Hello, good morning, everyone, and welcome to Weekend Endoscopy Live, which is brought to you by Medtronic, and this is live from the IT&T Center. I'm Prateek Sharma from Kansas City, and I'd just like to welcome all of you this Saturday morning. series of Weekend Endoscopy Live, which is just an hour of endoscopy, and I'd like to have you all join with our coffee cups or with your tea, whatever your favorite drink of the morning is, and spend an hour with all our experts telling you about endoscopy complications, how to recognize, and more importantly, how to treat them. So with that, I'd just like to introduce our fantastic panel. I'll just start in alphabetical order. Neil Gupta, who is professor of medicine at Loyola and the director of endoscopy, as well as the chief of gastroenterology. Welcome Neil. And Doug Rex, I'm not sure what words to use to describe or introduce Doug Rex, but Doug, besides being the master of colonoscopy and CRC screening, is our immediate past president of the American Society for Gastrointestinal Endoscopy, and it's difficult to talk about colonoscopy complications or any procedure related to colonoscopy without having Doug. So Doug, again, our pleasure to have you on board. Good morning, everyone. Next is Asma Shaukat, who is in New York, not in cold Minneapolis anymore. So Asma is professor of medicine at NYU and also a leader in the field of CRC screening and has been involved in several guidelines from our societies telling us what to do about colon polyps and colon cancer. So welcome Asma. And then last, not the least, is Judy Trieu. Judy is currently in North Carolina, but will be joining WashU as an advanced endoscopist very soon. And Judy's job will be to make sure that we are all telling the right things today. So Judy, welcome to the ASG program. So with that, I see close to 100 participants have joined already. So why don't we go ahead and get started. So first, I'll have Doug start talking about some colonoscopy bleeds. So Doug, go ahead and share your screen. And as Doug's doing that, we'll start off with some colonoscopy videos and talking about bleeding, which can happen right after removal of a polyp and what to do with it. So Doug, go ahead. OK, so our first, I think our main tools for control of immediate hemorrhage, certainly during EMR and polypectomy, cold snare bleeding can be stopped with a lot of things. But when we're using electrocautery to remove lesions and then we have bleeding, the two main tools are the snare tip, which will stop about 90% of bleeds, and then the coag graspers. So the snare tip, the most important thing is to switch the power setting from forced coagulation current or whatever you're using over to soft coag, which is a low. There we see we're finally with a little wash. We're seeing the actual bleeding point. And so that's the application of the snare tip, which I think is the most important tool for stopping immediate hemorrhage. But we want to have something that will take care. Sorry, Doug, before you go to this second one, can you tell us about the snare tip? Does it matter what snare and you use the set snare, which you're already using? And do you switch the settings to a specific one on your machine? Can you tell us a little bit about that? Sure. So any snare that is made for electrocautery, obviously, if you can't use it, if you have a cold snare bleed that you've induced, you'd have to switch to it. But you're generally going to use the snare that you've already been using. As long as you don't have a lot of crust on the end of it, it ought to work well. And you don't have to stick the thing out very far. But I think Prateek, your point about switching the power settings is very important. And I'm often surprised at how many people are not comfortable themselves with the electrocautery unit and often rely on the technicians to set things up. But we're ultimately responsible for having the right cautery settings. If we use the forced coag setting, there is a higher voltage and there's a little bit of a tendency for the tip of the snare to act like a knife. And so I think you can potentially get a deep thermal injury. I've even had people tell me they've perforated the colon using the snare tip. So when we switch over to soft coag, I usually have that on about effect five, effect four or five is about right, 80 watts. It's basically the same setting that you would use to use the snare tip to treat the normal appearing margin at the end of a piecemeal endoscopic mucosal resection to reduce the recurrence rate. So you can use the same settings all across the board, but really any snare that will deliver electrocautery will work. OK, sounds great, Doug, please go ahead. OK, so this is a situation where we've got more rapid bleeding, arterial bleeding, and so we're going to use here coag graspers, coag graspers, they have a flat surface. Again, we're going to use soft coagulation current. And typically what you want to try to do is is get a hold of the bleeding site, sort of see mechanical control of the bleeding, which I didn't really have there, and then give your soft coagulation current. So you want to have, I think, this this tool around. You can use hot forceps rather than this, but they don't have quite the same flat surface. They have teeth on them. This is a technique of you grasp, lift, burn and then release. You don't want to obviously pull things off, but good tool to have around. They're sort of they're sort of expensive. So I tend to usually to, you know, use the the snare tip. And as I said, the snare tip, I think, will control about 90 percent of arterial hemorrhage during EMR. But it's good to have a grasping tool for more severe bleeding. Judy, you're watching this. And anything different that you do? I saw Doug sort of like pull the, you know, close the coag grasper and pull it a little bit, tent it. I mean, can you use it just with the blunt edge of it and rather than opening and closing it? Would it work as, you know, causing hemostasis even in that fashion? We've actually used it before using just the tip of it as well to cut to create hemostasis. But like Doug had mentioned, grasping, especially if the vessel is a little bit bigger, would absolutely give you a better effect. I actually had a question for Doug if we've had it before where we didn't have the coag graspers there immediately or we didn't have it in supply. Can you use hot biopsy forceps? Yeah, yeah, Judy can use hot biopsy forceps. And of course, they're less expensive, which is a real advantage. I think