Probably your next, Dr. Shahal, is also one of our experts and has been to these courses for a long time. I'm not supposed to oversell, but I'm going to keep doing this, Raj. Definitely a wonderful group of faculty. I'm so proud of everyone who made time to be with us this weekend. And we'll learn about some intervention in the U.S. Probably you are the queen of intervention in the U.S., and I'm sure you'll have some very cool things to show us. Yeah. Thank you all. I'll try. All right. Some more exciting stuff. So I asked the morning group just a quick show of hands. How many of you are currently in advanced endoscopy fellowship? Fourth years. Excellent. Majority. Third years? Great. Second years? None. Okay. So third and fourth years. Excellent. Thank you so much. All right. So, you know, if you haven't seen already, believe me, you will soon enough. Complications happen just because of the nature of the procedures. Even you are doing your due diligence, you thought it through, you did everything right, still complications can happen. Important thing is to learn from them and move on. Easier said than done. But each of us, we should continue to try learning from other people's mistake. This is why if you are working in an endoscopy unit with other interventional endoscopists, it's very easy for us to hop in each other's room and learn and be there for them. And if something happened, everybody gets to learn from that experience. If during your fellowship you were part of a case that you thought was really cool or you found a new way of treating or managing a complication or just doing the case itself, I would encourage you to write that up. That's how we all learn from each other. If you just leave it in the room, there will be just a handful of people who learn from that experience. You know, I like this quote here, which says, usually, and this was in reference to the airline accidents, usually the accidents happen because someone did too much too soon, followed by very quickly, too little too late. Each of us, when we are trying to do this procedure, as somebody asked a question in the morning or a little bit earlier, have the relationship with the patient. Know your patient. Look at the imaging. Not just the clinical story. I kind of stress the importance of learning how to read the CTs and MRIs on your own. Because very often, we do pick up things that were missed by the radiologist. So get in a habit, learning those images, looking at the images on your own. Getting a full informed consent is the key. Having a relationship, especially with some of these tough cases that we do, pancreatic gastrostomy, gastrointestinal, gallbladder drainage, it's good to know the patient, sit down with the patient, discuss the alternative indications. If patient is not all there, talk to the family on what you're going to do. Look at your team. Sometimes I see myself requesting a different set of people in the room. If the current one who are there, they are new. Don't be shy in asking for the best possible team that you can get for that day of the procedure. Of course, you do that in a professional manner. And if something were to go wrong, again, don't try to sort it out on your own for prolonged period of time, making matter worse. If we think this is a little bit beyond our forte, be comfortable asking for help. Immediately look for alternatives. Do I need to call the radiology? Do I need to call the surgeon? Do I need to notify the patient's family who are waiting outside? Why is it taking so long? So keep this all in mind. Keep the communication transparent and going. Try to be calm during the procedure if things were to go wrong. And my talk today is going to focus on some of the complications of the interventional endoscopic ultrasound, starting with the pancreatic fluid collection. So most of us, when we talk about interventional endoscopic ultrasound, the one word that comes in mind is lumen-opposing metal stent. Now we equate IUS to LAMs. The first probably LAMs that you're going to use or our faculty is going to let you deploy is going to be in a pancreatic fluid collection because those are the easiest. Even if you misdeploy in the cavity or outside the cavity, the implications of that, they are minimal and can be easily managed. But still, all these complications can happen. And all these have happened in all of my patients except the two. I haven't had perforation and I haven't had a patient with ear embolism. So knock on the wood. But I've had patients with bleeding, stent migration, occlusion, delayed bleeding, and buried stent. Very common complications when you use the LAM. So this is the first case. Very common scenario in endo lab, patient with walled-up pancreatic necrosis. Come in for second session of direct endoscopic necrosectomy. This was a case by one of my colleagues. And you notice during necrosectomy, patient