So, let's start with our last session of this afternoon, or this morning, or this evening, worldwide. And then, thank you again, and all the speakers, and thank you to ASG, our sponsor, and also thank our course co-director, Dr. Odin Abiditan. Next topic is a very hot topic. Actually, the topic of everybody afraid to have this perforation as a GI gastroenterologist, and the leading expert in this field is Dr. G.S. Raju from MD Anderson Medical Center, University of Texas, and a professor of medicine there. And then, long-term, the senior member of our ASG committee, of the various committees, and then his topic is the endoscopic management of endoscopy-associated perforation. Dr. Raju? I think one thing I want to share with you is, although, as endoscopists, we used to worry about bleeding in the 90s, 1980s, 90s, and 200, early 200, that is no longer a problem because we could control that. In the last 20 years, if we have learned something, that is, we could even manage perforations, fistulas, and leaks. I think we shouldn't be afraid of any of the complications. I think the most important thing is to stay away from a complication. So these are my disclosures and acknowledgements, and these are my learning objectives, and let me take you through this session. So I think, you know, if you look at a large database, and to learn about the prevalence of complications related to colonoscopy, one thing is important to appreciate is we do have an excellent safety record, and the record has been steadily improving. If you look at the mortality, it has been pretty low. Perforation rate is also very low, and the bleeding rate related to various interventions has steadily come down. That is thanks to advances in our own techniques, as well as the ability to manage complications. In terms of one thing I want to share is we should not forget about the fact that the population is getting older, and we are taking care of senior citizens, and it's important to appreciate the impact of advancing age on colonoscopy. And if you look into this database, one thing that we have learned is the fact that although we tell patients about the risk for bleeding, risk for perforation, risk for splenic rupture, etc., related to colonoscopy, as a patient goes beyond the age of 75, 80, or even later, we should worry about vascular events, especially cerebrovascular events. Coronary vascular events and pulmonary events. Those issues are the ones that we should worry about, and not necessarily worry about bleeding and perforation, because these are the main events as we deal with patients in their 80s and 90s. And that is something to keep in mind, and that is something we should keep in mind to decide whether we want to put a patient through a colonoscopy or not. In terms of the impact of procedure, when it comes to colonoscopy, whenever you intervene, even including a simple biopsy, that increases the risk of complication, and when you intervene with a therapeutic procedure, the complication rate increases. So when you're consulting a patient for a procedure, you should keep this thing in mind and share this information with the patient, that as the intervention severity increases, the complication rate increases. But overall, despite that, we have the tools to manage the complications and keep our patients out of hospitals and out of emergency surgeries. In terms of the impact of IBD, because this is an IBD conference, I want to share with you, we don't have much data, you know, the data is pretty limited. And one thing that we know, based on the work of Boshan and Uday from Cleveland Clinic, when they looked at their huge experience, what they have shared with us is the risk of perforation is certainly higher in the IBD population than in somebody without an IBD. And when it comes to IBD, the risk is higher with advancing age, with the severity of the disease. And also, if somebody has been on steroids for a long term, the steroids do weaken the connective tissue, and they are at a higher risk for perforations and complications. And we all know that steroid use tends to impair the wound healing. So based on that, you know, this is something to keep in mind as you're attempting to take care of a patient in terms of assessing the risks. When we look at the impact of adverse events in terms of mortality, again, a big study looking at at least 4 million patients. The 30 day mortality for bleeding is about 13 per thousand procedures, but between bleeding and perforation and splenic injury, as you can see, the risk increases with perforation and with the splenic injury. And how about the impact of adverse events, especially in IBD patients? Unfortunately, we don't have data. So as the IBD experts like Boshan and others take up interventional procedures, maybe in the next 10 to 20 years, we will gather the data to comment on this. So when it comes to perforation, I would like to focus my talk on perforation, and I would like to share how you can stay out of trouble, especially with a mechanical injury, that is a sigmoid perforation, etc., when you're doing a colonoscopy. One thing is important is I work in a cancer hospital, and I have started this as part of my practice. In addition to doing the timeout, which we are all doing as a part of a routine, it's a good idea to go through the history, and also figure out in terms of if you're taking care of an IBD patient, the severity of the IBD, and the steroid use, so that everybody in the team, including the endoscopist, reminds themselves about the patient that they're going to take care of. When you're doing multiple procedures and you're running between rooms and trying to do cases in a quick succession, taking that timeout to reflect on that history makes a big difference as you're doing the procedures. Sometimes we may