Well, thanks, Vivek and Ashley, for the interesting discussion and cases, and I just want to run through a few little more routine complications, and so this was an elderly patient that had kind of a dilated esophagus, but was asymptomatic, and unclear why, but she had high-grade dysplasia intramucosal cancer at the G-junction, so was going to proceed to do some multiband resection, and so pretty standard, just kind of sucking in this area of dysplasia and cutting underneath the band, because we're going to do multiband areas, and everything seemed fairly straightforward, and then starting to look at the defect here. So what do you think of this as you examine this? So for the fellows, what is it that catches your attention there? It's pulsatile. Yeah, let me stop here for a second. What organ is this? That was at the G-junction. So as we go through that there, you can see some fat, so a lot of times when we first look at these defects, they look kind of impressive at first, but usually there's a little submucosa on the muscle, and it looks kind of whitish, but this was a surprisingly thin esophageal ball. Sorry, we didn't quite see it there. So, Harry, just not to belabor the point, was it on the cardiac side, or was it on the esophageal side? Yeah, it was kind of a bit of both. There was some cardiac, and then some squamous. I asked the question jokingly in the first place, but there was a reason I asked that. And you see this here, this is fat that's just a very thin layer and clearly out through the muscle. So I think you saw what I chose here, but who would use what type of closure at this point? What are your options, fellows, besides what you're staring at right there? OTSC. OTSC, sure. Stent, there is a risk of migration here at this level, probably. So if it's the level of the GA junction, it might migrate. What size stent? Plus, it's a focal defect. It's a focal defect in a wide space. So stent is not the application. What would the scope of that I would be concerned about? Because if you suction in, you're going to be suctioning in some tissue in the mediastinum. But if you have the grasper to pull the tissue in, it might be safer. Yeah, so with the OTSC in the esophagus, always be careful to use the grasper rather than just suctioning. You don't know what's coming from the other side from the mediastinum into your clip. Right, right. So that came up with the FTRD case, that you don't want to apply suction to pull in other structures. So they were pulling with the grasper. So I decided to use ‑‑ Why is Vivek asking about where it is? Yeah, anybody can answer that question? Why is the location important for band EMR? You can search literature for esophageal band EMR and let me know offline how many cases of perforation you find. Very uncommon to have a ‑‑ this product was designed not to perforate the esophagus. So why do we have a perforation? That's the reason I asked the question. There's no always or never in medicine, but it's almost never happens that in the esophagus you do band EMR and you have a perforation. So why do we have a perforation? Could it be the one you took? Sorry? I was getting suggestions. You're trying to help them. This is graduation time, second day, last couple hours. Otherwise it's a back room, don't be afraid. Aggressive suction? As I said, doesn't happen almost, never, almost never. Why is it happening? There must be a reason. When things happen, like I said in my case, I thought there was an anomalous blood vessel. What's the problem here? Has it been treated before? No, no. Okay. The esophagus was very dilated, and I'm not sure exactly why that is. She had no dysphagia or obstruction, but it was kind of an unusually diffusely dilated esophagus. So my theory, just looking at this clip, not knowing the case fully, is that this is more on the cardiac side, stomach side, and the band EMR apparatus actually is fully capable of taking the entire stomach wall, especially when you have a degree of atrophic gastritis and effacement of the mucosal layers. It was not designed to do EMR in the stomach. It was designed to do EMR in the esophagus. So, again, it's hard to know from the video. Dr. Aslanian probably knows the exact location. But my theory is that this is on the stomach side of things and less on the esophageal side. Yeah, so that's the esophagus, just very, you know, it does seem kind of thin-walled, very dilated. And then... Maybe a deeper, you know, maybe attached to the muscle. Yeah, like stomach can come out. And the other thing you want to be thinking... You see that? In case you have a perforation, are you in the thorax? Are you in the stomach? Yeah, you can see that. Turn your CO2 down. If it's in the stomach, then you may need to deal with nemoperitoneum, depending how much time. You see, it's right below the Z line, where it has made the hole. And monitor, so... You have to be thinking all those things, even as you're figuring out how to deal with this. But even then, it's rare. The stomach doesn't always perforate. So it's an unusual case. So, yeah, so I decided to use through-the-scope clips. And then we heard from Dennis yesterday about, you know, kind of similar to the poem closure for the entry site. So kind of really wanted to get that first clip to sort of bring this together. And whenever I've, you know, sometimes with band EMR, sort of closing those with clips is usually not so easy. But so I was kind of careful to make this first one really set us up for success. And so kind of