cases. As a junior staff, you know my favorite topic, but we're gonna talk about a couple cases. So, 64, this gentleman had indeterminate biliary stricture, had an ERCP 10, 13, long stent. Actually had two strictures, one like CDH and another mid-CBD. But anyway, so he now comes with pain, nothing else, no like labs, no peritonitic, he's doing well, no fever, and they do a CAT scan. And then you get that call from the radiologist saying, I think your stent may have migrated and maybe outside the lumen, you know. So, MAC user. This was, and then you start thinking, you know, okay, well, we'll see, is this tenting of the wall? And you start thinking, is it really outside? The patient is doing so well, it's been like a month, and you're like, should we just, you know, let it be? Should we just go back? And you look at your pictures and stent was pretty good. And so, you know, like we've talked already, I'm not gonna go over all this, but you know, you remain calm, you start really seeing the overall picture, because the patient has some pain, but it's not like excruciating pain. And it's doing otherwise fine, you know, you talk to, you know, you gather your data, and then if you decide to go ahead with a procedure like we did, then you make sure that you prepare for, you know, basically a perforation, may not be a perforation, but. So, this is the floral, so we repeat on the ERCP, and you start seeing a lot of floral, and I started, I started praying in Spanish here, I was like, oh gosh, and then this is what you see. It looks like I was walking into like a Greek, like temple or something with this column, like, I was like, OMG, this stent really went down. So, again, you, so at that point, obviously, you've prepared, right, like you think maybe there's a perforation from the stent, and then you have your equipment, hopefully, you've prepared your team. Also, another thing, you know, your techs may be very experienced, and they may know exactly what's going on, even your CRNAs or your, but always keep communication, you know, tell them what's going on, you know, like, because they may not know, they may guess things are good or terrible and may not be. So, you start telling, you know, like what's going on and what you're going to do. And so, what will you do in this case? Just like, okay, you start trying to, I mean, clearly, if you see the pictures, there's no flange there. It's like, there's no hope of that tenting of the wall, right? So, what will you do, Phil? So, I would phone a colleague. Being totally honest, like, I think that's what colleagues are for, you know, if anything, just to kind of get an extra pair of eyes to bounce some ideas off of you, ask for help. I think one of the biggest mistakes that a lot of us make is thinking that you're on your own and kind of thinking like gung-ho, you're like, you're going to be the hero and save the day, and everything's going to be fine. But I think, you know, you're never alone, even at night, even on weekends, there's always like a friend who can help you out. I think for situations like these, you know, just ask a friend. Call a friend, call a mentor, you know? But, you know, ultimately... Yeah, when Dr. Zuccaro, he's been like, you know, mentor to many of us at CCF, and he told me, you know, after 35 years, I still call a friend. So, never, never be afraid. So, yeah, so we did that, but... So, what will you... So, how about Dr. Shahal? Well, let me click on you. So, what will you do? Like, you will remove this. How will you close it? Like, any thoughts? I don't really know what I will do, Roberto. So, this is a 10 French stent. So, a few teaching points. So, when 7 French stent migrate, they generally don't perforate. It's always the 10 French plastic stents that when they migrate, they can perforate. Some manufacturers, they have a tapered end. Others, they have a bit more blunt end. So, this is a 10 French. We don't know when it perforated. Patient doesn't have any abscess or sepsis. So, it's a very clean, small, 2 millimeter to 3 millimeter perforation in real life. So, we can easily handle and tackle that. It's the 3 millimeter perforations. Upper end is not there. So, you can basically, if you want to do in an inelegant fashion, you can grab it with a raptor, pull it out. You know you're going to have a hole there, but it's going to be a tiny hole, which you can most of the time secure perforation, close it with the clips. But as you show your multiple tools there, I don't think you ever need a suturing device for that kind of a hole. Second, you can cut it, but that's more cumbersome, but a little bit more elegant. You can cut the stent, and then you have a small piece, but make sure you leave enough for you to grasp it with a raptor or a snare to yank it out. It doesn't go into the peritoneum. I go in an elegant way. Remember, go back to the CT. The other point is they typically perforate at an area that's hopefully retroperitoneal, even if it's lateral. You may not