I have two cases, and I'm going to try and blow for the first one pretty quickly because Dr. Elhaddad took my — it's like when you go with your wife and she orders what you want at the menu, and I can't order it, so he did an esophageal perforation. So I'll have to go through this fairly quickly, but it's a fairly humorous case, actually. All right, so this is a person who was transferred in the middle of the night, essentially, with a GI bleed, was already seen at two previous hospitals at night. They said there were gastric varices and put some bands on. And this is what I saw. So it's — despite multiple maneuvers, suctioning, couldn't see a thing. All right, so this person is bleeding out in front of you. And so these are — so these are your options for varicose bleeding in general. Refractory bleeding, what do you do? You're not going to be able to band because you can't see. You're not going to be able to glute because you can't see. So it's either send to interventional radiology or balloon tamponade or put a self-expanding metal stent in. So we put a balloon tamponade on this patient, and we'll talk about it. Does anybody — who has made it through their fellowship without putting in a single Blakemore tube? Has everyone put a Blakemore tube in? Wow, that's something surprising. I heard some centers don't use it that much anymore. We still use it quite frequently, actually. And we actually have on our travel cart exact steps of how to use it, actually. So always intubate the patient. You can go nose or mouth. I usually use a scope and blow the balloon up in front of me in the scope at the stomach and then pull it back, actually. We put it in about 300 to 500 cc, pull back with pressure, use a pulley system to keep the pressure. The good old days, they used to actually put the person on a football helmet. And someone finally discovered that probably wasn't for infectious disease the best to have a football helmet for years, passed it along, just scrub it on and on. When I first went to residency, I was in Philadelphia, and they had this — I'd never even heard of this football helmet. And this guy was in the unit. It was Philadelphia. They had a Dallas Cowboys helmet on, actually. And I thought they were making fun of the guy, too. He was in a helmet. He was bleeding out. Yeah, so we use a pulley system. Actually, Blakemore works quite well, stops the majority of the bleeds acutely. So we use it still fairly commonly if you're at a big transplant center. So — I thought it was just the breweries in Milwaukee that — Well, no. Yes. No, no. Yes. So we have Obese and Drinker. So we have a combination of Ash and Nash. So yeah. So we have quite a big transplant center, and so we're getting a lot of people bleeding. So after you put the Blakemore tube in and you pull tight, you put the pulley in, you should always get an X-ray afterwards. So I don't — no one's a radiologist here. What does this X-ray show? Well, so there's the big blue in the middle, right? That's the Blakemore boop inflated. Where is it, though? Oh, it's called in the chest. So the one thing about — my hole is bigger than El Haddad's, Dr. El Haddad's. So this is actually the middle of the night. We just perforated an acutely bleeding patient in the middle of the night, and they had scoped him. And where do you go here? And so you're right. I talked about some of the eye. And this is over a three-centimeter hole in the esophagus. So your options are call a CT surgeon, which I did, and this is the exact quote of my surgeon. Oh, that's too bad. I mean, they're not going to come and operate on somebody who's having an acute variceal bleed. We talked about clipping, which you can do. This is a pretty big thing to clip. Endo-stitch, actually, I don't know if there's any endo-stitches here, too. Actually, I looked through this. There's not that much data about endo-stitching. You don't have much data to back you up as far as acute perfs, particularly the esophagus. Stenting, you talked, which is what the most common or a combination of clipping and stenting. Clipping, again, probably the big issue teaching point here is this is probably too big for that. So the scope clip has to be, you know, in the one to two centimeters, a little bigger for the vesicle clips. Again, suturing, not much data on it, probably harder than the esophagus. So stenting is what we did. We put a stent in that night and covered it up. And I wanted to actually put a fairly – so the stent you select is generally put the largest diameter stent in, complete coverage, you can take it out. I wanted to actually put something that covered the defect and treated