So, I think the next talk is from my course co-director and my mentor, my colleague, my friend. You can talk about anything you can say, it's from Dr. Boshan. He's going to talk about the role of interventional IBD damage control, and he needs no introduction, he's a professor of medicine and surgery at Columbia University. He was at Cleveland Clinic for almost 20 plus years before he moved to Columbia. But I think it's really a pleasure to co-host this event with him. It's a pleasure to have him talk about interventional IBD. Actually, when I was assigned to this topic, it was actually a painful topic. People are afraid to talk about it. I just saw one of the purposes to this presentation, try to let people learn the lessons, experience I had for the last almost 20 years. So for the interventional IBD, endoscopic management of the IBD and IBD complications. So here's my disclosure. So common practice we do the interventional IBD is a balloon dilatation, as I showed by yesterday, Dr. Naina, and then a knife therapy. So balloon dilatation is an issue of the perforation, and the knife therapy is an issue with the bleeding. So now, sometimes the difficult cases like this, patient had extensive disease, tight structure, and then inflammatory structure and a structure, nearby structure, that's fistula. So it's hard, and some of the patient may not have a surgical option. So now, as endoscopists, we can bridge in the medical therapy and with the surgical therapy. And in the meantime, with the proper training, I think that every IBD specialist or therapeutic endoscopist should do something with this interventional IBD. Now three enemies we have, three enemies we have, when you do the interventional IBD is bleeding, perforation, and post-procedural ileus, or bloating. So talk about the bleeding, how do we control the bleeding? And then steroid is our enemy. So try to avoid any urgent procedure, the patient is still on steroid, ideally no steroid at all. So if you talk about the systemic steroid, the prednisone or solimedul, it's a budesolide or a topically active steroid may be okay. So steroid, if you have to do it, please make sure the dosage is less than 10 to 20 milligram a day. Now this, I can tell you, is a classic example. This, the patient even had a actually chronic disease and remission, came here for the diarrhea and even biopsy. In the biopsy, but a patient on a steroid, look at the two days after and the two days afterwards, extensive of the bleeding. So even the people on steroid, if we do the biopsy in it, people with IBD can cause issues. Very careful about a steroid. So now regarding the procedure we do for the bleeding control, there are two kinds of the bleeding. It's unsighted bleeding or delayed bleeding. Now you will see it's a, when you do the balloon dilatation, actually it's a one of the signs of the, actually you did something therapeutically, you see the blood. You don't want to see the too much blood, little bit of bleeding is expected. Okay. So important one, when we do the choice between the balloon dilatation versus a structural fibrotomy, typically in my practice, if the mixed structure or inflammatory structure or mixed type inflammatory slash fibrotic structure, I tend to use a balloon. If the more fibrotic structure, I use knife. So when you have the balloon dilatation, you have some bleeding, typically it's self-limited. So hardly you have a balloon dilatation, you have the delayed bleeding or late onset of bleeding. So the bleeding always within 24 hours, the most of the bleeding related balloon dilatation is on site. So here is a balloon dilatation of inflammatory structure. Now inflammatory structure, again, it's a mucus are very friable, you have some degree of the bleeding, if the bleeding too much, I highly recommend to have the 50% of glucose in your endoscopy suite, you know, endoscopy suite, 50 or 100 cc a bottle and a draw a bunch of them. And when you have the bleeding, the best way to treat the dilatation associated ozing type of the bleeding is a spray the sugar, spray the sugar. So here is another dilatation, endoscopic dilatation. You can see the bleeding, then we spray the sugar, spray sugar. You can use a spray catheter. Sometimes if you have to use the injection needle, and if you have the little bit of pulsatile bleeding, you can inject the needle underneath of the bleeding site. Now again, this is a bleeding after the removal of the inflammatory polyp. Again, this is like the inflammatory polyp, in my practice, if the more than one cylinder is a bit, since it can cause anemia, can cause a slight risk of the dysplasia, and then you remove it, and then you know that the inflammatory polyp is very vascular. So we always have this clip ready and the sugar ready to spray it. Now if the bleeding like this, and then if the can of the controlled by the sugar, then you can use a clip, but sugar is $3 a bottle, and the clip is $200 a piece. Now