it's just important for users to be aware of the differences. First of all, the hot forceps typically have teeth. And so you're dealing with bleeding. So you want to be conscious of that. They don't quite have that flat surface. And then again, you know, to release after you've cauterized. But you can absolutely deliver soft coagulation current with hot forceps. Now, Doug, just in this frozen image that we everyone's looking at, I can see like a blood vessel at the going from the three o'clock to the five o'clock position there. And usually after these EMR, sometimes you do see them. Do you leave them alone or do you go ahead and prophylactically, you know, close them so or cauterize them so that I don't have to wake up in the middle of the night with a post polypectomy bleed that I have to deal with? So what's your approach to those, Doug? So, yeah, no, that's a that's a fabulous question, because I think there are people who go around and cauterize them. We've actually had two randomized controlled trials that have looked at cautery of these exposed vessels versus just leaving them alone. And they haven't cautery of them. Prophylactic cautery has not produced a significant reduction in the risk of delayed hemorrhage. So most of these things that you see exposed are veins. Every once in a while, you'll see an artery. The arteries are, you know, little white vessels that they're actually you see something pulsating. I do tend to take care of that. But most of the vessels that you see, I think, including this one that you pointed out, critique our veins and the data says that that, you know, it's not helpful to go around and cauterize them. Now, I would say and I'll say a couple of things. First of all, you know, Dean Jensen presented an interesting study of going over the defect with a Doppler in order to see hidden arteries. And I've not actually seen the paper published, but in an abstract at DDW a couple of years ago, he showed that you could if you did identify a hidden artery that either cauterizing that or clipping that would prevent bleeding. Now, I don't I don't do that. I don't know if that's in the future. I haven't seen that paper fully published. But the bottom line, I think, is that the vessels that we see are not likely to be the ones that cause delayed hemorrhage. And so with the exception of exposed arteries, I tend to leave them alone. But I'd be interested in others comments. We'll have asthma switch over to her video, and as she's doing that just for the audience is please use the Q&A function, which is at the bottom of your screen to go ahead and start asking us these questions and we'll try to get to those. So asthma walk us through what's here. Please go ahead. OK, great. Good case, Doug. And I'm going to kind of reiterate and present a very similar situation and similar interventions. Can everybody see my screen? Yeah, go ahead, please. OK. And so congratulations to the new first year fellows, if you have any, and to the rising second, third and fourth year fellows. You know, now's the time to start perfecting your polypectomy techniques. So I wanted to put this case up. This is a polypectomy. We're in the periplexure. And and again, this is with an inexperienced fellow. So we were kind of learning the ropes. So first, you know, the polypectomy and many things you can probably see is the position that it was done. And you can see that immediately we see, you know, extravasation and bleeding. So at this point, would you finish the polypectomy first or deal with the bleeding? I think most of us would kind of finish the polypectomy. The more important thing was, you know, getting the polyp in a better position. So we actually had the fellow rotate the scope and now you can see, you know, the rest of the polyp. So we took it out in a smooth fashion. And then once that was done, then we could really inspect the bleeding site. So here it is. And then the next thing to do is to flush the area, sit there and watch the bleeding and see if it's going to stop or is it continue to wound. So you can see a pretty decent defect there. And if you look closely, you can kind of pinpoint the vessel in that bed where it's coming from. So then the next question is what to apply here. And there's, you know, different options and we have several tools available. We chose to do a coag grasper. And again, just like Doug demonstrated, you know, especially because we could see the vessel in the bed. So we thought that might be, you know, a good effective thing. Plus, you know, the fellow really wanted to get experience with it. So we actually grabbed it and were able to coagulate it. And then we also used the tip around the edges to achieve hemostasis. So Asma, one of the questions always comes up is when you're using the grasper to try and coagulate is so you close it, you tent it a little. So how long do you hit that energy button pedal for? Yeah, that's a good point. And, you know, it can vary a little bit based on the vessel, but I'd say we do it too short most of the time. So at least, you know, three seconds or longer, but you can see a pretty good response right in front of you. So just some short pulses and stuff. Right. And I mean, I think one of the key things, as you were showing also, is to make sure that you do tent it so that you're not like applying a quartry to the entire thing with the forceps. And it's just on the tip. There was another question there, Neil, perhaps you can take it, which was that if you go to the edge of the margins, can you use forced coag instead of soft coag? Or if anybody wants to comment on that. Yeah, I think even if you're if you're treating the edges of a polypectomy or resection site, kind of that data is still using kind of the soft coag as that technique. And so I would continue to use soft coag in that circumstance. I guess theoretically, you could say, hey, I'm not in the defect. And so it's a little safer, but I would still use a soft coag. Yeah. And there, you know, the really the technique to perfect is, you know, the amount of touch, right? Just because it's soft doesn't mean you kind of bury the tip, which I often see fellows doing. And then, you know, you yank off tissue is kind of controlling the tip so that and that comes with just time and practice. But being very mindful about how much contact time and how much contact is you're applying and that you learn just by by doing. Now, Asma, I saw you were doing this underwater or at least, you know, part of that, which is a great technique. And I know that it improves resection. Is