Good morning, I'm Vivek Kaul, in case you haven't met me already. Thank Ashley and Shivangi and Dr. Chak here to invite me for this course. I think you're the brave few who have survived overnight, right? Have some of your friends departed? Please give me their names so we can follow up accordingly. This is the section which is going to save your life, right? This is the most important session of the course, and better pay attention, otherwise hopefully they'll learn something from this, right? Now complications occur, and this is outside of the hours that you will keep significantly longer than your general GI colleagues. This is the other aspect of your professional life that is going to create a lot of pain. At this point in my career, 23 almost years doing this stuff, personal and professional life, I speak to this often whenever the opportunity comes. Very fortunate that there are very, almost nothing that gives me the level of pain that a procedural complication does. I think that obviously the pain for somebody in the family has morbidity is certainly there, but I think on a professional side, there is very few things that compete with this. If you're a good doctor, you're a thoughtful endoscopist, and you care for your patients and for your reputation and for the outcome of your practice, this is something you'll pay attention to. With this, I will move forward with a story. This is a real story. Most of the stories in my life are real, even however unbelievable they are. So Monday morning, I think I was in service maybe, or I don't know. I forget now, but this is a real Monday morning. I wake up. I try. That's when the alarm is set. That doesn't mean that's when I wake up, so that's a goal. It's a goal I'm pursuing. We don't quite have the Equinox in our small town, but another goal I'd like to pursue, so I do whatever little gym activity I need to do in the morning. I'm white-collar of many things, but with coffee, I'm blue-collar, and I much prefer Dunkin' Donuts over Starbucks, even though there are much, much fewer Dunkin' Donuts outlets out there. So coffee is very important to me in the morning. It's a beautiful day. Nothing has changed in my life. I reach the hospital. This is my schedule. This is actually a real schedule from some day. ERA means ERCP with anesthesia. EAN means endoscopy with anesthesia. So it's good. I think I feel professionally very gratified, satisfied. I've achieved something in life. I have 10 cases, 12 cases. First case is an ERCP, emergency room physician's father. As you grow older and you become famous and very good, physicians and nurses and lawyers will become patients. That further increases your pain. And when they are in the admit room, the first comment that the wife will say or the husband will say is, you know, we came from far away and, you know, we only came because they said you are the best. And at that point, I'm biting my tongue and I want to bite their tongue also. Because it is a consistent law of Murphy that when somebody says, I came to you because only you can do it, it's guaranteed you should call for an admission bed. That patient is going to get admitted. And so I'm thinking, what the hell is going to happen? I try to reassure them. I know what's going to happen. I know what's going to happen. OK. Now, I have to put on a game face. Game face is, oh, you'll be fine. I am the best. No problem. You know, we have a great team, a strong hospital. Nothing ever bad happens here, you know. We'll be fine. We'll be out. You know, get the Mercedes out by 10 o'clock and you'll be going home. Right. So it ends up being a difficult biliary cannulation. A patient has CBD stone and MRCP, has had intermittent fevers, mid-70s, bona fide case, elevated LFTs, the whole thing. But difficult cannulation. But then I'm thinking, even though I'm an experienced endoscopist, when you are dealing with a difficulty, you invoke your teaching and learning. That's why this course is important. Because if this course leaves you with a positive, impactful memory, those are the moments you'll be invoking when you're doing locum tenens in Montana, you know. And there'll be nobody with you. Short wire will also disappear. It'll be just you, dark room, and fluoroscopy. So then you invoke sagittal sections that you saw somewhere, you know. Something goes like this, pancreas goes there, bile duct goes at a more superior angle. So I'm thinking all that now. What the hell should I try, you know? So then invoke my other slide that I made for biliary cannulation a long time ago. This is not in any textbook. So don't copy it, and you will need copyright from me, okay? So I don't have sodium issues, but I have other issues. I'm invoking, you know, patient is under sedation, scope is short, glucagon has been given, you know. What else can I do? Slow movements. That's one thing we learned in Milwaukee. You know, the moment you walk into the Milwaukee ERCP center, they say, you know, if you move fast movements, you're not going to get any good. And at the bottom, we have all the other fine movements that you will learn in your fourth year. Approach from below, you know, small wheel to the