have to worry about being peritoneal, but I don't know what, it's near the kidney, so it's probably retroperitoneal, and you don't have an abscess, you don't have free air. You could even just take that out and leave it be, it may just do fine. Yeah, I was going to say that's actually a really, really good point, because there's a classic case from MD Anderson where a patient was getting a screening colonoscopy and they saw a plastic stent in the transverse colon, a biliary stent coming through the wall of the transverse colon. Wow. Just one quick comment. This has happened to us much more than rarely, so I don't know if we're doing something wrong. Sometimes it's hard to figure out where the hole is. To Praveen's point, it's not that big, so the only thing I'll really do is potentially mark it before I pull this stent, just because it gets a little bit bloody, not too much, and so I want to know exactly where I'm supposed to be to close it later, because I just pull it with a raptor or a rat tooth and pull it out, and then if you go back in, usually with an upper with a cap, I'll close it with that, and I want to make sure I know where it is, so sometimes I'll mark it. The weird thing is it should be draining bile into the peritoneum. You're lucky that it's draining out the flap here. It's very clean, so I actually think that if you did nothing, it probably would be fine. I agree with Amitabh. Yeah, I think it's pretty frequently. The people who have done really bad are people with peritoneal disease. I've had some people with a couple of, one, I remember one actually, one with ascites, and that did not go well, because then the ascites got infected, and it was very bad. Yeah, and just to divert, taking the prerogative, I actually wanted to report this in annals and being a physician, but I lost the video. I was on vacation. I get a call from Las Vegas from one of our colleagues who's family medicine. He's now chair somewhere. He's been admitted to a hospital in Vegas with supposedly free air, and they're thinking about doing a Whipple on him because he's got a free perforation, and it didn't make sense. He didn't have a white count. His pain had gotten better. He'd been on antibiotics, told him to come over. He signed out AMA, flew himself as I was flying back from Seattle, and gets admitted to our hospital straight from the airport after signing out AMA. Turned out he'd swallowed a date pit that his father-in-law had given him because around New Year's is a big Chinese holiday, and the date pit was sticking in just like this with a free hole. We took it out. Couldn't even find the hole afterwards, and he did just fine. That's great. Yeah, so Raj, also to your point, yeah, I've taken, I've closed perforations with different devices, and the point of sometimes either bleeding or localizing the hole is really important, like you want to mark. Actually, here I didn't, but I was ready to do it, and you'll see now. So we took it out with a raptor, and we didn't cut it like Dr. Shahal was suggesting. I think I've never cut a biliary at 10 French with an endoscopic scissors. It's pretty hard, I think, to cut. No? Okay, because I think it will be really hard. You know, there are blunt scissors, but I did not do that. I took it out with a raptor, and then you could, and I had obviously my OTSC loaded and ready to go. I didn't mark it because it was pretty obvious, and then we just closed it with an OTSC, and it went pretty well, and then, you know, I just injected a ton of contrast, like an endoscopic enterogram, and make sure that there was no leak, and, you know, I suspect it's a small hole, and then we just repeat on our ERCP, put a little shorter stent. Would you go with the pigtail stent, Roberto? You know, it was, no, I did not. Would you? I, I, I, yeah, from now on, yeah, it's a bad number in the first place. Well, it was, like, really deep. Anyway, so two strictures, but now let's move on to another case. So this is another ERCP. It came from an outside hospital, and I was supposed to just change the stent, you know, another stricture, and when you put the scope down, there's no stent, so you hope the stent probably pass, but it was a 10 French, so I had some doubts, and then you do your, your floor, and you're like, all right, this went up the other way. So, so what are the options here? Any takers, fellows? Good, okay. Any other options? Schaefer, what's your favorite tool for this? There is a stricture, yeah, I haven't, yeah, you'll see, but. You can put some sort of a grasper into the duct under fluoro, but an introducer, an extended introducer. Nice. So is there a stricture at the bottom, Roberto? There is a mid-CBD stricture. It wasn't high-grade. It was like, I'll say, moderate mild stricture. So that would determine the type of tools that you would use, wire-guided versus non-wire-guided. Yeah, so multiple tools, like you all are naming, right? So there's a balloon on the left fluoro. I think there is a grasper on, yeah, a