edge and I like that gate I'll start using that Linda that's a good point the gate procedure yeah so rather you know it's it but it's like a gate to a bridge or whatever over some troubled bleeding so we'll go ahead and thanks for setting that up so this is a 55 year old woman she came from an outside hospital where she'd been admitted for a while history of hypertension obesity gastric bypass alcohol abuse reported ankle injury taking a ton of ibuprofen outside hospital AGD showed la-grade esophagitis I too would have assumed that there's going to be a marginal ulcer so I would do a gastroscopy like they did there was nothing there transferred to us because ongoing bleeding melanoma requiring several dozen blood transfusions so ongoing extravasation we did an endoscopy they actually did three single balloon enteroscopies again just keep in your in your mind that picture of the single balloon enteroscope with a big red X through it don't do that she was transferred to our MIC you this was actually her third double balloon enteroscopy to try and get to the remnant stomach they weren't able to find it weren't able to get their way there but they did see that there's blood old blood and fresh blood throughout the small intestine ongoing more than 10 units of blood transfusion every day I'm a blood donor so it kind of kills me to know that all my blood is you know being used for something like this but I guess that's why we do it so she's getting her blood transfusion I took over bleed team so we have a bleed team service where for a week we're on for 24-7 for a week and you do nothing but emergency endoscopy Chris Gostow invented this service he was one of the founding guys who invented the overstitch device so here we're gonna so again you don't always have the expertise for us that's why this patient underwent multiple single balloon scopes but I said we need to get to the remnant stomach it's very clear on bleeding studies that the blood is is coming from the remnant or soon thereafter so we go ahead and place our gate stent I go ahead and dilate that tract every time so here we're doing our dilation between the two you could actually see blood in the stomach so that and you saw that my stent hung up on a big blood clot and I was kind of trying to shake it off when we deployed the stent here because look she's bleeding we this if there was any a time to go through your stent and do something I'm actually going to use what I know is full thickness suturing I do a lot of Tori for weight regain after gastric bypass so I'm going to use what I know is full thickness tissue at the gastro jejunostomy to take a really nice full thickness bite here so I'm going to get a this is not just you know a mucosal bite like we might do for esophageal stent fixation this is going to be a really strong suture here through the gastro jejunostomy like Amy was saying really important that you don't suture far far away from the stent that's a really great point if you suture far away and then cinch you're gonna actually pull back tension on your on your stent which when you're inserting your scope may be helpful as you're pulling out your scope you have to remember also your scopes gonna hang up on the stent as you pull back potentially that may actually be some you may have several vectors backwards that pull this stent back out so here we went mucosa to stent to mucosa I worry that if you suture through a stent first one of those t-tags could wobble and actually come through the interstices of a stent probably won't happen with an axios because the the weave is so tight but again here we went mucosa stent mucosa we're going back we suture we cinch that suture I always do a contralateral side suture as well so we had two sutures placed here we're going into the stomach we wasted a bunch of time because there's all this blood in the body of the stomach looking for a source looking looking and then eventually we made our way down to the second portion of the duodenum where we found potentially something a bit more active again that that slide actually was to remind me to tell you that I'm just watching fluoro constantly when I advance through the axios so I'm just keeping a really close eye and here you can see there's a nice duodenal ulcer unfortunately right this is our this is our worst spot it's right at the sweep on the right lateral wall of the duodenum as we're making this sweep from the first to second portion you can see here I love a clear plastic cap it's our friend for so many different uses but here I'm able to pinch off the artery that's bleeding in the ulcer when I put pressure on it with the cap and then as soon as I back off a little bit it starts bleeding now here's here's a conundrum and I we face supply chain issues I'm sure everyone else is too I didn't have a 20 millimeter axios so I had placed a 15 even with the 20 I would be extremely cautious about about going through it with a 12 6 over the scope clip yes it's on your 12 millimeter scope or your 10 millimeter therapeutic scope but the outer diameter of that little hook piece that the that the clip is lodged against is is quite wide so it's more like 14 millimeters so that I think you're very likely to dislodge the stent so I had a 15 millimeter axios even with over dilation I was a little nervous about pushing through an Ovesco which is clearly what I would use in this situation with native anatomy so I'm trying left and right I like the seven French gold probe because it allows me to suction beside it some of my colleagues will say bigger is better but I personally really like the the seven French gold probe and you can just stand there and cook these vessels and I'm amazed often with a lot of persistence you'll achieve hemostasis unfortunately this one as she expressed through her care you know I think she had amassed like 40 or 50 units of blood and I had to go to my least favorite device which is the which is chemo spray I find it a cop-out for bleeding but I have to admit when it's bleeding especially also related bleeding where you expect that you just need to buy some time for the ulcer to heal it works really nicely so this this is the most the perfect case for chemo spray alternatively now available soon to come for everyone from Olympus will be another kind of head of starch type material so this doesn't have to be you know one company to consider but great great great device that worked well for this patient so we left the edge stent in place this is not someone where you would pull the stent or close anything certainly acutely we let that track stay she had an endoscopy the next day because she had stopped bleeding so it was her first day without a blood transfusion she did really well stayed for two more days in the hospital she was discharged home with her edge stent in place and then she came back a month later when she had had no further bleeding episodes we did a quick endoscopy to pull out the stent and actually did closure as well which we already showed today so that's that's that case there's a question online why not coag grasper yeah coag grasper is great that would have absolutely been an alternative here particularly I don't know if you could tell the bleeding was kind of at the right upper side of the screen and in this position at the sweep it's impossible to I think it's impossible to rotate your scope around so that your working channel is up at that kind of tent two o'clock position so I love the coag grasper I use it a lot on bleed team but I felt that I wasn't going to get it where I needed it to go it's pretty big then it can be a problem with the coag grasper because you want to get the whole entire width of the blood vessel in into the force that you don't just want to grab one wall and then it shears off and the bleeding gets worse great point yeah that's another underutilized tool in bleeding the coag grasper is wonderful but you really do need to see the vessel all right one question absolutely yeah so this is something right it shouldn't have gotten to the point where she had had dozens and dozens yeah dozens of blood transfusions so there's a big cost to that too right yes absolutely this is someone where I think at some point she would have gone for either probably XLAP and maybe a maybe a gastrectomy all right well for the sake of time we're gonna move on but that was awesome

ongoing bleeding

endoscopies

stent placements

suturing

managing bleeding