there any advantage of this underwater technique to reduce bleeding or is it mainly more for resection? When do you do you think it reduces bleeding as well? So it was mainly for resection, you could see it was epihepatic flexure, so we figured we had a nice little pocket if you filled with water. Plus, as you know, you know, underwater EMR really makes the polyp, the edges kind of a little more easier to see and the whole polyp easier to find and reset completely. So we were doing it for that purpose. And I don't know if there's any data if it reduces bleeding. Yeah, there's there's some data, you know, in terms of follow up, it doesn't actually reduce the risk of delayed hemorrhage. And when you do have immediate hemorrhage, of course, you have blood floating up into the water column. So as as you did, Asma, you have to switch over to gas, at least temporarily, typically to stop the bleeding. But the advantages of underwater resection are you get a higher rate of on block resection. And then, you know, meta-analyses and systematic reviews are showing that that there may be a lower recurrence rate. So those are the two main advantages, but probably not a significant difference in the complication rate. OK, great. I'm going to have Neil now start, you know, sharing his screen for let's talk about upper GI bleed. But while, you know, we are doing that, Asma, one of the things we didn't get into is is what we do all the time, which is the cold snare polypectomy and a little bit of bleeding, which happens after every cold snare. So Asma, what's your sort of philosophy to that approach? I mean, how much do you wait before you say, OK, that bleed, I need to, you know, deal with that right away or at some point? Yeah, absolutely. So I think we develop a higher and higher threshold for being worried about the oozing and most oozing we can leave alone very safely without any major sequelae. Sometimes it's worthwhile to, you know, do your second inspection if you were going to do it. So if this was just oozing around the edges. I'd be totally comfortable, you know, flushing it, watching it, then even, you know, doing my my second look into the secum and coming back and seeing what it looks like at that point. But the oozing you can pretty much leave alone, which you saw around the edges. But if you have a source that is bleeding and if it's bleeding briskly, then then that might be something that you should, you know, address right there and then. So at least in the moment, looking at the polypectomy site, flushing it, you know, distending the lumen, collapsing it and seeing if you're seeing, you know, something more than just ooze. OK, great point, Neil, go ahead. Great, thank you. So in this case, what I'm going to show here, and I apologize, it is an old case from probably about 10 years ago. This was actually a submucosal lesion in the in the stomach that you can see is being resected by band EMR at the time. And, you know, I wanted to highlight just this beginning part of the video where after placement of the band, there seems to be a lot of blood on the surface of the lesion and even some coming out from the base. And so maybe that should have been a little bit of a clue at the time to say, well, be prepared for something to happen. And so as we're going through and resecting the lesion, everything seems to be going OK. We've got the lesion, gone ahead and suctioned it into the cat to go ahead and take it out of the body. And as we're going back in to go look at our resection base, you'll see kind of the the oh boy scenario where now we've got a bunch of fresh blood in the stomach. And I think one of the key here is, you know, I probably panicked at the time, as this was 10 years ago, probably early in my career, saying, oh, boy, what did I just do? And so to stay calm, you know, I tried to suction out as much of the blood in the clot to give myself a clean workspace. As you can see, this patient was not intubated. This was done under just, you know, moderate sedation. And you can see a pretty pulsatile vessel kind of spraying right in your face, right in the middle of the resection defect. And so a lot of different options and tools that you have to kind of deal with this situation now. You know, and a couple of the things that I was doing in my head at the time is kind of thinking through the pros and cons of different options. You know, this was a submucosal lesion that I'd taken out. I really had a hard time seeing the full base considering the amount of blood in the area. And so as you can see, I'm just thinking in my head right now and trying to suction out the blood as I'm thinking. And so I was worrisome of applying more cautery in this defect because I didn't know how much muscle was still there or whether there was any kind of injury to the muscle layer because I couldn't see. So I wanted to apply maybe more mechanical closure technique to close this. And so at the time, we're really dealing with, you know, traditional clips or the over the scope clips. Considering the size of lesion, the amount of bleeding, you'll see here in a second, I went ahead and elected to go ahead and place an over the scope clip on this. And as we have the clip device on now, the key part here is you really get one chance of deploying this clip. And so you got to make sure you're suctioning and getting the entire lesion correctly on here. And so you can see taking some time, that first attempt of suctioning, I wasn't quite happy with it. And so going back, really trying to reposition that edge of the cap at the kind of the proximal edge of the defect to make sure as I suction, I get the whole thing up in there. So I go again a second time, take my time, really try to make sure I'm getting the whole thing flowing into the cap. And then I think here is where I deploy it. And so now after deploying, we can go ahead and see that the clip is on the lesion. It's fully appears at least a time to be fully on the entire defects. And so spend a lot of time cleaning up all the blood and taking a good look now to make sure that the clip is fully around the entire defect. There's no further bleeding. This is about five minutes later after I cleaned up all the blood and clots in the stomach and kind of treated the lesion while at the same time, trying to close a defect so that if there was any kind of subtle muscle injuries, that those are kind of also taken care of. And I'm not exacerbating those. So, so Neil, I mean, excellent demonstration, but also, you know, walking us through what was your