm, switch to CO2 if you're not already on it, assess for tension pneumoperitoneum if you need to put an angiocatheter to decompress the free air in the abdomen, keep the patient NPO, IV antibiotics, hydration, and NG tube decompressions are key. Again, early and immediate identification of the perforation is essential because that has the best outcomes, and surgeries result when patients are septic or conservative measures fail. Lastly, coming to esophageal fistulas, these are usually malignant or when patients are on prolonged mechanical ventilation, sometimes related to endoscopic interventions such as POEMs, ESDs, full thickness resections. Most of the fistulas communication is usually to the airway, so sometimes patients may require stenting of the esophagus as well as the airway. A multidisciplinary management with thoracic surgery, oncology, GI, interventional pulmonary is what helps manage these patients. All the tools that I talked about for perforation can be used for management of the fistulas. These are traditionally managed with fully covered self-expanding metal stents and over-the-scope clips. There are newer options available such as the biodegradable stents or the implacer device. Again, these are all new and have been reported in certain case reports. So endoscopic success, here you can see a tracheoesophageal fistula. The APC is used to epithelialize, de-epithelialize the site, and then using the anchor, the over-the-scope clip is successfully deployed. Endoscopic management does have limited success because these fistulas are usually fibrotic, scarred, and the success rate is very low compared to the other complications that I spoke about. It has a high recurrence rate, especially within the first four weeks, anywhere between 40% to 60%. So in summary, for any complications, make sure you have an appropriate indication for the procedure. You have a detailed informed consent. Complications are inherent to what we do, and early identification and a multidisciplinary management is key. Have appropriate right equipment ready to go if there is any complication. Make sure you have adequate backup by ICU or IR, whatever is needed. Monitor the patients and have a clear, open communication with the patient, family, and your team. Teamwork is essential, keeping your cool. I know it's easier said than done in the heat of the moment, but trust me, your energy is what drives the energy in the room. So it is extremely important to be patient and address the issue at hand. And do not create a new problem while fixing the under one, and your patient safety always comes first. Thank you.

esophageal complications

bleeding

perforation

endoscopic procedures

early identification

thermal therapies