started oozing. It's not a spurter, but it was a continuous ooze. My colleague deployed multiple stents. Still the bleeding continued. And then guess what? Patient went to the IR and they were found to have pancreatic oedodenal artery pseudoaneurysm, which was coiled. So bleeding in these patients when we are dealing with pancreatic fluid collections can happen for multiple reasons. First at the entry site, which is easy to manage. Or if you are doing the same session balloon dilation for direct endoscopic necrosectomy, bleeding can happen, again, from the fistula, easily manageable. The more difficult ones are intracavitary bleed, especially if it's a smaller vessel. Again, you can manage that with topical hemostatic agents or by clips. But if you are dealing with something like pseudoaneurysm, which was undetected, that can be something catastrophic for the patients. Again, cannot stress the importance of looking at images. Because oftentimes when radiologists report imaging, they just comment about size of the collection. They may not comment, oh, well, there's a big blood vessel, splenic artery, swirling through the fluid collection, or there are big blood vessels between your fluid collection and the gastric wall, especially in somebody who has chronic pancreatitis, occluded splenic vein, and now there are multiple collaterals and varices. So look at the imaging before we do these procedures. Another common scenario, why is it important to read the patient's chart? For example, again, I cannot tell you how often I've seen this scenario. You walk in on Monday, and you are approached that the patient's collection has in 72 hours gone from 8 to 12 centimeter. And then you're like, OK, that's really strange. It was steady, and now it blew all of a sudden. Yes, they could have blown another duct, and it could be just plain pancreatic fluid. But if you notice his hemoglobin have gone down, pressures are becoming tenuous. They got a repeat CT scan. Now, the density of the fluid is different, which is suggestive of blood. That should all cue you in. That's probably pseudoaneurysm. And even if the CT didn't show it, it's good to send the patient for angiogram to detect that. So how do you manage that? If it's an entry site, it's easy. You can either clip them, cauterize them, hold the balloon dilated to tamponade it, or putting in a bigger caliber stent or stems. When I'm actually deploying these lambs, as I mentioned in the previous hands-on session, it's important to torque around, especially if you're using bigger caliber stent, like 20 millimeter. So just turning the Doppler on is not enough. When the stent is actually deployed, it's going to cover more than 2 centimeter area. So in patients with multiple varices and collaterals, torque 90 degree either way before you actually go on to finalize a location for stent deployment. For intracavitary, especially if you're doing den, what I'd like to say is go for the low hanging fluid. Do superficial. There are newer equipment that are out there that allow us to do necrosectomy, but they are very aggressive. So if you actually read the literature, there's high complication rate with bleeding and perforation. So my go-to is braided snare. If you're doing necrosectomy and go gentle, go on top and just gently peel it out. And of course, if you see any cord-like structure, which is pulsatile, we stay away from that. So moving on to the next case, 50-year-old male, history of alcohol-induced acute pancreatitis, came in with abdominal pain, gastric outlet obstruction. They found a pseudocyst in the head of the pancreas causing gastric outlet obstruction. Patient underwent 15 by 10 lumen-opposing metal stent, and the lumen-opposing metal stent was placed in the antrum. So right then and there, if you're choosing antrum as a site for LAMPS placement, be cautious. If you can avoid it, avoid it. But sometimes we cannot. It's just that's the only place you can access it. Antrum is a high motility area. The risk of buried stent, migrated stent is highest in the antrum. And patient was brought back eight weeks later for LAMPS removal. Now the important point here is follow-up. So whenever we are placing LAMPS, especially for the pancreatic fluid collections, data shows try to take them out within four to five weeks, maybe six weeks. Several reasons. One, the risk of bleeding pseudoaneurysm has been reportedly higher if you leave it longer than four weeks. There was a good RCT that was published by Orlando Shams Group. And second is if you especially went into the antrum, I mean, the risk of complications like buried stent, et cetera, is highest. So you brought the patient back. This is what you see. The good thing in this case is you can actually see endoscopically a small opening, a hole. Sometimes if the stent is buried, there's nothing. There's tissue on top of the stent, and