suctioning a bit and trying to get, you know, those wall opposed in kind of an early pucker. And kind of a similar concept with the poem closure. You want the first one not really so much the goal of closing the defect, but setting up the walls coming together and then allowing you to close it. So here we started distally and then moving proximally. And we're able to get a nice tight closure on this. And so, yeah, it went really well. You know, we recognized it immediately and then just went right to the closure. And that's another, you know, nice thing about through-the-scope clips. We don't have to change device or reorient ourselves or get another device in there. And then so I was actually able to send this patient home and it didn't do any kind of imaging or anything like that. But it was, you know, quite small. And but just from, you know, seeing how it kind of achieved the closure was very happy with that. So just. Sure, you don't have a leak. Yeah, it wouldn't be unreasonable, I guess. I don't know. Like, I don't know. I was just so confident. It happened so quickly and it was only open for maybe under two minutes or something. So I really felt like this was fine. And the actual perf was pretty small in the center. There was, you know, muscle and submucosa. So I felt like it was, you know, secure and it did hold up well. And then the patient refused surgery. We ended up actually doing cryotherapy and she did quite well as far as treating the cancer. A couple of comments on the case. So one of the nice things about this one is the location of the perforation. It looks like at least initially when you were approaching it, you were able to approach it on fast. So one of the advantages of that is even though it's in a tricky position where the G junction is, sometimes in a non-dilated esophagus, a perforation at the G junction, they can be difficult to close. You don't have a lot of room to maneuver. And this patient, due to the anatomy, being able to approach it on fast, your other option, if clips would have not been a possibility, was to use an over-the-scope clip, given that the actual perforation itself was not very large. The other good point is if you look at Harry's positioning of the clip, right, so a lot of times we suction down to decompress the bowel in order to bring the sides in. But this is, even though it's blind, it's not really blind. He knows where the clip is before suctioning down. So I've seen sometimes people, when they start doing clips, they think that let's suction down, hope for the best, and throw the clip. But what you want to do is position the clip where you need to be, suction down, have them close. Once you're close, before you deploy, start re-insufflating to make sure that the clip is actually in the position you would want before you fire it off. So don't just suction down, hope for the best, deploy, and then now it's not in the right position. That clip is causing you more difficulty than not. You're ripping it off. It's now starting to bleed. The perforation just got bigger. I know Annie about this. It's not from personal experience. In the partner's room, this happened. I'm the one walking to the room, you know. Saving the day. All right, here's a similar theme. It's kind of hard to explain how this happened exactly. That's always how it starts. Yeah, the factors involved were, it was a patient with a pancreas, sort of an unscented mass causing obstructive jaundice. So we were planning for EUS and biopsy the mass and then ERCP and stenting the biliary obstruction. So a lot of times I'll just put the patient in the prone position planning for the ERCP. Sometimes we'll do the EUS left lateral and then move the patient for the ERCP. It's sort of dependent on, you know, sometimes you have your whole staff there and it's easier not to bring everybody back to move them, but maybe their respiratory status and these kind of things. So it was one of those unscented cases where it was unstable and D2 and it was like, you know, you had to be deep to get the mass. It wasn't really a head mass. And then it was, you know, occasionally you can't get the EUS sheath out because there's so much torque on the scope and you have to kind of clear it. And then so I'll sometimes have to straighten the scope. It happens less now with the current devices, but it was a combination of that and then the unstable position and we'd sort of slip out. So in sort of had the unscented mass lined up and then the scope slipped back. And I thought it was in the stomach and then I'm advancing the sheath because it was sort of hitting the elevator because of the torque. And so somehow in that process, you know, in the stomach, you can usually adjust your length of your plastic sheath pretty safely. But somehow we ended up in the esophagus with this kind of like EUS sheath out and ended up with something that looks like this. So to show that again, so it became apparent that we were in the esophagus and there was a perforation of the esophagus that the EUS sheath kind of scraped the wall of the esophagus as the scope had fallen back. So this one also decided to clip and it just kind of lined up well to sort of start proximal and move to distal. And it was just sort of coming at us in a very sort of favorable way that it was sort of closing and then sort of approaching the kind of approaching the scope. And so here I was able to move kind of proximal to distal. And just kind of worked in that direction. Perforated the G-junction? Yeah, it