right, use the big wheel to, you know, approximate the ampoule. I'm thinking all of this. What am I not doing right, right? And I say all this is nonsense, you know. This is standard cannulation, double wire, pancreatic, reverse this and that. So I'm going to put, I have a great tool in my armamentarium, and that is a needle-knife sphincterotomy. Dr. Mock is a big fan of it. I was very happy to see that. I'll have a personal conversation with you after this video. All right. So this is a needle-knife. We had a very venerable, respected older physician when I joined Strong, and his name was Dr. Ashok Shah. He is father of, he was father of the ACG past president, Sameer Shah. He was 42 years in practice. He was the best ERCP guy in the region, and he told me once that a needle-knife is probably the most important intervention in endoscopy, invention in endoscopy, because it transforms a procedure from a failure to success, especially in those patients who have minimal alternatives in that moment. So we put the pancreatic stent. Stent is going in. You can see the papilla is beat up. It's a flat mucosal surface at this point, right? Fellow has tried. I've tried. Stent has gone in. It's beautiful. Now we are preparing. I've prepared this video to show the needle-knife in action. It's a five to seven millimeter needle. It's a monofilament needle, and we embark on the first cut. All right. And just touching the wall is creating some issues, right? So now it's ballooning up. Where we have a stone, now we have a balloon, right? Stent is getting buried. Now blood is going to start coming through the pancreas as well very soon. So what did I do here? I just started a simple needle-knife, and now I have a catastrophe on my hands. So what happens to me now? That Monday is gone, right? I'm trying to inject it, do some things, what's around. At this point, cold beads of sweat are coming, you know, physician's father. All that stuff has gone out the window. I have 12 more cases to do. What am I going to do with this? There are three, two definite locations in the human body where the endoscopist is really at the mercy of God. One is, does anybody know, by the way, who's the person who was being picked on yesterday? Mary Jane, you want to answer? When I ask a question, I already know the answer, so that's another problem. Two areas that in the human body, in the digestive tract, that the endoscope is extremely limited in what it can do when something like this happens. Meanwhile, you are watching, things are getting buried. The duodenum is now converted into a bag of blood. So two areas, one in the pharyngeal esophagus, bad things happen here, we have very limited control and ability to fix. And the second is the retroperitoneum in the second duodenum. Major structures live here, the portal vein, bile duct, pancreatic duct. The wall is very thin, major vessels go through there. Still to this date, we have limited capability to, now this case is over. Now do you think, who thinks this patient will get more obstruction and more like impending cholangitis? Anybody? You think? Yeah, it's a fair assessment. So I'll move on from the video. So how do I react in this case? situation. I think the purpose of this is not just to see videos. Videos certainly show the catastrophe at hand. But what should I be doing in this moment? My heart is beating fast. My brain is getting foggier and foggier, right? All the ego is coming down. Best guy, worst guy. Now I'm the worst guy. You're only as good as your last complication. Pardon me? Right? So I'm the worst guy. And how does that brain and heart fogginess and confusion translate to my hands that are shivering now? Right? And certainly in the first five years, you will shiver more and be more concerned than in the last five or 10 years. But these are normal human emotions. And how does it impact the patient outcome? That really has not been studied very well. And I struggle with that every time there's a complication. Now next steps are who does what? What should I be doing? What should my senior colleague be doing? Right? What the nurse should be doing? And what the fellow should be doing? What are the options? I'm thinking now, can I fix this? Clearly, that bleeding is mostly intramural. Right? The cut was not even made. It was just a touch. And it was a jinxed needle knife. It came from the opposing health system. Someone had dropped it off. Right? How do you make good decisions? And how to avoid bad decisions? There's a lot of bad decisions that are made when complications occur. Right? For example, your EMR did a esophageal perforation. And now you go down with an Ovesco clip. And you lacerate the esophagus. Now you have a full thickness laceration and a perforation. So that's happened to me as well. And so the bad decisions are avoidable. I went to call for help and so forth. And then what happens to the rest of my work? Now remember, you have a waiting room full of families and a couple of other patients at the inmate room. So with that in mind, we had actually put together a poster that actually got accepted. It's massive life-threatening hemophilia and the importance of teamwork