here's again, if you have the bleeding, you try to control with a D50 spray. If you cannot control it, then you put a clip there, so that you have a typical, in my practice even I wrote a side card, it's a bedside endoscopy, I always had the two things available, clips and the 50% glucose. Now tampon is our friend, especially when we treat the anal rectal or anal pouch disorder, structure, inflammatory polyp, like here, we live with inflammatory polyp has bleeding. Now you can use sugar to spray on it, but the easiest one is to use a tampon. In all clinical practice, and in our endoscopy suite at Columbia University, we always had the tampon available. You can use a dry tampon like this. Also you can use a sugar soaked tampon. You can put just sugar to the tampon tip, and put it there, compress about five minutes, sometimes less than five minutes, the bleeding will stop. And then also the patient underwent the bleeding, excuse me, the anal rectal structure therapy, and then we also recommend in our instruction, make sure the tampon is available, and just in case the bleeding at home. Now the biggest enemy for us, it is delayed bleeding. Bleeding is one day later, up to four days later in my maximum time period, when I had experience with people with post-procedural bleeding. Post-procedural bleeding, again, is more often in the people in the scapular gastroenterotomy or in the scapular gastroenteroplasty. Now there's a bleeding, you cannot see the site very well, and there's a blep, the blood vessel blep, then you can inject epinephrine. Normally I hardly do the epinephrine injection, I quite often use a clip, so like this. Now this patient has the circumferential cutting, use a needle knife for the anal, excuse me, the ileoclonic anastomosis. Then you can see the middle of the area, there's the bleeding vessel, then you can use a clip. So that's the issue with the delayed bleeding. When we do the endoscopic electroincision, we create the ulcer area, and in the middle of the ulcer area, they have a bleeding vessel developed within a few days. So here is a classic example, we use the needle knife therapy, and there is a circumferential cut with a tight structure in the ileocecal valve area. And you can see that after that, the patient had the post-operative post-procedural bleeding, you have to see the visible vessel in the middle of the ulcer. What do you do? You either inject the sugar or inject the epinephrine, but my favorite one is still the clips, always make the clips available. Now, if you have the post-operative bleeding, you cannot control it by the clipping, epinephrine, you always have the radiology, interventional radiology available. In rare occasion, embolization is needed. Here is my algorithm. So when you have the bleeding, the bleeding has three phases, endoscopy during the onsite, first the 24 hours, and then 24 hours, up to the four days later, five days later. So when you have the onsite bleeding, and then you try the spray, 50% glucose, you do the clips there. And if the patient had the hemodynamic not stable, you need to be admitted to the hospital and for 24 hours admission. And then if the patient delayed bleeding, and quite often you need to admit to sort of the emergency room, get a blood transfusion, bowel prep. And remember, when you discharge the patient, we at least had a clear liquid diet after the procedure for at least one day. So that most of the patients do not need a reprep, just in case you have re-intervention with endoscopy therapy. Now how the perforation is our worst enemy, biggest enemy in interventional IBD, everybody afraid of it. So we need to, first of all, before we do the endoscopic endoscopy, we need a cross sectional imaging, just get it ready, make sure there's no fistula near the, to be treated the structure. So cross sectional imaging, either MRI, CT scan is important. Now regarding the, actually, when we do the endoscopic therapy, if we have the CT scan MRI, we will say typically the situation, people with the enteric fistula, this setting is a ileosigmoid fistula. And typically the distal to the ileosigmoid fistula, there's a structure there. Now if the distance between that fistula and the structure, if longer than five centimeters, maybe use a gentle balloon dilatation, it'd be okay. But if the fistula is very close to the structure, when you do the balloon dilatation, you may end up with a double perforation, small bowel perforation, and colon perforation. So the mapping, the disease status, and then concurrent fistula, and even the access is very important. Now if the people have a very short fistula near the structure, so here's the fistula from the ileum to the cecum, very short, and the structure at the ileocecal valve actually is not a contradiction for the endoscopic therapy, but you do not do the balloon dilatation there. You can use the endoscopic structurotomy or endoscopic fistulotomy here. Now here's what