You know, one of the most important things as you're doing interventional endoscopy is you are going to have complications, shouldn't even use the term complications, adverse events might be a better term, but your skills are not that you didn't have an adverse event, your skills are actually judged by how you handle those adverse events, both during the procedure and also how you deal with the patient, the family, et cetera, after the procedure is done. So I'm going to ask Dr. Mo, are you starting off? Yes, he's got a flight to catch too, so. And again, please feel free to ask questions. Good morning, everyone. Thank you again for the invitation to be here today. And please do not hold me to the quality of the videos, because I wish I've taken this course early in my career. I did not. I was not one of those lucky ones who ended up training with Raju and the giants in the field. But I kind of learned my way through putting some of these videos. So the focus of this session will be mainly the technical part of managing complications rather than the video skills. So I have to make this disclosure up front. And I hope you've enjoyed the last day, day and a half of being here. I think this is great for anyone who's wanting to get into this. And if you are an advanced endoscopy and you have not seen a complication, you're probably not doing enough. And you are going to deal with quite a bit of that. And this will be sort of the core of what you do. The biggest inspirations and things I've noticed in the last 10 years of my practice is the ability, what I call, to clean up our own mess, which we did not used to have. If you go back 15 years when I left fellowship, we used to call on the surgeons for a lot of things. Luckily, we don't do this nearly as often. We can close very effectively. And I think you agree that perforation and bleeding in combination is probably 90% of what you're going to see in terms of your complications. And we have a great way to control both of these without having to really get anyone through surgery. Some of the other stuff will require, obviously, collaboration with IR and surgery. But we are able to do a lot of that now sufficiently, independently, and without having to rely on anyone else. And I think this is a great thing to boost our competence and confidence in doing some of the borderline, more aggressive, more risky type of stuff, especially resections. So this is actually a run-of-the-mill case that I don't know how many of you have done esophageal stenting or stenting of migrated stents, which I think is sort of the core of this case. I'm not a huge fan of stents for peptic strictures, benign strictures. But there was a wave, I think, in the last 5, 10 years. A lot of people jumped on it. And I think we've kind of recalibrated back to more serial dilations rather than stenting because I don't think stent effect lasts long once they're retrieved and removed. But this is a patient who actually did benefit from a stent because it was refractory to pretty much everything else that was done endoscopically prior to that and did well, started to swallow better. And then within a few weeks, dysphagia came back. And a chest x-ray showed it migrated the esophageal stent. I have to say this case was not one of the cases where we anchored the stent. Now, pretty much, we're all doing that. I think this was done by another endoscopist. But I was the one who retrieved it because of the timing that was needed to be done. But I think many of you now either suture or use the clip to anchor the top part of the stent, which I think for fully covered metallic stents of the esophagus used for benign indications, this is almost a must. We've published a few papers in that field. And your migration rates are over 50% if you do not anchor the stent. So this is an example where you can get in trouble for not doing that for a benign stricture. I heard this mouse is jumpy. So I'll see how that works as I go through the video. So you might appreciate that the stricture is better. But there's still a stricture at the lower esophagus. And this is sort of what we see. Get in, and the stent is already sitting on the greater curvature of the stomach, the typical. This is, I think, a 23-millimeter fully covered stent. As you can see, trying to just clean it out to identify the string, I highly recommend that you always do that. Identify that suture or the string that allows you to collapse the top part of the stent. And I think the biggest problem that you face when you try to retrieve a migrated stent from the stomach is the ability, and I'll push this forward here for the sake of time because I know my colleagues have wonderful cases I don't want to take the whole time. But the biggest challenge in these cases is aligning that long axis of the stent with the axis of the GE junction. As you can see, I'm struggling here, or I think my fellow was at this point, because it's tangential. It's not aligning 100% with the GE junction. And you have, on top of that, a stricture, and you create a perfect storm for esophageal wall injury during the retrieval process. So this is pretty much where it comes down to trying all the different angles, potentially even if you can, getting a 2T scope to have both ends of the stent or the suture collapsed or using a snare to collapse the top part of the stent or different techniques described on how you can do that. But eventually, we got it. And coming through a stricture is hard. This is a fully expanded, fully open stent. And this is our teaching point, I guess, is if you don't think it is safe to take a stent out because of how large or how small the stricture is, leave it in there. It's not going to cause short-term damage. Do serial dilations, bring the patient back, and retrieve it at a time when the stenosis has improved after dilation. Anyway, we managed to get this out. But as Ashley said yesterday, go down and see how much damage you've caused. And it's always that kind of a moment when your heart skips a beat or two when you go down and see something like this, which is a lot of blood, obviously. That's not totally unexpected. But then on top of the bleeding, you get really close to inspect the tear that you caused by pulling that stent across the GE junction. And I have to say, this is a pretty generous tear. And if you look close, actually, there's a full thickness injury there across the muscle layer. So a key thing when you see something like that, as all the very seasoned attendings in the room will say, do not panic. And just keep your cool and keep the visualization optimized as much as possible. It's not that it's not as much of a problem because blood will eventually get out of your field to the stomach with gravity. But in the stomach, you can really lose a lot of that if you don't stay close, stay focused. And if you need to wash or suction, just stay ahead of that. Do not let a big clot obscure your vision. And I'm using here a standard closure technique with clips because I think this is what you probably all will end up doing. Esophagus is a tubular organ, so suturing is not great. Vesicles are not great, although we've done those off and on in different scenarios. But for an acute atherogenic perforation or perforation that's within two or three