and appropriate decision making when endoscopic catastrophe strikes. This is something that, on the left side, I've summarized it. You've got to remain calm. It's not easy to remain calm. It is not. But you have to try. You have to work on it. Patient stabilization takes a number one priority, even more than your calmness. You can be off to the side dancing like a monkey. But patient has to be stable. Somebody has to take charge. And in our unit, we have done for a long time is we call immediately a couple of the colleagues and they provide objectivity. They provide dispassionate decision making while you're fumbling over there. And they help a lot. The decision regarding continuing or stopping the procedure is a very important one. You know, if you're at a critical juncture, you've achieved cannulation, but you have a duodenal laceration, for example, you can manage the abdomen with a various needle while you put the stent. At least take care of one catastrophe that the patient came with while you help manage the other one. But sometimes you have to stop. If you have an mediastinal situation, you have to pull out, get the chest tube in, and then you can go back and deal with something. Delegation of tasks is very important. In this situation, blood is getting, we can get type and cross, labs, the fellows and admission service and all of that. And then you engage with some thoughtful evaluation. OK, now patient is stable. Now do we have to go to IR? Do we have to call the surgery? And remember that three, four hours have gone by and nobody has talked to the family. So in our unit, we used to have pre-COVID, the nursing team would keep the family updated, you know, while the work was being done. So this type of a project covers all those questions. Then, of course, there is a lot of guidance we have that, you know, in every area of complication, major societal guidance is there. This is from the ASGE. You know, it talks about ERCP complications, but goes back to proper training, proper case selection, and guideline-based interventions that you should be familiar with when bad days start. So I think that's important for you guys to understand. In most complications, but certainly this is a visual complication that there is no subtlety to it, right? But there are other complications such as retroperitoneal perforations, minor leaks. If you're not paying attention in the room, then, you know, you're going to miss it, and sometimes patients are sent home also. So prompt and early recognition is important. This is an old article that specifically looked at complications of sphincterotomy by Dr. Freeman, 1996. And again, it looked at the same risk factors, coagulopathy, cholangitis. You know, I believe in this paper they talked about needle knife as well. And intraprocedural bleeding is a marker for delayed bleeding as well. So what is a toolbox here? In this particular case, I tried injection therapy. There wasn't really much to cauterize, and yeah. Yes, let's, yeah, and the panel, of course, is there. So yeah. What would people do with this? Would you like to notify IR, for example? What else? Do you have access to the biliary track? Oh, at this point, you saw what happened. You have a hematoma and you've got a pancreatic stent that's getting buried. Yeah. And bleeding. So what? Try to get a wire through the stent. Get a wire where? Through the stent. Through the pancreatic stent? Yeah. Any sort of access? So the PD stent is in. I think the question Dr. Chuck is asking is two questions. Number one, probably less important, should we continue with the procedure? You're answering that question, is should I deal, continue dealing with the bile duct? But I think the more important question is what to do about the bleeding, really, is what we're asking. So. Epinephrine. So it seems like epinephrine would like give, maintain your visualization, and then if it slows down at that point, to the point where you can actually do something, then you can continue to proceed, because you've bought yourself maybe like 20, 30 minutes of like hemostasis. And then you can always repeat that if you ever need to. And then now that you have pancreas, I know you started with a needle knife, but you could also go trans-pancreatic synchrotomy. You have other options now in time to deal with it. In a regular case, yes. But you see, just touching with the needle brought out. I think there is, what I'm thinking is there is an anomalous vessel there that is not going to go away with 20 minutes of time. Schaefer? My first step is always to take a deep breath. Yes. And it's amazing the power of just doing that. And during all cases, just to remember to breathe occasionally, because we kind of hypoventilate, which definitely is not good in stressful situations. Do you do your ERCPs all general anesthesia or monitored anesthesia? Now we do, yes. Okay. And these were from that time frame, yes. So I would think ABCs first, if the airway isn't secure, I would make sure that the airway is secure. Yeah. Yeah, absolutely. The other thing that I think that you had when you were talking was, it's okay to fail. So this looks like something that you're