stent is totally buried inside. Then you have to resort to doing EOS, trying to localize it, going in and dilating it. You can still take it out, but it needs a little bit of maneuvering. So in this case, fortunate that the fistula was still there. When the patient was in the floral room, we were able to pass the guide wire. Since it was a 15 lamps, this looked like a mature fistula. You're not concerned about causing perforation. Dilated it to 15 millimeter. You can drive the scope in, grab the stent, but since the cavity had already collapsed, you can actually see the lamp sitting right there. You can grab it with any of the grasping device, and it's a gentle traction pull, and you're able to remove it. So very often you'll encounter these issues throughout your career. Stent has migrated. It's no longer there. Whenever you're placing lamps for the index procedure and for follow-up, especially if it involves removal, it's good to have patient in a floral room because you don't know what you will see, especially if it's some patient has been coming back after a long period of time. Another point is see what you're draining and what's the distance between the lumen and the collection or the lumen that you're targeting. Sometimes when you're draining gallbladder or fluid collection, especially if the fluid collection is in the tail of the pancreas, the distance between the collection and the stomach may be more than one centimeter. So around the side of using saddle length, or you can actually go old-fashioned saldinger technique and put in a longer fully covered metal stent, put pigtails in that area. And during the hands-on station, I'm sure you guys will be taught two different techniques, endoscopic deployment of lamps and then sonographic. Sonographic is preferred by most of us, especially if you're in a tricky spot, tight location in the bulb or near GEJ where you're not obligated to torquing, twisting, trying to see the black marker. Lamp can migrate, especially if you're doing same session, direct endoscopic necrosectomy. But one, another tip, you can, sometimes I intentionally take the lamps out, drop it in the stomach and do necrosectomy because the fistula is bigger and it allows you to take bigger chunks of the tissue out. And you can use that same lamps, ball it up a bit, grab it with a raptor forcep, bring it in your 1T scope, and you can use the same lamps and put it back again. So you save 5K. So that's another tip and technique to know, especially for necrosectomy or if you're deploying across anastomotic strictures, you misdeployed, you can use the same stent instead of opening up another one. So for external migration, you know, while you were deploying the stent in the fluid collection, you misfired, it's out, easy, pull it out, put a new one in, don't panic. Only thing you'll be dealing with this now, a gush of fluid that comes out to the fistula. If you drop it in the fluid collection, whopon and pseudocyst, that's also not an area for concern. Leave it dropped in there. You can go in with a second lamp. Now the question is, what do we do with the one that was migrated in? You can either try to dilate the fistula tract, take it out in the same session. Nothing is going to happen. They're not going to migrate. You can bring them back a week, two weeks later, whenever you are planning on bringing them back, and you can take them out at that time. So this is another case of a common scenario. So there's a theme here. This stent was also deployed in the antrum. Patient was brought back six weeks later for stent removal. This was a case of pseudocyst and also pseudoaneurysm. You see the coils here right in the middle. Six weeks later, the stent was buried completely. So this patient was referred to me for stent removal. So you notice here it's totally buried. I'm trying to try the inversion technique, grab the distal end, see if I can pull it out. That didn't work. I didn't want to grab the coils out, even though the pseudoaneurysm should all be sclerosed by now. So here I'm trying to now grasp the proximal buried dent. One thing you would notice is when we are trying to use a raptor in this situation, you can monitor how much you want to open. You don't have to open all the way. So I'm trying to open it a little bit so that you're not causing trauma. And I'm trying to intentionally fray the stent a little bit. It's not denuded. It's still all intact. I'm trying to fray it intentionally so that I can get more purchase in pulling that out. So after just a little bit of a gentle fraying maneuver, half opening of the forcep, I frayed it enough where now I can grab three or four of those wires together, give me enough traction to pull the stent out. So there you go. And of course, always go back, check the cavity, just more so in this case where there was a pseudoaneurysm. I'll just quickly go over this case