days, clips work really well for closure of these. So here's a technique I recommend. This is what we use for poem incisions as well. You start distal, you zip it up from distal to proximal. Every clip rides on the previous clip, essentially in the same axis. And you keep going, three, four, five. I think I've done 15 in one case in the past when you see these deep tears. But methodologically and consistently, you will close that. And clip closure in the esophagus, and we have huge data on poem closures now after all these years of doing it, it is very safe. It's very effective in terms of closure. Your other option here, so I think we got into probably seven or eight clips here. Other option is to put a fully covered stent. And I think many of you probably would have done that in a subacute perforation of the esophagus or one in that kind of getting into that chronic phase and getting into a fistulizing sort of situation. The problem with stents, you have to suture them, especially from the top, to allow esophageal secretions to not leak into the hole, basically. So you have to anchor them. But clips for acute perforations work really well. And let me see if I can move to the next. Can I present one more or a couple of cases? You guys are good with that. This is just, again, a quick show and tell case. Again, not a very recent case. But post-EMR bleeds are very common, especially as you start with a blend current or forced coag current, and then you move to the cut in the last phase. Sometimes if you have too much tissue and you're not getting that piece off with your snare, not uncommon that after 45 seconds, you would just go and cut it. And this is where you shear through some of these blood vessels and get into more brisk bleeding in EMR. This is a patient with a nodule area in the proximal part of the gastric body that was removed. I believe this one was removed using a cap-assisted or band ligation technique. And as soon as the tissue came off, let's see if I can get this to start, you'd see this very brisk bleeding at the base of the resection. Not uncommon. Again, keep your cool, stay close, and keep the target right in the middle of your screen. It's easy to kind of lose that. But clips is another quick and easy. I wouldn't have wasted time maybe trying to coagulate this, although you could use soft coagulation with the forceps. But I felt that clip would have been a more effective way. As you can tell, this is not a very recent video and preceded our third space experience. So I think we were more comfortable doing clips, although I think that's another option here. Sometimes one clip is not sufficient. Maybe two, maybe three. But again, for freshly cut tissue, the margins are very clean. And clips do a really nice job in terms of getting you all, getting the source controlled. And now with the days of third space, you can use forceps quite sufficiently if you are versed with that. But if you're not, clips are going to be your friend. And this is a case, a quick FMB to obtain liver tissue. A lady with multiple risk factors for chronic liver disease from obesity, diabetes, and being also hyperlipidemic. And she's had chronic elevation of liver enzymes. As you'd agree, this is a high risk for liver fibrosis patient. She has pretty much all the risk factors for that. And during endoscopy for dyspepsia, I think it may make some sense to, especially if you have elevated liver enzymes, to attempt to get a liver biopsy. We're all doing many more of those. So those are random liver biopsies to assess for fibrosis. And after an FMB, it's not uncommon to get bleeding. That's why you need to select your FMB site very carefully. This one happened to be actually intraluminal. A lot of the post-FMB bleeds are retroperitoneal, extra gastric, or subcapsular in terms of the liver. Some of them can be retroperitoneal if you're doing pancreas. But again, this is a large hematoma in the gastric wall. You might, again, stay close. Keep your vision clean as much as possible, even if you have to reposition the patient to get a clot off, or make sure you suction. And again, another good utilization of clips to control the source. You're left with a fairly large gastric wall hematoma, but that's fine. Those patients typically don't have much of any pain waking up from just hematomas in that case. And that was successful. But what caused that? Probably shearing through one of those short gastric vessels that are between the the tributaries of the gastric. Was that a 19-gauge? It was a 19-gauge. This was a 19-gauge acquired needle. And I can tell you the new, we call them second-generation FMB devices, can have the potential to cause more significant bleeds. So be careful with them. I don't think a 22 is going to be meaningful for any liver biopsy, guys. It has to be 19 to provide these nice core, contiguous cores, rather than fragmented specimens. And when you use 19, you have to be ready to deal with something like that. I'll skip over the next one, but I have to show you just a really cool video. Neumoperitoneum. When you have a perforation, you might have tense neumoperitoneum. You may not realize it, but CO2 escapes and you have a big belly. We see it all the time in poems. And I think it's important to understand the importance of decompression before you, in conjunction with closure. So you close the mucosal defect or the full thickness defect, but you also decompress for different reasons. I had a patient who coded once because of severe neumoperitoneum. Venous return gets highly impaired in this situation. They get respiratory dysfunction because their diaphragm is not able to inflate as well. And also for comfort as they recover, especially now as we are managing these conservatively. We're not sending them to surgery. It's important to do that. And this is actually an iPhone video I took after one of our poem cases recently. Essentially, this is a eucentesis catheter. You can use an angiocath as well in the left upper quadrant. You go in under suction and then you keep a little film of saline or water. And then you apply some pressure as you decompress, going in into suction. And I remove the plunger out of the syringe and continue to push on the abdomen until I get some relief. Have you guys seen this done before? But in perforations, this is a great thing to have in your back pocket to decompress and get the patients feeling better. And then you go with a closure, either clips or ovesco or suture, whatever you need. But that's a nice adjunct to learn. This was a eucentesis. They come in 10 and 15 centimeter length. Depending on the body habitus, you might want to go with a longer one if you have a this was a larger patient. So I think those are the ones. As far as the diameter, I don't recall exactly which one was that. Do you use the angiocath usually? Yeah. Or I've used an LP needle. Or an LP needle. Yes. But honestly, any needle works. It has to be deep enough to get you through the thick abdominal wall. What is the purpose of the column of liquid? Just to see the bubbling effect of the CO2. It's just visualization so you see it all. Yeah. Excellent. So those are the few cases I had for you guys. Thank you.

managing complications

interventional endoscopy

adverse events

technical aspects

effective treatment