thought process. So whenever I see that, you know, of course, I try to quickly hand that scope over to my colleagues so that they can take care of it, you know, which is the easy way out. But so, you know, all this washing and stuff is, you know, does it ever, I know that sometimes when we are doing this, one of the thought that always crosses your mind is, is the easy way out just to spray something, you know, and let it sort of like settle down, but that's also maybe the end of the procedure because you can't do much after that. So how do you resist that temptation that let's try to just spray some powder, apply some gel or something like that you know, when this is happening? Yeah, I'm not, I'm not sure, you know, 10 years ago, really the only option at that time was to inject or spray epi. And I think that's definitely a reasonable approach to help slow things down so that you're not dealing with so much accumulation of blood in your kind of operative field. And maybe to give you some time to think and to improve your visualization of where the bleeding is. So I think that's a reasonable chance, a reasonable approach. I think now different gels and sprays, that makes it a little bit more harder because once you do that, it may make it even more challenging to go identify the exact site of the vessel and treat it. And so I think that's a pro and con, you know, I think challenge that we're gonna have moving forward about, you know, what is the right technique to apply in a situation like this? I still feel today that applying stronger mechanical pressure on that vessel will help you both in the short term and in the long term over the next seven days, as that lesion and that scar starts to heal, as opposed to some of the topical agents, but you know, I don't have any data necessarily to prove that. Right. Judy, I mean, you know, again, for this is, you know, I mean, you have to pull the scope back and reload the clip and everything and go back when it's the over the scope clip. In a situation like that, is it reasonable to consider just our standard, you know, hemo clips as well? I mean, is that something which can also be done in this situation? I think that a lot of maybe community places may not have the availability of over the scope clips. So I think hemostatic clips are definitely an option in this. You just have to make sure that the prongs are long enough in order to approximate the edges. That would be the best thing for this if you don't have the over the scope clip. Gotcha. Doug, I mean, yes, go ahead, Doug. I just wanted to ask Neil a question. First of all, what the histology of the lesion was, but there also is a literature and the setting I'm thinking of is the patient with atrophic gastritis who has multiple carcinoids. And some of those seem like they're mucosally based, but when they're large, we have at times, and, you know, there's a literature on this, just band them and just leave the bands on and just let them slough off. Is there a setting for that? Or do you think we should always try to get tissue? Yeah, you know, it's a great question. I'm leaning towards, at least for myself and my practice, I try to get tissue when I can. This was a carcinoid lesion, a submucosa, and it was actually turned out to be a poorly differentiated carcinoid with some kind of aggressive features to where there was a discussion with this patient about whether they should have a subtotal gastrectomy because of the risk of getting some metacronous lesions over time. They were older, so they decided not to. But I think in patients with, you know, this field defect of atrophic gastritis, and they're going to get more and more carcinoids over time, you know, I think depending on the age and comorbidities of the patient, just letting them slough off might be reasonable, especially if they're never going to consider, you know, surgery for their condition. And Doug, the same question, you know, as you know, always also comes up for esophageal lesions, right? I mean, because it's the same banding thing. And the issue is, I mean, what are you achieving at the end, right? I mean, if you have good histology, I mean, it's great. But if you don't, then, you know, I'm not sure you've really helped anyone except feeling good that maybe those lesions are coming off. My question, both to Doug, you and asthma for the lower GI sort of similar bleeding, we didn't see either one of you apply clips in that at all. So have you guys moved away from clips now? Is that the general theme by using more thermal methods so that you can complete the resection? Is that the goal or you just guys don't like clips? What's going on? Well, I mean, I think, you know, applying clips is a well-established way of preventing delayed hemorrhage. We were, I think both asthma and I were really showing examples of controlling immediate hemorrhage. So in the setting of immediate hemorrhage, the issue about clips is that they can get in the way of continuing the resection, depending on how close they are to the interface between the semicostal defect and the rest of the lesion. So I think during that time, during the resection, just controlling the bleeding with thermal means allows you to continue with a clean field. Once you're done, then you have the issue of should you apply clips and close the defect prophylactically? And currently our criteria for that are, first of all, you remove the lesion with electrocautery. I think there's too much clipping of lesions that are removed cold. And for in general, if you finish a cold resection and you don't see ongoing bleeding, you're not going to have delayed bleeding either. So remove with electrocautery, two centimeters or larger, and then proximal to the splenic flexure, that's for non-pedunculated lesions. And I think clipping it for the stock of the base of large pedunculated lesions is also a one way to prevent delayed hemorrhage there. So sort of two different things, but in the immediate setting, it just depends on where the bleed is located in relationship to the rest of the polyp that you need to finish removing before you're done with the procedure. Thanks, Asma. You want to add anything to it? Yeah, I agree. I totally agree. We still use a healthy amount of clips for no other reason, but it's also important to kind of learn how to use them in settings. And I think I have a clip later to show a bigger role when there's a deep neural injury and we're worried about it. But clipping the vessel with the edge of the ulcer bed is a good strategy. You're trying to achieve