not realize the patient is another IBD patient, but another IBD patient with a different protoplasm. As you're going through the colon, and you're trying to reach the cecum, as a trainee, we always are focusing on what is ahead of us, but I think it's important to also keep in mind and reflect on the journey, or track your journey, you know, whether you formed the loop, and whether you're trying to push through a loop, because that is important to stay out of trouble. And the reason I say that is, as you're going through the sigmoid to the descending, if you have gone through one, two loops, and you're trying to push through those loops, that's the time you could end up in trouble with the hockey stick injury. So when you are trying to go through a difficult sigmoid colon, and the scope is not moving, but you're introducing a lot of scope into the colon, you should stop and take some precautions. One simple step could be, if the patient is on the left lateral position, to just push them forwards to a little more prone position, and that will open up that angle and make you get up into the descending colon. Another option is water immersion technique that we have been using routinely as you're going through a difficult sigmoid colon. And if in case you are still struggling, and you're pushing and you're finding that there is quite a bit of resistance, it's probably a good idea now to back off and take a thinner instrument. Nowadays, we do have instruments that are as thin as an endoscope, with enough length to reach us to the cecum, and that is something worthwhile doing that. Just yesterday I had a patient where I was struggling with a pediatric scope, and basically I pulled the scope out and asked for a slim colonoscope. The other option is, in the past, we used to use either a single balloon or a double balloon scope. Probably with the thin, slim colonoscope, the number of times I've fallen back to those instruments is probably very small now. And if in case you do have a long, redundant colon, and you are not able to reduce the loop, nowadays there are special overtubes that will fix the sigmoid and prevent it from looping too much, and thus prevent the risk of hockey stick injury. These are some of the things that you could use in your practice to stay out of trouble. Although, as a fellow in the 1990s, we have learned a lot at that time about barotrauma, because at that time we were not using carbon dioxide, we were just using room air. But that is probably no longer a major problem, since the majority of the endoscopy units have shifted to carbon dioxide as a routine, because carbon dioxide gets reabsorbed from the colon much faster than room air. If in case you're going through a difficult sigmoid and you're not moving, probably not a bad idea to shift to water immersion technique, and also get into the habit of frequently palpating the patient's abdomen to make sure that you have not introduced too much of gas into the colon. If that were to happen, one thing that I do is to take off the biopsy port cap off and let the colon vent out. That would make it easier for you to get up into the colon and avoid the risk of barotrauma. Finally, retroflexion injury, especially in patients who have had colitis and the rectum has become smaller, is probably better to avoid retroflexion, because there is potential for retroflexion-induced rectal perforation. What I do routinely is I use a cap-fitted colonoscope for all my procedures, so I try to deflate the lower portion of the rectum, and with my cap I can still keep myself in the anal canal and examine the lower portion of the rectum. It does avoid the need to retroflex and avoid the risk for retroflexion-induced perforation. In terms of perforation related to IBD, I would like to make a couple of comments, because strictures are quite common in IBD, especially in the setting of Crohn's disease. We have been managing the strictures with balloon dilation. When it comes to balloon dilation, it's important to figure out the type of stricture that you are trying to manage. Like the esophageal strictures, colon strictures could be classified into either a simple stricture or a complex stricture. Simple stricture is a short stricture and relatively straight, and you can see the lumen through without worrying too much. These strictures can be managed relatively easily. On the other hand, if the stricture is long, angulated, fixed, and quite tight, that is a complex stricture. Complex strictures should be managed ideally with fluoroscopy guidance so that you can see as the balloon is dilated. And also make sure that your wire has gone deep into the small intestine and not abutting against an angulated, fixed ileum. When it comes to dilation, it's important for the assistant to pick up a shorter balloon, not the regular long balloon. Long balloons, you'll get into unnecessary trouble. Take a short balloon. And to educate the assistant to dilate the balloon slowly rather than going very fast and tearing the stricture and getting into trouble with the perforation. And as the dilation is happening, it's important for the assistant to share with the endoscopist if he's feeling resistance and if he's struggling to inflate the balloon so that the endoscopist can make a decision about whether to go further or just hold on there. And that's why it's very important for the assistant to work very closely. And as an endoscopist, we should train our assistants to do that. It's also a good idea, irrespective of whether you do a stricture dilation or a receptor polyp, to examine the site of your intervention and to check that site. We have learned over the years to identify the depth of injury and a perforation, and if there were to be a perforation like you see here, you could immediately close that defect and avoid