the esophageal variceal bleed, so I wanted to go in across the G-junction. So I just clipped it in with a good old-fashioned endoclips. Multiple papers on stitching, and it works better, but I'm not going to do that two in the morning because I don't know how to do it as well. There's some on vesicle clips. So how did you put the stent in? So you're obviously in the ICU. Yeah, just – I probably don't have fluoro. No, you probably don't have fluoro in the room. Oh. Yeah, you don't have fluoro in the room, yeah. And it's just under fluoro, actually, because I wanted to actually – you want to make sure it's – so I did my usual, I put a clip at the mark three centimeters above. I wanted to make sure my stent was over the defect completely, and it was over what I presumed was a variceal right at the G-junction and whatnot, and that actually – a couple days later, actually, we scoped through the stent and put a DABHOF tube in. So there are some – You don't have fluoro. Sorry. What's – Oh, no. Actually, I was going to say there are commercially available, through the scope, fully-covered model stents. Yeah, yeah, yeah. Yeah. So – Or I guess you could – Or you could work at a real hospital. You can. You can. It's not that I've never heard – most – because they're always doing broncs in the ICU. You don't have fluoro in the ICU. Come on. Oh. They are. So they – yeah. 18, 22 – But you want the biggest possible. This is a 23, 28 stent, actually. 23. They are through the scope. You can endoscopically – You could, yeah. And look back. You can make a guess. Yeah. Yes, if you have to. If you're – So other trick would be you can – if you don't have fluoro, you don't have through the scope stent, you can go over the wire and then go with an XP scope next to it. And then you can deploy it under endoscopic guidance. Yeah. I think the thing is just large diameter, covered, so you can pull it out, essentially. And they can start – there's actually good data on – in general, about a 75 percent closure rate. This is one small study, but actually for acute perforations, it works pretty darn well. It's by far the simplest thing to do as well, too, I think. Complication-touch migration. Actually, I think the migration rate is higher than this, actually. Sometimes you can put them in. They don't – even without clips, don't migrate. But if you're going past the G-junction, you've got to do something to keep it in there, actually. I'm going to keep on going. So this is that patient, actually. We want to remove it. I – for a perf, I'll keep it in for 48 weeks. This is that patient, actually, and that hole healed up completely with stenting. And luckily, it was actually a non-serotic portal hypertension. If this was probably a serotic, this person would have died. I mean, you can't perf a serotic and survive. So this guy actually did survive. And again, this is sort of going the same things. There's lots of different tools you can use for acute esophageal perforations, clips, over-the-scope clips, suturing, stenting, often using both clipping and stenting, and also – even though my CT surgeon did not help me out that night, you've got to get them involved to help the patient and sort of cover your own butt. All right. I'll go a little slower because I've been – I'll just say try to stay more towards the four than eight weeks because the other problem ends up being overgrowth and hypertrophy, and then you can't get the stent out. So – All right. Let me click on my second case. I can get my mouse to work again. Do you get upper GI series before stent removal? I got upper GI series on this person. I do not do it on everybody, though. Well, I think he probably got septoraxone as a variceal bleeder from the very beginning, actually. Yeah. So that's another – similar to yesterday with – was the hypodermia. My answer was constant renal. This would be constant ID. Yeah. So CSS. I only know septoraxone, and then if you have a penalty, Cipro. That's it. I've heard of Vanco, too. I don't know. I'm in a box. So, yeah. So we've done our part. We've put the stent over. Let ID take over. Can anybody use partially covered stents? I'll use – for cancers, yeah. Yeah. For soft-tube cancers, I'll put it. If I know it's for a palliation, I will. I've seen bad things. Same here. Yeah. Bad things. In what sense? Well, no. Like, I was going to say, like, because I've seen cases where it's, like, partially covered and the stent migrates and then embeds. I've seen a tumor. It eroded through a tumor. Nope. Yeah. Just one question. So, like, whenever I had these kind of cases, I always worry about, like, when I think about them, like, clipping, and