hemostasis. In this case, I think it's, again, important to use the software Grasper because we hadn't addressed the edges quite yet and the clip would have interfered with it. So that's the reason we do it. So in short, both skills are important and absolutely should have in your toolbox. I think there's another issue when you're clipping with a regular hemostatic clip is that the bleed may be coming from a really tiny point. And there's actually a gap between the arms of the jaws of the clip. So if you're going to use that, like say in the setting of a delayed bleed, you really want to gather up as much tissue as you can around it to sort of increase the amount of tamponade that you have on the vessel. But I think that's another reason to sort of avoid them in the acute setting, the immediate hemorrhage during the procedure. Okay, great. And let's have Judy, if you want to know what we're going to do is, Neil, thank you for that case. We're going to switch gears now. We are at the halfway point for our weekend endoscopy live. So those of you who are joining in, this is a quarterly series and we are talking about complications from general GI procedures. So we finished our talk quite a bit on bleeding, which of course is the most common complication. But then Asma just mentioned about thermal injury, which the worst form you can get a perforation, which we don't like, but again, it's part and parcel of doing procedures. So Judy, walk us through this case that you were involved in. Yeah, sure. So this actually is a case and I was not involving me, but it was a case done by Todd Barron at UNC. So you can see the over the scope clip is already on here, but this is a duodenal perforation that was identified. And over the scope clip was already placed on after evaluating the lesion. So you could see that there is a perforation, a defect here, right in the bulb of the duodenum. And they already approximate that it's a small enough area that can be suctioned into the over the scope clip. So right now, as Neil had mentioned earlier, you want to make sure that the edges are able to be suctioned completely into the cap itself. There are some practice sections. That's how I call it. When you suction in, you can absolutely suction one side more than the other, especially when you're not completely on top of the lesion and you're at an angle such as this. So right now we're able to suction it completely. And then the clip is deployed in this instance right here. After deploying the clip in this setting, we're taking a look at the bottom edges to make sure that we did close the entire defect. In this case, it was an advanced case. So we did shoot contrast down and looked under fluoroscopy to ensure that there wasn't extra. But you can also do this with an upper GI series afterwards as well. I did want to mention some things, particularly about deploying these types of clips, is that as fantastic as they can be, if you look closely here, I'm going to pause, this starts to look like the lining of bowel. And so this is actually a complication of a complication after deploying the clip is that you can see that you can actually suction in surrounding structures. And so there's literature on, I think your reader, I think I read something about that before in this case, the lining or the bowel actually was suctioned in here. Just as a quick follow up afterwards, things that you should be watching out for, especially afterwards, a CAT scan did show tethering of the colon to the duodenum in this area. But you should be concerned a little bit about the narrowing of the lumen should you suction too much either on the duodenal or the colonic side. Also fistulas can occur too. Luckily with this patient, we actually called her when I was putting this video together, I gave her a call and she's still alive and doing well without any complications. But these are just things to think about. So Judy, is this, do you think, again, great case. And again, thank you for sharing also the fact that you can, and being honest about how when you're trying to fix something, you can create some other issues as well. So when do you consider the defect to be of a size which can potentially be repaired or closed with the over the scope clip? I mean, what sort of criteria do you use in your mind versus saying, well, this is too big or the edges aren't that good. And this is, maybe needs a different type of either therapy or even considering surgery. So what are your sort of suggestions about that? So the over the scope clip, it has to fit on the actual scope itself. So what I use it when before you even put any clipper on, you have to really evaluate the lesion really well. And so if the lesion itself is, if you place your scope really close to it and I feel, and that's not super scientific and I hope maybe someone else may have an opinion or thoughts on that or tips on it, but you just put my face right onto that lesion and see if whether or not that is larger than the face of my scope on the screen. And so if it fits in, then you'll be able to suction the entire lesion in, but that's kind of like a very, I guess, quick and dirty way. I don't know if there are any other tips. Neil, you used it also for your case. So is there like a size, like two centimeters, three? I mean, what's the maximum Neil you've done? Yeah. So that's a good point. They actually, these clips come in different sizes as far as the cap about how deep they are and how wide they are, as far as also what scope they fit over. So generally if you're using these in the upper GI tract, when you start getting anything over one and a half centimeters, it's really challenging to fit the entire kind of defect into the cap. And while you can probably get a two centimeter lesion in there or defect in there, it's going to be really, really challenging. And so my mind is generally if I'm over a centimeter and a half in the upper GI tract with the six millimeter depth caps, I'm thinking of alternative closure techniques. In the colon, the same device and technique is used even for full thickness resections in the colon. And generally anything on that cap size and diameter, anything over two centimeters is where you really want to start thinking about an alternative technique other than this. So Neil and Judy, any practical tips about how much to suction, right? Because again, Neil, you showed very nicely that if you hadn't suctioned that in your cap, you probably wouldn't have stopped the bleeding. Whereas here we see that, you know, again, even when Judy was