grasper on the right side. Anyways, we try everything, you know, like, we try. You can see the stricture is not bad. I mean, this is not the best fluoro, but there was a mild stricture. The ducts are not dilated, right? Not really big ducts. And then we decided, after we failed all the tools possible, calling one or two friends in the room, and then we just went, we ended up going with the SPI to actually take it out because nothing was working. And, you know, patient anesthesia, I don't know how long, you know, over an hour for sure, trying multiple tools, multiple times, going back sometimes to some tools. You know, it's just, we were able to grab it, but it could not be pulled out. And this is like a shorter video because I attempted multiple times, and the flange was anchored. Like, it just could not, I had to push it up into the liver, make sure I'm not perforating the capsule, you know, because it was pretty up high and tried to reposition. This is a successful attempt, but it took a few times. Even a mini-snare, I tried because the flange was really anchored. I had to, like, fill it and negotiate with, you know, it was really anchored. But I think, Dr. Shahal, you also have experience with this. Any tips with removing stents in the liver that we would spy, or any other tips, or any other takers? Ashley, any other thoughts? You did it beautifully. I mean, I think what you did, you just try, you know, you just think of, like, whatever. It's kind of nice when the ducts aren't dilated. It seems worse when they're dilated. It's sort of floating. You can get lucky, get a wire in because the sun just never here. I mean, yeah, just try all those little tricks that the balloon decided. I would put a dilated balloon in a wire, and then, like, a tender, and blow it up as big as you can. Not a full material, a dilated balloon, and then blow it up that way. Even up high, high in the liver, right? Yeah, that's enough. Or pull it down a little. Pull it down, and you might be able to stand it. Yeah, I think the problem in this, it was the, it was anchored, you know, really hard that I had to push it up and try to move the flange, and then it was successful at the end. I'm not going to bore you with a lot of data, but I was, I was looking for papers, and, you know, I thought this was interesting, because it's from Subash, and they basically call patients after ERCP. They did a thorough assessment immediate after the ERCP about, like, on adverse events, and then they call them at one day, seven days, 14, 30 days, and they found that, you know, like, there is delayed pancreatitis, like, diagnosis of pancreatitis, like your case, Pat, right? Like, not immediately, but sometimes we're taught that it's immediately, or that day, but patients were brought to the hospital six, seven days later with pancreatitis, with bleeding, you know, so delay adverse events. So I thought it was really cool, because their adverse events were, like, 1.9% on the day of, or, like, within 24 hours, and it went up to 10, you know, like, that's, like, a tenfold, almost, increase with phone calls. And they also took in count, like, other symptoms that were not related to procedure. You know, people could get a cold, and so they captured those. So it's interesting. So this was, I just want to throw it out there. So in summary, post-procedure, especially delay adverse events, like we saw with stents in these two cases, you know, overall in ERCP, in this session, you've seen multiple, in general, in endoscopy, I think are, you know, rare, but you will see them, as Dr. Chak and the other faculty were saying. I think you will, you know, as you do more, you will probably have one or two cases, and always prepare, you know, prepare for multiple scenarios, call a friend, call a mentor. Now with FaceTime, sometimes, you know, you will also have mentors at the tip of your fingers, and always communicate with other teams, you know, including your local team. As I said, sometimes I realize that I may be talking things that my CNA may not know technically, so I need to explain a little bit, or nurses also, kind of, so they know that either this is a very serious situation that you're in, or it's not as bad as they may think. And then also your surgeons, radiologists, as you see, as you saw in the other cases, and also the last point, I think is extremely important, I think a couple of faculty mentioned, but keep, be very transparent with patients, you know, that's why it's so important when you take consent, that you have that relationship with patients, treat them like your own family member, and if things are happening, be very transparent up front, tell them that, reassure them you're going to take good care of them, and if things are happening during the procedure, you can step out, you can send someone, your fellow, to update the family, they will appreciate that. And that's it, thank you.

biliary strictures

stent migration

perforation

stent retrieval

communication