the need for surgery. If there was one thing that we have learned in the last 10-15 years is our ability to assess the depth of injury and also either take a prophylactic step to prevent a delayed perforation or close an immediately obvious perforation. Recently there has been some work looking at the role of covered stents for management of tight strictures, and these covered stents could be deployed through a colonoscope, and these are retrievable stents, and this is a study that has shown the role of these types of stents for management of strictures, and hopefully we will deal with less of perforations when we try to use those covered stents. Finally, I would like to talk about perforation prevention and polyp resection. One thing is, as patients with IBD go beyond eight years, we are obligated to provide surveillance exams for colon cancer, and endoscopic resection has been increasingly being used, unlike in the past, of total colectomy for these patients, and if you look at some of the data, this data is quite encouraging in terms of the complication rate, pretty low, you know. Bleeding risk is about 2%. Again, perforation risk is also quite low. So unlike a regular polyp that we see, one thing is in IBD, most of the lesions tend to be flat, and they're visible during a chromoendoscopy, and when it comes to polyp resection, especially flat polyp resection, it's important for the trainees to appreciate that the strongest layer in the colon is the submucosa. As long as you maintain the integrity of the submucosa, you will be much safer with the less issues in terms of any delayed complications. Once the submucosa is gone, and you cause some injury to the muscle, that patient is at high risk for delayed perforation. So when it comes to polyp resection, it's important to keep the snare, if you're doing a snare resection, to keep the snare parallel to the wall. I think it's very important to appreciate and learn how to keep the snare parallel to the wall, because that is one thing that would avoid entrapment of the muscle. If you go at an angle, there's a possibility that you could entrap the muscle, and when you cut, you can end up with a perforation. Keeping the snare parallel to the wall is a critical step. Another one is when you close the snare, and it's important for you to appreciate the movement of the tissue above the snare and below the snare. And if there's a lot of pinching effect below the snare, there is a possibility that you have entrapped the muscle. And if you are in doubt, the best thing is ask your assistant to slowly loosen the snare while you are putting in CO2 to distend the colon, so that the muscle, if it's been trapped in the snare, it will fall back. And then when you close, you should be able to close with a smaller amount of the loop required for a snare closure. And by doing that, you would avoid muscle entrapment and risk of perforation. And obviously, get into the habit of looking at the resection base, and here you can see a nice submucosa. And if it's a little bit deeper, you can still have a wisp of submucosa. The muscle layer is still intact below that. And if the damage involves the muscle, that's when you should worry, and you should do prophylactic clipping to prevent a delayed post polypectomy syndrome or delayed perforation. Obviously, if there is a complete muscle injury and perforation, then you should be ready to close the defect with clips. One thing is important is when you are doing resection, make sure that you have all the necessary equipment available so that the assistant can pick up and give it to you without losing much time. It makes no sense for the assistant to go running from room to room trying to find a clip once you have perforated the pole. So, it's important to make sure that you have all the equipment ready so that you could manage the patient promptly. In terms of perforation management, if it were to happen during the procedure, small perforations, especially related to snerosection, if it happens in a clean colon and there was no spillage of fluid through that perforation, you could save that patient from surgery by just doing endoscopic closure. On the other hand, if there were to be a large perforation related to mechanical injury by pushing the scope too much, or if the perforation were to happen in the setting of a dirty colon with some spillage of contents into the peritoneal cavity, those patients are best managed by surgery because simple closure is not going to take care of the spillage that happened that results in peritoneitis. In terms of the closure devices, you know, we have through the scope clips, over the scope clips, and over the scope suturing devices. In colonoscopy, it's best done with a through the scope device because it can be done immediately without leaving the operating field and you don't have to struggle to go back with an over the scope clip or with an over the scope suturing device. So when it comes to clips for closure, I would like to share two important principles. Every clip, as it closes, it actually retracts. It retracts by about a few millimeters. I think you should actually try this outside, you know, in your own lab and show it to your assistant how much the clip retracts. And the reason why that is important is in order to get a deep approximation of closure, the assistant should close the clip slowly, not fast, slowly, so that it allows you the time to gently push the clip or the scope so that you could get a deep approximation by compensating for that retraction of the clip that happens as the clip closure, as the assistant closes the clip. And it's important to make sure when you close a defect, the two blades should be closing the defect completely and you should not see any gap in between the two blades of the clip. And those