showing that you could see the bowel wall, you know, in the back of that defect. So I think no matter what, Judy, you had done, you would probably get that. But the question always is how much is too much and how much is too little. So is there like, do you need to see a complete reddening of your screen, maybe half the reddening or three quarters? Is there any magic to it or is it also just comes with the experience? I'll throw out three things or three tips that, you know, I'd consider when placing these clips almost for any reason is one is think about the location. So if you're putting these in any area, that's really floppy. So the most of the colon, other than the rectum, so like the non-retroperitoneal colon, the duodenum, or even in the stomach, it's really easy to grab something else that's outside the lumen by using a lot of suction. So be cognizant about that. Second is when doing that, if you can use a traction device, so you can use with these clips, they come in with different traction devices to grab the lesion, either grab it like with a grasper or different devices. And instead of using suction to pull that area into the cap. And so that reduces your chance of grabbing something from the outside because you're not relying on suction to get the lesion into the cap. And then third is when you're doing suction, it's actually the opposite technique a little bit of using a bander, which I think people often confuse is when you use a bander, you're used to just kind of driving into the esophagus or into the area and suctioning up. Here, what you want to do is you want to kind of not drive into it. You want to keep your scope a little away and hope that as you use suction, you're pulling the lesion up into the cap, into the lumen, and you pull the scope away a little bit. So that way, you're getting it more into the lumen and you're grabbing just what you need, as opposed to something that's extraluminal. So those are my three tips that I generally try to recommend when doing this. Excellent. Judy, go ahead. Yeah, just quickly, as Neil had mentioned earlier, the depth of the cap. So there are two depths, three millimeters and six millimeters. So even you can use that as kind of like training wheels as to how deep or how much tissue is actually suctioned in when you're approximating the edges. Okay, good point. So we're gonna have Doug switch to colonoscopy thermal injuries and show us some examples of that. But Judy, thanks, a great case. I mean, hopefully I don't see it in the near future, but you know, again, I mean, now I know how to deal with it as I do it. So similar sort of like examples during colonoscopy. So Doug, please walk us through these. Okay, let's see. Yeah, I'm on. So this is an example of a type three muscle injury that the Australian group, Michael Burke's group has classified muscle injury into five types. So type three is where you cut the muscle, but you haven't perforated. Type one is you just expose it. Type two, you can't quite tell. So type one and type two, well, type one exposing the muscle is not really a problem, but anytime you cut the muscle, you need to repair it. And it's important to be able to recognize this sign. So we're doing a conventional EMR. And what you're gonna see as this piece comes off, there'll be a couple of white bands down here in the defect. That's muscle that is cut. So that's a type three muscle injury. It's not a free perforation yet, but this is what the, this is the bottom side of that specimen. And that white circle there is muscle that is on the specimen. This is it after it's out on the table. So in this setting, I think you can still finish the resection, but you're gonna wanna close this because if you don't, there's a significant risk of a delayed perforation. And so that's the type three muscle injury. Doug, real quick. So initially in that previous video, as you were going through it, this is the full target sign in which it's circular. You see that, but sometimes you do see those just linear sort of white fibers, which are not quite circular, but just sort of like breaking their halfway. And I've not been doing anything with those. I mean, is that also like a type three injury, which needs to be closed? I'm not sure. I'm not sure I understand exactly what you're saying Pratik, but I would say, first of all, there's a lot of stringy white stuff in the submucosa and you differentiate that white stringy stuff in the submucosa. I'll go on to another case and maybe we'll save there. But if we look over here in the submucosa, you see lots of white stringy stuff. That's typical submucosa. And we're going to see another type three muscle injury where you basically see these thick white bands. They're much thicker than these submucosal fibers. We're grasping this piece of tissue and then re-grasping it. I think the risk factors for this, one of them is just during conventional EMR using big snares. Here again, we've got these white bands there. That's cut muscle. Sometimes you actually see some depth underneath that, but that needs to be repaired. Now we're using carbon dioxide here and you don't want to over insufflate. I'm going to show an example of turning a type three muscle injury into a free perforation. And I actually decided to put a clip on this just to reinforce it before I finished the EMR. And then you kind of want to come back and close this really tightly with clips, multiple clips that are pretty close to each other. That's my own preference. I think hemostatic clips are very nice here. I find it more troublesome to, these kinds of defects are usually quite small, just a few millimeters in size. And to come back out and load the over the scope clip, I think is unnecessary and just more time consuming. So here I'm finishing the EMR and then we'll go back and close this defect pretty tightly. And then of course we could prophylactically close the rest of the defect with clips to prevent delayed hemorrhage, but we're closing specifically that muscle injury to prevent a delayed perforation. So Pratik, is that what you were referring to, the difference between submucosal fibers? No, I mean, I was talking about in which, so for example, if you just, and maybe, I mean, so sometimes like just right on what you've frozen on the screen there, if you look at the three o'clock, four o'clock position, sometimes you have the muscle fibers that you see, but they are not circular. They're sort of like disrupted. And they're different from those submucosal sort of stringy things that you are calling. So again, I