just based on your experience, probably like, you know what, I'm not getting in the bile duct. I am done. That does not say that I couldn't get on another day. So I think it's, especially when you're first starting on your own and you're like, you're just sweating it because you're like, I should be able to get in and this is going to be terrible if I fail. You know, it's worse to do dumb stuff than just come back another day. There's, you know, a patient, if they are cholangitic and dying, they can go to IR. And if they're not, they can wait two days till you're on endo again and try it again. The bile duct may be like, hey, I'm here, you know, two days too. Yeah. I think absolutely. Yes, Dennis. No, I was just going to add that sometimes when these things happen and we're stressed out and you're trying to fix it, you kind of develop this view, very narrow view, and you keep trying the same thing. And sometimes you need to realize that if it's not working, it's probably not going to work. You got to move on. And that's where I find the value of having a colleague come into the room. A lot of times they offer a completely different perspective that you may have not thought about at the moment because you're so stressed. And even sometimes just having that other person taking the scope, you know, maybe they don't find a solution, but just taking the scope from you and you take a step back and watch, it relieves some of that tension in you and the team. And you just, because you feel you're not alone. You have that support. And I think that overall helps with the dynamics. This is what we mentioned earlier. I think we found that useful. It's not always required for somebody to take over, but just being there at the bedside, turning the patient, you know, reassessing. Or even suggestions like I had a patient who they had a stone a month ago and finally, you know, came to me and I couldn't get in, couldn't get in, but the patient had been feeling fine and we didn't have any new LFTs. And then I, you know, call Amitabh in the room and he's like, well, you could do an EOS and make sure there's still a stone there because I couldn't get in. So, like, this seems like a very sort of obvious thing, but in the heat of the moment, you're so focused on getting in the duct and then you do an EOS and you're like, okay, there's no stone, so I'm done, you know. So, it's those things that, you know, that just like Dennis was saying, sort of taking a step back, but when you're in the heat of the moment, you're like, I got to get in this aisle duct, you know. That's why you need an Amitabh in every endoscopy. In every unit. All right, let's. We will rent an office for you. And Ashley went into protective mode now. But no, I'm done with this case, guys. Yes, Phil? Yeah, so actually, so I have two comments about this. I fully agree with what Dennis just said in terms of like, you know, having a colleague come by. Even if you're like the only interventionalist, I find that sometimes having a good, solid senior general GI colleague is very, very comforting. Just basically knowing that you're not alone. And at the end of the day, you might still be the one making the decision because you're the interventionalist. But just having the presence of another person who just kind of like, kind of holds your hand is very, very comforting. That's one. Two is, there's a couple of positives about your case, actually, about your situation. Even though the situation may look like it's catastrophic, one, you have to think about positives, right? So, one, you have access to the PD already. So, as far as like, pancreatitis is concerned, you already have access to the PD, you have a PD stent in place. So, it's not a full loss here. Two, you have this massive intramural hematoma that built up, right? But as we kind of cynically learn as GI fellows is, all bleeding stops eventually. And if you have a big, massive intramural hematoma, you actually have big, massive intramural tamponade. And so, you can make a good argument to say, you know what? I'm going to bail out because you have this hematoma, cannulation is not going to happen because you have this big swollen thing there. But you know, you can make the argument, this guy is not actively cholangetic, admit him, wait a couple of days, let the swelling come down. It's tamponaded because of its own limits, you know, as a hematoma, and you come back and try again. Absolutely correct. On Mark, there was another hand. Yeah. So, I was thinking, if the bleeding is not able to be controlled for, you know, we tried everything, and there's no access to the bile duct, so is there a role for hemospray, just, you know, as a result, like, you know, if I think that's a good or... Right. So, in this particular case, we were able to access the vessel, but the vessel is not exposed necessarily. So, the ooze is not going to be, I think the major issue is going to be how much of the bleeding is in the wall of the duodenum, and is there any bleeding going into the retroperitoneum. So, in this particular case, a CT angiogram was done a little bit later, I think two or three or four hours later, by the time the patient