there's a varix underneath it, and then if you're trying to secure the stent, how do you deal with that, or what's your, like, strategy? Because, like, sometimes you have these varices that are all the way up in the mid-esophagus, and you can't really, like, safely clip because you clip it, you'll show the varix. Well, so a couple things. So this person did not have esophageal varices, so I could clip this person. It was pretty easy, actually. I'm not putting stents in too often for refractory esophageal varices. I mean, I think this is a weird case. That's published, putting a large dimer stent in when you're not for esophageal varices, but I think I probably have not clipped stents into an esophageal varices case ever. In addition, people have used clips for varices in the past, too, to treat. That's important as well. Yeah, that's what I was going to say. The idea that clips on a varix is bad is not necessarily true. There's a great case from Japan where they clipped the varix above and below, and then did ESD of the cancer that was above the varix, and showed the varix coming out with the cancer. So you can do mechanical clipping of varices. Yeah, I've done that. I've clipped varices in the past. When you have those no other choices and whatnot, yeah. So it's not necessarily a contraindication, but you're not stenting too often for refractory varices. It's reported, but I would do it in this case, because we were doing that for the varix and the defect. All right. So I'm going to do one more case. Hopefully nobody is repeating their fourth-year advanced fellowship, because I presented the same case about four years ago. So no one went back, actually. All right. This is actually a very interesting case, too, as well. So this is an 8-year-old female, symptoms really of biliary-type symptoms. She has normal LFTs, though. Outside MRCPs showed common bile duct stones, and they failed the ERCP at the outside institution, sent us. So this is actually what we saw going down there. There's sort of like a gigantic reticulum with a smiley, not a smiley, a face mocking me in the back there. And you can sort of see the tick, but not really, actually. And so we'll talk a little bit about cannulating with ticks, actually. Generally, if you can see the papilla in any way, you should be able to get in. The ones that are really hard are the ones you cannot see at all. But if you can engage it and pull it, you should be able to cannulate in the majority of cases. And, you know, not 100% or not 95% like normal, but, you know, 69% is pretty high. So you want to get the papilla out of the diverticulum, if possible, using two devices. Sometimes people call this the chopstick method. You actually put one catheter down, pull it out while you cannulate with the other catheter. I can't – I put this in last time I'd done this. I – double endoscope method is putting two scopes down in the same human being. I couldn't find the reference for that, actually. I don't know how that would ever work, but that's – I put there some in the past. Endoclip – I think people always try this, where you actually endoclip, and that moves the papilla out of the diverticulum, and then you can see and access it. You can actually put the scope into the tick if the tick is big enough. If you can get in the PD but not the bile duct, obviously, stent that, so that makes it easier to cannulate the bile duct, or if you can get out, I would do a double-assisted. People have used CAP-assisted methods to cannulate diverticulum bile ducts. And obviously, if you fail, US or IR rendezvous. So this is – so we actually – I put the scope in long, because I couldn't see it in short position. I put the post in long position, and I drove myself into the diverticulum to cannulate, and we are able to, unfortunately, just cannulate the pancreas duct, but not the bile duct. So we were trying for a while. We talked a little bit on the ERCP thing, actually, and the variation when you convert to pre-cut sphincterotomy, and how many pre-cut sphincterotomies you do per year as staff. It's interesting. Most staff, those who aren't in the study, did maybe a handful a year nowadays. There's one of the fellows – I don't know if he's still here – was from Baylor. He says they go 10 minutes and pre-cut everybody. I don't know. Are you guys – the other staff, who is a high – early pre-cutter or late pre-cutter? I believe in early pre-cut. You do? Yeah, I've been early. Yeah, it's sort of, you know, what you've been used to, and I always feel – every time I pre-cut, I either feel in the case I did it too early or too late. Like, if I did it too early, then