wasn't sure if, I mean, should we be waiting to see like a target, like a complete circle before we think it's a deep muscle injury? I'm just trying to make sure that the audience understands what requires clipping versus not. Right, right. I think if you see the circular muscle and it's intact, it's not disrupted, you don't necessarily have to close that. You know, that during ESD that they, the muscle's seen all the time. So that doesn't necessarily have to be closed. But I think in this case, this is another example of type three where you've got a band of muscle here. I don't know if you can see my arrow and then you've got, you know, depth next to it. You know, that is a dangerous injury that needs to be recognized and closed or you're very likely to have. Right, so Doug, I was talking about that. What if you had that band that you just, we could see your arrow very nicely, but if you had the band, but you didn't have that little deep pocket right next to it, would you still close it if it was just for that band? I think what I would say is if you feel comfortable that you can see the circular muscle and it's intact, you don't necessarily have to close that. You might choose to close it to prevent, you might close the whole defect to prevent a delayed hemorrhage. I think if there's any uncertainty, that's kind of what a type two muscle injury is, you know, so Michael Burke would say, if you do cold avulsion and then in a relapsed polyp, so, or you come back in six months, you see some flat polyp, you pull it off cold, then you take the snare tip and burn the heck out of it. The layers may be fused together. He would close that to prevent a delayed injury. He would call that type two because the muscle's there, but he's not quite sure if it's injured or not. And so I'd say when in doubt, I would close it. That would be my thought. I don't know if others want to add to that. Keep going Doug, thanks. So there's another injury, let's see if I'll go forward here and after you get them, I like to clip these, you know, fairly tight and then a good maneuver is to go over the top of the clips, go to the sacral side of the clips and bend them back and just make sure that the defect looks like it's completely closed. And here is the specimen lying in the sacrum. There's a little seed or something on it there, but again, and you can see this is tattooed. The tattoo was under the lesion, the tattoo from the referring physician. I have not had much trouble with tattoos with regard to EMR, but there are some case reports that suggest that tattoos under the lesion have increased the risk of perforation. And I do think they cause some fibrosis. And I know that during ESD people complain if there's a tattoo under that, that there's more fibrosis. And this thing is so black, the submucosal defect is not from the stuff I injected, which was blue, but rather from the tattoo, but that's muscle right there on the bottom of the specimen. So the target sign, that's the classic target sign. We also refer to those bands of muscle that are visible in the defect as the target sign. Here's just quickly showing a type three that turned into a type five right in the middle of the procedure. The two sections of the colon that are most likely to perforate are the cecum and the transverse. And this lesion is in the transverse. Very important to have respect for the transverse. I was sort of going for an unblocker section. You can see I've got a lot of mucosa on the normal mucosa, that made me uncomfortable. So I re-grasped in order to get less on that side. You can see again, there's some tattoo from the referring physician that is really close to the lesion. So I think if you're tattooing, you want to tattoo several centimeters away or on the opposite wall. Another thing that's very helpful is to always say where you put the tattoo in relation to the lesion. But this is an example. Type four is a free perforation. Type five is a contaminated perforation. And here it's type three. You can see it type three briefly right there. And then just a second, it's going to become type five. So as you're continuing to work here, there's the free perforation. So as you're continuing to work, you want to monitor the patient's abdomen. I decided to go at, this is an older video and we're sort of cleaning up the edges. And then I went ahead and closed this. And again, you want to close it really tight. But you don't want anything to go out that hole, right? You don't want anything to go out there. This patient had a bit of a fever in the hospital, a little bit of abdominal pain. And we're feeling the patient's belly all the time to make sure that we're not over distending their abdomen if this perforation is into the peritoneal cavity. And so everything was going fine. And I'll just show the closure at the end. And the patient did fine, but I didn't really see the contamination, but the way they acted in the hospital with fever and white count, at least overnight, there had to have been some contamination. This is a type four injury. This is a serrated lesion. I never use electrocautery anymore to remove serrated lesions. And you're going to see a free perforation at type four perforation. So first thing is don't start washing. You know, I decided, again, we're monitoring the patient's abdomen with our hand and then going ahead and finishing up the resection, which may seem a little crazy, but so we took some polyp off here and up there and then close this tightly with clips with, and I, again, I typically use hemostatic clips. Often- Yeah, Doug, let's see the first one. So how does the first one go? Because that's the critical. Yeah, so I think you have several options, but a lot of times I'll put it at the end. I say a lot of times, like this happens every day. I only have this happen in every, you know, one in 250 to 300 EMRs. Michael Burke's group, they get it a little bit more often. I think that they're maybe a little bit more aggressive in taking big pieces of polyp. I'm not totally sure, but, and then put the clips close to each other, but starting at an end will a lot of times bring the whole defect together. And here we're- And I also noticed, Doug, that you're not necessarily trying to get the edges of the normal tissue to close it, right? I mean, you're also using part of the submucosa of the defect, which has already been created. Yeah, that's a great question, Prateek. I hear people are, they're often concerned about placing clips into the submucosal defect itself. And that's totally fair. I've done