was down there, and there was a large hematoma, but no active externalization, so. So, how do you plan the rest of the cases? You know, this probably might have taken, like, a couple of hours. Yeah, it took about six hours, yes. Yeah, that's exactly what I was going to ask. Yeah, so, that's previous slides, we talk about, you know, work delegation, management of the rest of the workday, it's not always ideal. Some people will leave, and that's okay, but I think nursing has to step up. Everybody has to be focused on the fact that this was not something anybody planned as a sabotage, this happens, it does happen every few years, there's a case like that that happens. Everybody has to step up, so. But those are real issues, and I mentioned them in my slides. So, in terms of treatment, epinephrine was discussed, balloon tamponade, that's if you actually have a sphincterotomy, these are generic recommendations for your typical sphincterotomy bleed, doesn't apply to this case. And then cautery, I use that a lot, there's a special clip that is made nowadays, it's the only clip that really works with a duodenoscope, every unit should have it, and it's the 11 millimeter size of the DuraClip that works, and then of course fully covered stents, which are placed for the purpose of bleeding, they should be really short stents. Hemostatic agents have been used. My personal preference is that I think you should stent the pancreas if you're putting this on the ampula. So the non-endoscopic interventions are referred to here, surgery is rarely needed. I think every so often there's a case that needs IR, but in this patient we will check blood coagulation, platelets, and all of that stuff. And this is actually a recent paper just off the press, looking at blood thinners and ERCP, and sphincterotomy just came out, and it confirmed our impression that basically, at least in high-risk cases, if you resume blood thinners sooner than later, which is one of the guideline recommendations, they tend to bleed more, and patients in general going back on blood thinners will bleed more. So this remains a contentious issue, because the guidelines say one thing, and then the real life actually presents something else. The bigger message here, though, is it's still okay to deal with a post-endoscopy bleed than have a myocardial infarction or lost brain. This is just a couple of the perforations, retroperitoneal and full duodenal laceration, wire-guided perforation, and then take-home points, which are pretty self-revealing. ERCP was the original advanced procedure, it remains the most dangerous procedure even to this date, and I think sphincterotomy definitely increases the risk. The other points I have alluded to, the last point here is that all of this high-risk sphincterotomy business might be changing in your lifetime, in your careers, whereas EOS-guided biliary interventions gain traction when more specific devices that are dedicated to that are developed. Last couple of learning videos real quick, you know, cannulation technique is described here, the approach from below, see how small the papilla is and how big the catheter looks in relation to it. This is going to be mostly a wire-guided cannulation, but unless you achieve that angle of cannulation, you're not really going to learn ERCP, and that's important to know, all right? So this one here is the proper technique of needle knife. This is a good day needle knife. I think Dr. Yang referred to it, or maybe Dr. Keswani yesterday. When we have a new fellow, practicing over the biliary stent is the absolute safest way to do it. So this is, instead of extending the sphincterotomy on the second round, we'll just start with the needle knife with the fellow, and this is a step-by-step cutting process. And of course, this is a fellow doing it. This is the best way to learn it. Needle knife is not something you want to do right out of fellowship. There are many, many examples in my own career, as well as those that I've heard outside, where it has caused real complications and is best avoided unless you're well-trained in it. Thank you. And I will hand this over to my panelists and colleagues. Thank you. Thanks. All right. So just a quick comment. Great presentation, Dr. Call. Regarding collaboration with the NIH, I think it's important for us to make sure that we are working with the NIH. I think it's important for us to make sure that we are working with the NIH. nursing. While this is happening, the patient's family outside is getting restless. So you get your nurses in, somebody's communicating with the family that, you know, the doctor will come out, patient's still in the procedure. You have a favorite IR and surgeon. There have been times we've even FaceTimed the surgeon during a PERF and they're looking at it, they're like, okay, I think there is adequate closure, so have a favorite IR you're going to call SOS, have a favorite surgeon, and the nursing unit always comes together. So send a message out, send the troop in, get the colleague, and, you know, it does set the stage even for the nurse in the room. As much as you're shaking, the team in the room is also shaking with