wasn't the scope. And this is the only time I've had like an EUS sort of needle-based perforation, but the catheter, it was like an unstable D2 position. They were prone and it kind of slipped back and I thought it was stomach and it sort of like slipped back further. And I think I was trying to advance the sheath and I thought it was in the stomach. We had a little extra sheath out and I think the scope fell back in the esophagus and the sheath kind of like ripped the esophagus. So I think, you know, we kind of, you know, here I think it was very clear that this was open. And then so, you know, just recognize that and then move right to closure. And yeah, this patient I certainly did admit they did very well. We didn't have to do any other intervention. We never did do the EUS or the ERCP. But she, you know, felt well. We were able to discharge her and then she asked my partner to do the EUS and ERCP. I was fired, but it went okay. Which ones? Yeah. Or antifungals too? And again, this was close. I mean, this was very quick. It was, you know, we recognized it probably within a minute and had it closed probably within, you know, under four or five minutes. So, but yes, I would typically give antibiotics, usually maybe like Unison or if they're panallergic, maybe like Cipro. I usually don't give antifungals, especially if, you know, if it's something that's open very, very briefly. How about you guys? What would you do? Antibiotics. Broad spectrum. I think most of the surgical literature says to give antifungals up front first. Oh, great. Of course. Give antifungals on, you know, you go into their unit. I always add fluconazole if it's a role of NG tube. Yeah. I mean, here, you know, I guess I was, you know, again, very confident this was closed. And so I think here I did get a CT and it was, you know, a fair bit more impressive than the other one. But so, yeah, if I didn't have, you know, high confidence that it was tightly closed, then I think NG tube would be appropriate. What do you guys think? Yeah. Yeah, I agree. Yeah. So I have a question. And so some people's practice is before any EUS they do an EGD. I do not, but I do ask the patient do they have trouble swallowing, which isn't always, or does food go down? You know, you have to describe it many ways, right? Just have you had esophageal stricture? Have you ever had an EGD? Because you just kind of don't want to get surprised. You have trouble with pills. You know, like trying to sort of, I don't know. But some people's practice is to do an EGD always before EUS. Yeah. Yeah, we do that. We've got extra cancers, like esophageal cancers on the way down that nobody knew about. Yeah. Yeah, we published something on this once, and then it just became our standard practice. And, you know, I think also, you know, if you're having trouble at the pharynx or the G-junction, like a big hiatal hernia, there are some, you know, some blind spots with the, you know, oblique viewing EUS scope. One company has a forward-viewing radial, but, you know, the linear is also oblique. And I think also, too, you know, the way that sort of EUS is looked at where the EGD is sort of bundled in it. Like it's, you know, I think if you did miss like a G-junction cancer, it would arguably be part of the procedure that EGD is somehow bundled in it. So, you know, it's become our standard practice. It only takes like three minutes or so to do a reasonable EGD. So I continue to do that. How about you guys? So quick question. This may be more relevant for the fellows, but, you know, I noticed that the perforation and the closure was all done with the forward-viewing with the upper scope. But obviously the EUS was done with a linear scope. So how did you recognize that something had happened? Because obviously you had recognized it, right? And then you pulled the scope out and switched the scope and went back in. Yeah, I think it was sort of able to see, you know, somewhat that area. And I think it was more just kind of when we realized, oh, we're actually in the esophagus and not the stomach when we were manipulating the sheath. And so I think there was enough of a clue that I think it became apparent that we wanted to sort of take a closer look. But will X-TAC or end-of-stitch have been appropriate as well to close both perforations? Yeah, I think so. You know, I guess it's sort of a combination of how, you know, again, you would, well, X-TAC, you don't have to change scopes and you have a stable position. The clips are so readily available. So if you really feel confident that you can finish with the clips, then I think. But it's, you know, over-stitches, I think, you know, very good. But then you're going to have to set up and change devices. I think, you know, the band EMR maybe seemed a little small for X-TAC. I'm sure you could do it. But what do you guys think about X-TAC for this thing? A comment on the X-TAC. Remember that the X-TAC is not approved for full thickness defect closure. It's a mucosal defect closure. If you look at the helical TAC, the screw portion of it is very, very short. So while the esophagus is very thin, one of the problems you're going to encounter is you're going to try to get a good kind of anchoring of that helical TAC. And when you pull that in the esophagus, especially the mucosa, it can just easily rip open. So I think, I mean, I wouldn't discard as an option, especially if you have very difficult maneuvering with clips or other things. But in this particular case, I think clips would