it ruins my anatomy, or I've been going too long. There is – as far as the complications with needle knife, is it the needle knife, or is it the fact I tried 45 minutes in the good old-fashioned methods, and then did a needle knife, and then my papilla is complete garbage, actually. So yeah. Well, and never believe a video of a needle knife you see at DDW, because you see these videos where there's a little hole, they put a zip, and the whole thing opens up like they're parting the Red Sea, and they put the catheter in. Usually it's garbage bleeding everywhere, so those videos are highly edited. So the one thing you'll learn about is, at DDW, all videos are highly edited, actually. So yeah, it never works like that ever, actually. So there's a few techniques. Freehand is probably what most people use. That's when you put the needle knife in the papilla and cut north. There's something called a fistulotomy. You know, the bile duct follows the duodenum segment above, and you can just poke in above the papilla, and then cut a little bit up from there. Sometimes nice, if in those cases you're going into a PD multiple times, you can do it over a wire or over a stent in the PD. There's trans-pancreatic. That's where actually you're in the PD, you just torque yourself to the left and cut towards the bile duct. You cut across the septum. Those are all... It's not a needle knife. It's just more of a pre-cut stentorotomy. Success rate is, again, very limited, but it's quite high, and it's probably the first method we use. We can, again, through natural methods. Are there increased complications? Increased pancreatitis rates? Yes, probably, but is it the needle knife itself, or is it... It's a hard case, plus needle knife. There probably are increased perforation. I was telling Gerard and Ashley last night, the advanced fellow who did MA the year after in Cleveland went to Henry Ford, and his first ever case he did as a staff at Henry Ford, he couldn't get in, had to have a needle knife, and perfed the patient. His first ever as a staff, actually, and so he had to go to his partner, so I'm really not that bad. So there is an increased perforation rate, because it's sort of a blind stick in there, actually, but he's joining you guys' faculty in a month, too, right? That was much... Hopefully, he's gotten better, for God's sakes. All right, so here's my needle knife. I'm actually in the tick, actually, and I'm looking backwards towards this and cutting, and needle knife technique, actually, we were talking about yesterday, the use of these, either whether it's... What is the correct length of the needle knife to put out? It's sort of the Goldilocks length. You don't want to go too deep. I think a mistake we all make is going too little, and you just cut the tissue. It's a needle knife sphincter item, you're trying to cut the sphincter, so you need to actually get in the sphincter and see bile. So this is after I did that, actually, and we tried more, and we still couldn't get in. So we were getting pretty tired, so we put the person into recovery. Here are the risks for pancreatitis that are in the literature, and the risks are primarily... The greater risks are patient-related. So young females with normal LFTs, nobody's doing much sphincter-related myometry on SOD patients anymore, never needle knife those people ever. If they have recurrent pancreatitis, if they've had pancreatitis in the past, those are all high patient-associated risks with post-ear-speed pancreatitis. There are some procedure-related risks. Multiple touches of a pillow, and there's some data that says over seven times. I think we had 75 times, sorry, in this case, actually. Injection of PD, again, in this case, we have multiple, multiple times. The needle knife is associated, you know, we don't know why, but it is. Anytime you touch the pancreas, pancreatic syndrome, amyloid, sphinctroplasty are all risk factors for pancreatitis. This was a person, well, she wasn't young, but she was female, normal LFTs, and the first two, we injected her PD multiple times and touched her with a pillow multiple, multiple times. So, we put her into recovery. Oh, here, I'll go over this first, I'm sorry. So prevention, stents into the pancreas has been shown to reduce pancreatitis. Meta-analysis, 13 to 30 percent, so reduced the risk of pancreatitis, fairly good, actually. Most commonly is in high-risk groups, meaning those groups we talked about, either patient or procedure-related, and those stayed right there, again, too. So you're supposed to put small diameter, short flaps only on the outside. I put it in, it has to be easy, because you