that I had. This patient had walled-off pancreatic necrosis drainage the old-fashioned way with a fully covered metal stent that was placed three years ago. The stent was lost to follow-up and then came back with splenic abscess. And then when we go down, I'll just go to the part where we are removing the stent. So I tried multiple things. There was not enough space. Cavity was all gone for me to do stent in stent. So sometimes if you are dealing with buried stent, especially for the biliary, you put in another fully covered metal stent in or esophagus, that causes tissue necrosis and now you can pull both stents out. But since the cavity had completely gone, there was not enough space for me to land the proximal end of the stent. So here you notice it is totally denuded. It's a 6-centimeter-long esophageal stent. At some point, it had coating. If you deal with this scenario, what you can do is some stents, they have lattice design. So you can unravel the stent. So it's literally taking the stent apart wire at a time. So grabbing a wire each, clock and counterclockwise torque and torsion, you can peel it off and then peel the wire out. So it was a tedious procedure, but we managed to get everything out in the end. So that's how it looked. Before we get to this point, I had gone in and placed in a plastic stent into the splenic area. We fashioned an NG tube. That was taken care of first before I pulled everything out. So another technique to remove the buried lumps. So key points, if you put the stent in, take it out, ideally within four weeks, can go up to six. Maintain a lump's recall log, which is very important. Because all of us at a busy institution, we do the case, patients are gone, we're not seeing them at the clinic, patients are not coming back. And when they do come back, they may have situations like this. Type and screen, especially if you're dealing with somebody who may have had a stroke, bleeding or a pseudoaneurysm. Be mindful when you are trying to deploy it antrum or on the side of leaving pigtails in if you are going from antrum as a site. For lumps, buried stent, multiple things that you can use. You can APC the tissue, especially if the proximal end is out. You can balloon dilate. That allows you to give a little bit more space to pull it out. You can try the inversion or you can try the stent-in-stent if it's feasible. And of course, if it was a fully covered metal stent, apart from stent-in-stent technique, try the unraveling, which is a little bit more tedious. I'll just go quickly over a case of complication with a gallbladder drainage. One word I would like to say is, so whenever we embark on all these procedures, it's very important that we know the anatomy. You know, what is the anatomy of the organ that we are trying to treat and target? You know, just like we are doing all these endohepatology procedures, you need to know what the anatomy is, what are the blood vessels, veins, and arteries, and ligaments that we are looking at. Similarly for gallbladder, need to know the anatomy, the neck, fundus, and body, what area is the biggest, what should we be targeting. The arterial and lymphatic supply of the gallbladder is on the posterior wall. That's where the risk of bleeding is low because you are looking at the anterior wall. And oftentimes, try to drain it from the duodenum. Sometimes you have to go the medial wall, sometimes on the lateral wall. If you are going the lateral wall, be mindful GDA goes through that. So sometimes I've seen cases where a patient had catastrophic bleed just because of the area of the duodenum that was used to access for the gallbladder drainage. So this was a case published in GIE where they tried to drain a gallbladder from the neck. I think immediately, if I were to just pause here, this looks like, I mean, this is why we learn. Somebody did this, they published it, and we all learn from this. This looks like asking for trouble. You know, there's liver underneath. You are choosing the smallest part of the gallbladder for drainage. There's not enough landing space. You know that's going to be a trouble. So that's exactly what happened. You see the liver bouncing underneath. So the cautery system, there was not enough space. They did not lift the foot off the pedal soon enough. It punctured the contralateral wall and also caused trauma to the liver. So this patient ended up with, they were able to salvage it. They abandoned this, went from the another side, put in another stent, went in, closed the perforation that they created in the gallbladder. That patient still ended up with significant hematoma just because the liver was also traumatized, needed surgery, and IR drains. So you notice the cautery system is beyond the gallbladder wall and already going that into the liver. So when we are choosing to drain the gallbladder, needless to say, go for the biggest