we do, and I use a jagged wire, the soft tip of wire, detect the fistula, and then nearby there's a structure at the ileocecal valve, and careful, you always keep the scope in a straight position, and you do the gentle cut, and then put a clip on both sides. So this is the combination of the structurotomy and the fistulotomy. So now, a wonderful study by our group, and I think that Dr. Namanitha is also a co-author there. So we showed that people with IABD endoscopy versus the non-IABD, IABD endoscopy, either therapeutic or diagnostic, had a higher risk of perforation. Just in the nature of the disease, here's a perforation, if they calculate it by 10,000 per perforation, and it's 19 versus 2.5. So the IABD do increase the risk, it's just underlying disease, do increase the risk of procedure-associated perforation. And also another study by Dr. Namanitha and myself, published almost 10 years ago, more than 10 years ago, showed what's the risk factor for the people with the perforation in the IABD. We use a national inpatient sample. So the IABD patient with dilatation versus non-dilatation, there's six-fold increased risk for the perforation. So be careful about dilatation inpatient with IABD. Now this is an institution sample, when we are at the Cleveland Clinic, we use a Cleveland Clinic sample to institution. The similar findings, if you have a severe disease, severe IABD, or concurrent use of the steroid, then if you do the endoscopy for the colonoscopy, you increase the risk for procedure-associated complications. So that's why this data showed if you have a severe disease, inflammatory disease, be careful about endoscopic therapy. And if the patient had a steroid, try to postpone or reschedule the patient ahead in a therapeutic endoscopy procedure. Now this is the classic example that people only have the structure, the pinhole structure. You do some dilatation there, and then you can see the mucosal tear is very deep. And then in the meantime, you can see the mucosal swelling, but you always have that Plan B available. Make sure the sugar is ready and the clips are ready. Now how about complications complications? So when you have the perforation, some of the perforations may be associated with mortality, ICU admission, and even the stoma. So this is the same study from our institution there, and then you can see the people with the steroid had the increased risk for the complications complications. So the steroid is the enemy. Now these are summarized the risk of the perforation and the perforations complications. So consequences after perforation. So if the patient had endoscopic dilatation, on top of that had a severe IBD or steroid is the worst. And the next risk group, slightly better, is endoscopic dilatation with underlying IBD. And then all next group is a diagnostic endoscopy with IBD. And then least risk of the group are probably the other benign disease and people with a diagnostic endoscopy. So try to avoid a steroid if possible. And if you have to do use, must be the lower than 10 to 20 milligrams a day. So but always have the Plan B available and just in case is the perforation, you have the clip there, you can use it over the scope of the clip or through the scope of clips. Now here is when you do the perforation, actually, when you do the perforation with the balloon dilatation, actually, if there's a perforation, will be the perforated area is larger than you use it. You use an electro incision with a needle knife or IT knife. So here is a big tear and then we have to use it through this over the scope of clip to contain the perforation. Now is the example for this structural anatomy. You can see the cut of the structure, you already see the other side of the almost serosa very deep, but it's a straight, it's a straight, the hole is not big. So we can put a clip there to prevent the bad consequences. Now if they have the pneumoperitonea, very big, can compromise the people, the bleeding, the patient, the breathing, respiratory status, you know what, we can put the angiocatheter in the belly area to let the air out, at least to save buying time for the next intervention. So let the air out. Always have the surgeon available behind. So that's why you do not do the therapeutic endoscopy the late afternoon or the Fridays. So always have the surgeon available just in case you need surgical intervention for the immediate management of the perforation. So but this don't get all surgeon excited. Some of the young surgeons is really looking for the patients, right? So after the procedure, after the procedure, sometimes especially use electric incision, with a needle knife or IT knife, it has some of the air out, outside the abdominal cavity. So they call it a pneumoperitoneum. The most of the patient may have a little bit of pain, but no leukocytosis and vitals unstable. This air, especially you put it in the carbon dioxide, this air can be absorbed. In this