clips will stay there for the next few days while the wound healing happens. You don't want a clip closure where the clip has been applied superficially and the clip drops off by the time you come off, come out of the scope. That's not going to help. So you need to have a deep closure. And it's also important to document that you have achieved a mucosa to mucosa closure by taking photographs on both sides of the clip closure so that after the perforation, because you want a surgeon to be on board and you want the surgeon to be comfortable that your closure is adequate. And to show that, make sure you take pictures of the clip closure on the proximal as well as distal side of the closure. Recently, we have, we are fortunate to have through the scope suturing closure that's currently available. This is something that would probably change the way we manage, especially if the perforation is too big and the clip is not able to bridge, then you can use the through the scope closure to either do primary closure or through the scope suture closure plus clip closure to achieve a complete closure. And some of you may have seen, but I want to show you the principles. This involves putting a tag on either side of the perforation. And then as you bring the tags together, and then a couple more, and then bring the tags together and deploy the suture closure by deploying the knot. And this is very simple. I suggest that everybody should learn this technique. If in case we end up with a problem and you cannot close with the clip, this will be helpful. We don't have a lot of data. This is relatively new, but when you look at the principles, I feel that this will work. And those sutures actually just go into the submucosa and not necessarily through and through. And as you know, that submucosa is the most, the strongest layer that will hold on to the sutures and allow the closure. In terms of the perforation, if you observe signs and symptoms of perforation in the post procedure, if the patient is asymptomatic, especially if it is a low rectal perforation, probably they can be managed medically along with the surgeons on board. But on the other hand, if they have symptomatic perforations, they need operative treatment, whether it is a repair or a resect depends upon the underlying pathology, as well as the size and the amount of peritoneal contamination. Coming to the post polypectomy bleed, just to briefly share a few thoughts. Most of us have trained on the use of clips, loops, use of epi, and for perenculated polyps, the data shows that it prevents early bleeding, but we don't have much to say that it is effective for delayed bleeding. When it comes to management of flat lesions for post polypectomy bleeding, what I would like to share with you, that is, I've changed my practice, that might be helpful in your practice, is if you are using an Erby machine, that's what I use. When you set up your Erby machine, on the left side, you have the endocut. On the right side, normally the machine sets up for forced coagulation. Forced coagulation is sometimes we use for polyps, but for all my EMRs, I use the endocut mode. I don't need a forced coagulation on the right side, so I changed my forced coagulation to soft coagulation and set it up at effect 4 and 80 watts. The reason that's important is, once you set it up, if in case you resect a polyp and you have some bleeding, you can use the snare tip and you can control the bleeding immediately by tapping on the blue pedal, which delivers the soft coagulation, and you can control majority of these small vessel bleeds that you encounter during endoscopic mucosal resection. On the other hand, if the bleeding is a little bit, is coming from a little bit bigger vessel and you need a hemostatic forceps, you can get a hemostatic forceps and use the same soft coagulation, effect 4, 80 watts, and quickly control the bleeding. The reason I want to share this point is because sometimes in the middle of the procedure, asking your team to change your electrosurgery settings can be painful and you will get distracted, so you don't want to waste your time if you can actually set up everything before you start the procedure by having endocut on the left and a soft coagulation on the right, and all you have to do is use the blue pedal for delivering hemostasis using soft coagulation. Sometimes if you have a big vessel and you're having active bleeding and you are not, you are not able to find a vessel, sometimes you can actually use a clip to grasp the surrounding tissue and occlude and cause the hemostasis, and what I have done is if, if there was still a lot of polyp to cut, I try to hold on to the clip for three, four minutes and let the thrombus form and reopen the clip so that I could continue my cut without having the clip in the field and worrying about electrical sparks going across the field. In terms of the role of clips, although there was quite a bit of debate whether clips will be useful or not for the last 20 years, a recent randomized controlled trial has proven that clip closure after EMR cuts down the risk of delayed bleeding, and the benefits are much more in the proximal colon and in those who are on antithrombotics. There is some preliminary evidence from Europe about the use of this self-assembly, self-assembling peptide that some of our colleagues from Europe are using after resection to prevent bleeding, and we, I think if we wait, we will get data in the next few years about, about the robustness of this approach. In summary, we talked about colonoscopy complications and given what we have, I think we should, we should feel good that we could tell our patients that we can manage them safely. Thank you.

endoscopic management

complications

advancing age

vascular events

IBD

strictures

polyp resection