part body of the gallbladder, avoid neck. Be careful on what size of stent we are using and what your full intention is. Stones, are you going to do lithotripsy? Go in, call your docoscopy. And don't stay on the pedal. When you're doing the LAMP session, the people that we worked together this morning, you just stay on the pedal as long as you're going through the lumen wall and the other organ that you're targeting. And then the foot should be off. Yeah? Yeah, well, that's really granular and I have to think what exactly I do so Yeah, no, I don't know yeah, so I don't push too hard So one thing that I always do is of my I lock my big wheel So I'm really right next to the lumen. My elevator is almost a little bit halfway closed. So I'm not going parallel So the it's coming at a 45 degree angle and it's it's extremely gentle And I know I'm quite opposed to the lumen if I'm going through the stomach or duodenum And then I step on the pedal. It's literally less than a second and it goes through Correct correct. No, there's no manual pushing. Yeah, you made me think on what I do. Okay Yeah, yeah, no But good question so one thing that I would like to share is This is a good table to know especially if you are doing biliary drainage, you know CDS you're Doing GJ's gallbladder drainage on what's the landing space that you would need for stent without getting too much into trouble That being said can we make this for example 10 millimeter stent? Can we deploy that in a 15 16 millimeter space? Yes, but I would suggest Getting a lot of experience on how the axios work under your belt before we actually start Tackling smaller confined spaces. You have to modify the steps You have to deploy the proximal phalange in extremely stepwise fashion in piecemeal in order to make that work But but rule of thumb you need enough landing space For 20 millimeter at least aim for 35 millimeter landing space for 15 to 25 millimeter landing space I also encourage everybody, you know have planned in place and make sure your toolkit is all stocked The last thing you want to see is that well, you misdeployed during CDS and now you don't have salvage You don't have the long wires or you didn't put the wire in you don't have the long wires You don't have the skill set to do the salvage or technique. You don't have fully covered metal stent to get yourself out of the situation So make sure you have the appropriate team and then the kit one final thing. I would like to make a comment about GJs So this is a nice article that came out in GIE more than a year ago where they categorized complications from maldeployed lamps type one Is the the easiest to manage the duodenum or jejunum stays intact It was just a hole in the stomach you pull it out close the hole The morbidity mortality is lowest the complications from two and three They the morbidity and mortality as highest for obvious reasons where you have created a hole and then here This is totally misfired and also on the other end This is where people have described notes type of a procedure to salvage the situation But still despite that the risk of patient needing surgery is also highest so I'm just finish up with this lovely video by Manolo Perez Miranda where a Similar situation happened to him and I'll just show you how these things when everything are going well It still can be a tricky case. Okay, so here so we target for this kind of a loop Orientation you see the loop nice distended loop. It's going down enough landing space This should be chip shot. But guess what it the stent misfired. They were outside Ended up in the peritoneum so things can go even though everything is lined up perfectly So this is where they were able to salvage the procedure they went through the Go back. So they went through the gastric side of the lamps the wire They put the wire into that loop of the bow. So they maintained access Went down dilated the lamps 1t scope 2t probably is better if you have that because then you can grasp With the biopsy force of the loop that you're talking keep it anchored and then you can go put in another lamps Which they had 1t scope they did a needle knife into that existing area while the wire was in place And then they went on to deploy the second lamps and salvage the case You know this they make it look easy But oftentimes it's easier said than done because if you don't have a wire access next thing You know the loop of the small ball is sitting in the pelvis. It's very difficult to find which one was it it was and Least of all trying to retract it and put a stent across it But the point of these cases is again things can happen Be prepared know your skill set ask for help. Keep your stool toolkit stocked Stay hungry learn from each other. Thank you so much

interventional endoscopy

endoscopic ultrasound

pseudoaneurysms

gallbladder drainage

lumen-opposing metal stents

Dr. Shahal