have been, you know, Harry did a great job. If not, I would have used the over-stitch. But the X-TAC shouldn't be kind of like, or at least I don't think it should be the first, second, or maybe even third option for full thickness closures. To echo on that, especially now with like mantis clips and whatnot, you know, I think especially for when tensions run high in the room and you have an acute event like a perforation, every tech knows how to set up a clip and give you a clip. So giving you a clip, either like a large size clip or a dura clip, if people like the short stem ones, or the mantis if people like the big sharp jaws. It's just very readily doable and techs are familiar doing it. You know, you could have the whole defect closed confidently before the tech even knows where the over-stitch is. You know what I mean? Because for over-stitch, it's not like you walk into the procedure already expecting you're going to perforate. Usually if like a perforation happens, it's unexpected, and so the tech has to run out, go find the over-stitch. You have to count on them actually knowing what the components are. They bring it in, they run out and get a double channel scope and everything. You know, in that amount of time, before the tech has even made their way down the hallway, you could have already closed it with a couple of clips and a very good clipping technique. I think that's a very good point about devices. I thought when I was in tech school, all of you guys would have great techs at MD Anderson. Knowing where devices and accessories are, I think it's really important as a fellow to know your endoscopy unit. You should not rely on the tech or the nurse that's going out of the room. We're just talking about this, how a lot of endoscopy units now, we have travel nurses. There's a huge turnover, so people may not know where devices are, so you should be familiar with your endoscopy unit. In our unit, I have like a cart where all the third space endoscopy stuff goes into that cart, plus the management of all adverse events. They bring the cart into the room for every single case, but you should just be familiar with those things. We're just about out of time. Let me just do one more quick one to round it out. Similar theme with a slightly different twist. This was a small neuroendocrine tumor of the rectum. Someone had previously biopsied it, so it had biopsy proven, and then it looked like this when we saw it in the rectum. We just put a band on this. And it seemed fairly straightforward, but it looks like that. And then to add insult to injury, I'm going to get some of this. So here we ended up using the Ovesco, and then this is that twin grasper. So you see, you grab one side, and there's a separate controller for the other arm. And then we grab the other arm, and then you see the Ovesco cap, and then we're pulling that in. And then going to release that. I would say the other important part of dealing with these adverse events, particularly perforations, not only just to figure out what kind of devices you have available, but also deciding how fast to have to deal with it. And that depends, obviously, on the location. So for instance, here in the rectum, the rectum perforations are pretty forgiving. So you can have some time, even though the bleeding added a little bit more excitement to your case. You have more time to think about how you want to close that, which is a total difference from the other case that you did in the esophagus, where the mediastinum is not a forgiving place. So you might want to think about time. How quickly do I want to close this? Because every second you're in the mediastinum and blowing air is something that you have to deal with afterwards, versus something in the peritoneum where you can believe that tension with a needle, but in the chest you can't. So it's nice to think about, oh, I'm going to bring this device, and I'm going to wait for this clip to happen. But you really want to also think about what location you are and how fast you need to close that. As much as you're in a hurry to put that over the scope clip, make sure the twin grasper is adequately inside that cap before the Ovesco is deployed. There have been cases where the twin grasper was caught into the Ovesco. Now you've created a new problem, fixing the old one. One more thing, in general, full thickness perforation, iatrogenic, is associated with more bleeding than just mucosal or submucosal injury. So like you saw in both these cases, esophageal as well as the rectal, there are more major vessels in the muscle and beyond. So when you see a pool of blood in the esophagus and you think there's a perforation, there probably is. So Schaefer's good advice is take a deep breath, then turn the video on. And just give a few seconds of spurting blood. It's always the ones where you say, I don't want any record of this, that afterwards you wish you'd turned it off. One more funny thing about that case was, so the pathologist calls me afterwards and is like, your specimen has muscle, and there is a lymph node attached to the tiny neuroendocrine tumor. Yeah, yeah. But that patient did great as well. In my stomach perforation, I had omentum, so they called with omentum, like we thought it was coming from GI. Was this patient in the OR? All right, let's take a short break, and then we'll come back in like 10 minutes.

perforation

endoscopic procedures

multiband resection

through-the-scope clips

endoscopic ultrasound

obstructive jaundice