situation, we do not have a data how often they have a pneumoperitoneum happen after IBD endoscopic therapy. We do not have the data. So I pulled the data from the pulmonary surgery, peroral endoscopic myotomy for echolacea. You can see this pneumothorax in the people with air insufflation is about 16%, 16%. Intervention needed is 34%. Now look at how often you have a pneumoperitoneum, pneumomedial styne is always a 48%, right? But if you use a CO2, the number is lower. So that means air outside the abdominal, the bowel, not necessary peritonitis, not necessary with your abscess, just need to closely monitor, closely monitor. If you have this sometimes, immediately after a procedure, if the people vital signs are stable and no leukocytosis, you get a CAT scan. If the CAT scan is in the air, and get some of the young surgeon make it excited. But you need to show them it's like the most air, and if they're in good prepared bowel is considered as almost normal, not necessary is a contained perforation or the abscess. So how about a diverted colon? Diverted colon, it's a, again, it's the higher risk for perforation because the colon tissue is a very fragile. But since the patient already had a stoma here, most of them, the perforation, almost all of them were resolved by itself. Do not, no need, most of the cases, no need of surgery. You just need some interventional radiology to train it, give the antibiotics. Now here is the algorithm for the treatment of the endoscopic perforation, IBD. And then, again, the three phases, on-site, first 24 hours, and more than 24 hours. Typically the people with the perforation, with bad consequences that happened with the first 24 hours. And in most cases, actually, you can see the patient wake up in the middle of the procedure, and they had vital sign changes, then most of the time, it is the sign of perforation. You need to mobilize the endoscopy personnel, anesthesiologist, and call surgeons, make available. And in the meantime, if the perforation is small, you can use a clip, over the scope of the clip, through the scope of the clip to clip the lesions, and then rescue them. So post-operative ileus, post-operative ileus, post-procedure ileus. So majority of IBD patients have some form of the surgery. They have the short bowel, or part of the larger bowel, small bowel is gone, they have the poor tolerance of the air. So that's why the minimum air insufflation is important, and the CO2 is preferred. If you stay there too long for the procedure, stay there too long, you can, at the end of the procedure, you can put the decompression tube, nowadays I use NG tube through the anus, and linked the NG tube to the wall suction, in the recovery, to help the patient recover quick from the ileus. But sometimes you can see that the patient already has a partial small bowel obstruction, you do some therapy, you put additional air, right, then if there's more air there, then you may need to push the decompression tube higher, and then patient observes in the endoscopy longer, endoscopy suite longer. Now the patient has, sometimes the patient can have the risk of aspiration. Why that happen? Because this quite often happens to people with a colectomy. For example, the people with the pouch, with ileostomy, you do the endoscopic procedure, you stay there maybe too long, too much air, then the patient can aspirate. So lower your threshold for intubation for general anesthesia. If you anticipated the procedure is long, if you anticipated that you will be pumped a lot of the air there, and especially when you use heat, use the heat like electroincision, APC, et cetera, you pump additional air or gas there. Those patients do not be reluctant to put the patient in the intubation. And you're buying a really, this is a really good practice. OK, these are my summary slides. So therapeutic endoscopy IBD carries a higher risk for complication than diagnostic endoscopy or endoscopy in a non-IBD patient. We need a procedural imaging to mapping the altered bowel anatomy, either by the disease itself or by previous surgery. We need a characterization of the lesion, especially stricture, fistula, and epsis. Avoid or minimize corticosteroid use and minimize the air and CO2 insufflation. Lower your threshold for general anesthesia with intubation, even if you anticipated the patient may be high risk for aspiration. You always have the exit strategy available, clippings and D50, doxycycline, D50 glucose, and then surgical backup. Normal peritoneum itself, not necessary, is the result in the peritonitis or epsis. And sometimes it is considered as a norm when you use an endoscopic electroincision. But those patients with the abdominal pain symptoms should be carefully monitored. And avoid Friday procedures and then, of course, you know, late evening procedures. Thank you.

interventional IBD damage control

bleeding

perforation

post-procedural ileus

steroids

endoscopic perforations