you. So, you know, they get their resources and you get yours. I would also piggyback on that and say that, you know, sometimes when this happens, especially if it's the first couple of times and you're rightfully so freaking out, and you might need time to process this, you know, some people are really good at working on the fly and a lot of us aren't. And that's natural because you're just in a state of, you know, flight or fight. So, you know, you know what you're going to need to do at least in terms of backup. So you know you're going to need to grab labs, you know you're going to XYZ call IR, etc. So when you know there's going to be a standard protocol for that, you can immediately just start delegating. And then while you're delegating, in the back of your mind, you're thinking, okay, what am I going to do? And then even after that time of delegation and you still haven't decided what you want to do, it's also okay to tell your team, I'm still thinking about what the best approach is and what's the safest approach for this patient. I'm going to get back to you or I need a few more minutes. It's okay to admit that because you just want to communicate with your team that you have control and that you're thinking, you know, about what you want to do and what's the best outcomes. I think in terms of this area, endoscopically, you're right. It's a very challenging place. There's very limited things we can do. You know, hemo spray would have been a good idea if there was an exposed vessel. I think putting the PD stent is what sort of is the positive here for sure. I think one other thing you could have done is that if it didn't stop bleeding or even if it stopped, and you know IR is going to be the next step, and if you have IR like we do and they need like 20 million data set points before they want to do anything, putting a clip in there right at the top of that cut, that's where the bleeding's from. It's bleeding at that cut site. So if you can put a clip there, even if you're not trying to stop bleeding, it's not doing anything, but at least a mark for the IR physician like, okay, maybe we can just go not do the CTA and just go straight to the table. So just added information and quick things that you can do. But again, there's no wrong in taking the time or admit that you need more time to think about it instead of rushing into bad decisions. And one of my favorite quotes is good judgment comes from experience and experience comes from bad judgment. And it's so true. So these things will happen and the key is to learn from it, right? So you have one of these cases, I'm sure Vivek never forgets this case. Yeah, so you got to remember and just kind of build on your toolbox. Other thing I'd add when all is said and done and even during your fellowship now when you get your first complication and you will, go and talk to the patient and talk to the family. The tendency is you feel guilty like you've done something wrong, you know, you haven't, that's part of the procedure. Sort of think through it and think what the family is going through and you have to be very open and candid and you want to run away because you think, oh my god, they're going to blame you. They want information from you. They just want to hear that you care and that you're trying your best and you've done your best and you really have, that's when you really, when you're successful, great. You don't have to spend as much time, you can go on to the other six cases. When you're not successful, spend time with the family, spend time and really show that you're not running away, that it's nothing that you've done, that they're not going to blame you, they're going to blame you if you don't spend time with them. I also think that as a fellow you don't feel the weight of these adverse events until you're out on your own and so when that first adverse event happens, when you're out on your own, it will feel differently and that comes along with that first year out being so difficult is that having colleagues around you that you can lean on to get you through that time is important. And the second very important thing I can tell you is that if you have a severe adverse event, it will affect you and recognizing the effect that it has on you early and getting help is really important for your long-term survival in this field. And I think also, you know, managing the patient as they go, your tendency, like Dr. Chalk was saying, is to go and let someone else deal with it but, you know, you want to pick your surgeon who you rely on who is going to make good decisions and you're going to tell them, you know, I know what you're saying, why you're thinking maybe surgery but, you know, there's some characteristic of this, maybe we can wait, you know, you want to be in their managing so they don't end up having further iatrogenia down the line. So I think it's a good experience as a fellow to go through that a bit so you're a little bit more prepared but we're kind of making it like bad things happen all the time and they don't.

endoscopic procedures

complications

sphincterotomy

teamwork

biliary cannulation

duodenal laceration

treatment options