don't want to give your patient the pancreatitis by putting the pancreas stents in, and sometimes it's not so easy. So you have a hard case, and you want to put a stent in, and you then spend time getting the pancreas duct, and the wire goes in the side branches or not. So you shouldn't spend 45 minutes putting in a prophylactic PD stent. Repeat x-ray procedure, I don't do this anymore, I used to always get x-rays, but if you put flaps on the outside, five-inch stents, they all fall out. I've never had one stent ever, so I don't always get it, I don't ever get x-rays anymore. Rectal adenomycin, fairly common, nine, meta-analysis, that it reduces the risk of pancreatitis. Question for the group here, do people give investment for everybody, or just high-risk for the staff? High-risk. We have a few everybody's, but mostly high-risk, and that's what I do as well, too, actually. Well, that's what the data shows, actually. I think there is a couple of papers that shows that, actually, everybody's not a bad thing either, though, and we don't think there's many risks of giving rectal adenomycin. So actually, in recovery, she, so you're thinking, oh, this person has pancreatitis. There are actually going to suggest giving it to everyone, although I argued against it. All right. So whose opinion do you value more, the guidelines or Dr. Chalk's? That's a take-home point from this one. So you're really concerned about this person, and this is more, oh, she doesn't look horrible. So we went back. She looks fantastic. No pain at all. Drinking fluids already. So at 30 minutes. 60 minutes, things start to change. You're in your next case. Oh, God, we dodged a bullet there. So she has shortness of breath with O2 sets in the 80s on four liters. She develops the following symptoms. Whole body rash. Peripheral swelling. Wheezing. Strider. That's her ABG in recovery, actually. We went back, and we're actually in the case. She had, on her allergy list, it said shortness of breath to aspirin. So we're like, intamethasone's not exactly aspirin, and shortness of breath isn't really an allergy. So it was probably just one of these things. It's intolerance, all right? And this has never been reported before, actually. So it was like, ah, this is a high-risk patient. We need to prevent pancreatitis. So she had an acute allergic reaction to her rectal intamethasone, actually, and got intubated and almost died, essentially, with that pH there. So again, just like we have already counseled ID and renal in those previous cases, we counseled the intensivist, and they took care of the patient. She went to the unit, was intubated for one day. She still has her stones in the bile duct, we think. Because this is an outside MRCP, we repeated the MRCP next day, and she does have stones in. So now we've failed an ERCP, already, in this patient. It's been failed outside, too. We needle-knifed the ERCP in this patient, actually. We almost killed her, all right? She got better with a day of treatment, actually. What's the next step to get her stones out? Her gallbladder's out, already, we'll say. I can't remember, but it probably is, yeah. Gallbladder out. No, wait, there's data on this. What's... If she doesn't have a gallbladder, you could ask surgery to try and go in, and they could do directly the operation. Is that normal right now? What's that? Is that normal right now? Her LT's have been normal the whole time, yeah. I would at least let her recover at this point. There's no urgency to go back right now, and she's recovering. Yeah, I mean, we're not going to do her when she's intubated with a PHS-715, so I'm not that bad of a doctor, despite my two complications here, actually. So no, there is data on what you do in this, actually, and to back you up. So if you do a needle knife and fail, what do you do? Try again. Yeah, I mean, so yeah, you can do... You can bring her, but you can do a rendezvous, you can do IR, I mean, surgery. But if you have confidence in your skills, bring her back. And there's actually lots of papers on needle knives 48 hours after, and that's what we did. We brought the person back, and you pop right in, actually, and we took the stones out. And that actually is pretty common, actually. It looks like garbage, and you're done just two days, and the first pass, it goes in. And that's what we did. So the patient recovered completely, and her stones are out. But just remember, there's rectal amethyst, and it's not 100% safe, actually. So... All right. Thank you much. Thank you.

gastrointestinal bleed

varicose bleeding

balloon tamponade

common bile duct stones

cannulating the bile duct

pancreatitis