that a zillion times. There we are, bending that, those clips over to make sure that the defect is fully closed. And I, Prateek, I don't want to keep going like this because we're almost out of time. You may have another case you want- Yeah, so I think what we're going to do is just talk a little bit about it and have Neil switch to the decompression one, if he can, because you're not talking about this. So Doug, as you were just going through that, I saw that, you know, just the clips and not the over the scope. Okay, let's just go to Neil first. So this is what Doug was mentioning. If you start getting free air, you always look for, you know, what's happening with the patient and the belly and stuff like that. So Neil, go ahead, tell us what you would do if you had free air and the abdomen started getting distended. Yeah, thanks, Prateek. And I want to thank G.S. Raju for this video, who those of you who've been on G.I. Leap with the ASGE have hopefully seen, but a great demonstration of what you can do to decompress pneumoperitoneum in patients who start getting significant pneumoperitoneum after a perforation and especially becoming at risk for some cardiopulmonary compromise because of that severity of pressure in the peritoneal cavity. And so here is something that any of us can do using just standard materials that are in our G.I. lab. So this patient is prepping the abdomen and really this is similar to kind of doing a paracentesis technique. This is just a regular small gauge needle with a syringe with water. And after kind of palpating out kind of where the air is, you're inserting the needle and you can start seeing, finding that space where the air is coming through. And then this is just using kind of like an angiocath over a needle. You can take the needle that's in your ped kit that has a little plastic catheter over it and advance it into that spot where the air is. And now you've got a needle decompression of the pneumoperitoneum and you can kind of press out on the abdomen, expel out the air. If you want to maintain this, you can put like a three-way stopcock valve that the nurses often use for IV lines, attach it to that angiocath and then that way kind of decompress as needed to ensure that the patient doesn't get that cardiac and pulmonary compromise. So Neil, I mean, if we had a case like Doug was showing in which you have a free perforation and let's say it's not contaminated and Doug has closed it and there is free air in the belly and you've drained it like this. I mean, is the patient now treated completely? I mean, what would you do? You just put the patient in the hospital for a few days or just give IV antibiotics? I mean, what's the next step that really happens in real life? Yeah, so I'll throw out the first thing is you don't have to, I would not do this just kind of prophylactically. You do this if you start seeing significant pneumoperitoneum to where you're kind of talking to your anesthesiologist or you're looking at your monitors and you start seeing some blood pressure decrease or some other respiratory compromise. So don't just prophylactically do this. But I think it's a good point is after a perforation, especially one that's a full thickness perforation, whether there's some contamination or spillage or not, I would not be sending these people home. Personally, I think they should be kind of monitored at least overnight, IV antibiotics. I think it's wise to have a surgical team at least on board seeing the patients. And I think it really depends on what happens as far as the peritoneal cavity. So those that have spillage of luminal contents through that hole, they're gonna start having more peritoneal signs. Maybe they develop some localized peritonitis or a small abscess where they may need other drainage. But I think the ones where you don't get spillage and you don't get any contamination through, they generally do fairly well. And maybe it's just a day or so of observation and then you're able to kind of start advancing their diet and see how they do. Okay, great. Thanks guys. We're down to the last minute or so. So if I could just have the panelists probably give us one take-home message that they may have for our audience. And as we are looking at that, I think Dr. Samu has a good point about, I think we are doing more cold EMR. So hopefully those thermal injuries that we see with the hot EMRs will continue to reduce. Doug, the question was, why is it in the transverse colon that you see more sort of perforations? Why is the transverse colon more likely to get these? Yeah, I think partly it's that it's on a mesentery and swinging free in the abdomen, but I don't have a perfect explanation, but it's a clinical observation that's established. Asma, you showed us a beautiful video of underwater EMR. Sadat is asking that, how do you evaluate muscle injury after underwater EMR? Because you don't have that blue dye there, which usually helps us look at the submucosa and stuff. So any clues for that? Yeah, so I mean, just by inspection, and you can always then switch to air also. You can suction out the water, inspect it in air if you're worried about any deeper injury. But I think underwater evaluation is just as good. Okay. Judy, for you, Sophie has a question about the differences between the three and the six millimeter for the depth. What are the differences between the T and the GC? Yeah, so the T, it's really the length of the, the tip of the prong. You can actually Google pictures to just take a look at it, but it's the length of the prong of the teeth of the clip. So then we typically, at least where I've trained, we use the T a lot more, but the GC is usually used for gastric closures because the gastric wall is a lot thicker. So then you want longer teeth in order to really puncture that tissue and then keep it anchored. Okay, great, guys. It's 10 a.m. Central. It's right at the dot. Thank you all very much. It's been a super and a fantastic sort of learning for me personally, as well as I listened to all our four experts going over these complications and how to deal with them. So again, this is Weekend Endoscopy live from the IT&T Center brought to you by Medtronic. And please join us in three months for our next session. And again, to Neil, Asma, Judy, and Doug, thank you all very much for being with us today. Bye. Thank you.

endoscopy procedures

complications

bleeding complications

control bleeding

thermal injuries

muscle injuries

classification of muscle injuries

pneumoperitoneum

perforation during endoscopy