Welcome to our newly created webinar series called ASGE Global Spotlights. This new series was created with our global audience in mind and at a different time from our usual offerings to make sure that you all have a chance to join live. These webinars will feature global experts in their field, and I am very excited for today's presentation. We have attendees joining us from all over the world, and the American Society for Gastrointestinal Endoscopy appreciates your participation. Today's event is entitled Adverse Event Luminal Endoscopy Prevention and Management. The discussion of this webinar will focus on the awareness of potential complications during endoscopy and management of them. My name is Reddy Akova, and I will be the moderator for this presentation. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box in the GoToWebinar panel on the right-hand side of your screen. If you do not see the GoToWebinar panel, please click the white arrow in the orange box located on the right-hand side of your screen. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. And now it's my pleasure to introduce our presenter for today, Dr. Alberto Murino, who is a consultant gastroenterologist and advanced gastrointestinal endoscopist at the Royal Free Hospital in London. He's also an honorary associate professor at the University College London. We are very fortunate and honoured to have him present today's webinar. I will now hand the presentation over to Dr. Murino. Thanks, Freddy. That was a very nice introduction. Good morning, everyone. I guess it's early morning there in the States. So I am very honoured and glad to be part of this webinar. And I just want to, those are my conflict of interest and let's start. So I will give you a brief introduction about adverse events and then we will define adverse events, complication and management of complication and conclusion. Please feel free to stop me anytime to make any question. And we will try to do a dynamic, to have a dynamic event rather than, you know, formal, the usual formal event. So any question, any time is more than welcome. We'll stop and we'll answer. So complication in endoscopy occur. Complication is part of the game. Whatever, you know, you do in endoscopy, you try to be very careful and therapeutic endoscopy, you try to avoid complication. Despite everything you do, you will have some complication if you perform therapeutic endoscopy. Because there is no one performing therapeutic endoscopy that never had a complication. That's impossible. So what is important is to recognize the complication and to take care of the complication. So it's important to have a plan in place before you start the therapeutic procedure. And always think about how you would eventually handle the complication if these occur. So if you start the resection, just or dilatation, just always have on the back of your mind that the surgeon might need to be aware that you're starting a complex procedure. If the complication happens, then it's very important, if it's possible, to spot the complication as soon as possible. Because these many times improve the outcomes of the complication. And it is so important to respond promptly to complications. So once you identify the complication, so put everything in place to manage the complication as well as you can. And we'll see how this will happen. Now, another very important thing, which seems obvious is that we have to consent the patient before the procedure. And by consenting the patient is not just take a signature and go through the procedure, but it's also explaining what the risks are. And when I consent my patient, even for a gastroscopy or a diagnostic colonoscopy, I always mention that there is a little risk of bleeding, a little risk of perforation. And I tell them that in case of bleeding, we might stop the bleeding. And in case of perforation, the worst case scenario is surgery, although it's extremely unlikely to happen. But patients really appreciate when you're honest and you tell them what are the complications. So please, please, please. The important, really important key factor here is to have an open and clear communication with the patient for all kinds of procedure you're going to perform. In particular for therapeutic procedure, complex procedure, you really need to go through complication because patient needs to know what the risks are before the procedure and how you would eventually handle this risk before the procedure. And now in my hospital, where we perform ESD or dilatation, we see the patients in clinic beforehand. We have a chat and we ask them to sign the consent in the outpatient clinic. And during the complication, once you detected a complication, you manage the complication as best as you can. Then once the procedure is finished, you need to tell the patient what happened. And if you admit the patient, then you need to see the patient every day. This is what has been called during a meeting, I will never forget, by Professor Hawkins, the best friend role. Why? Because if, let's say, you perform a dilatation of the esophageal stricture, you make a perforation of the esophagus and you have to admit the patient, then what you want to do is to see the patient every day. No matter what, you go to the ward and you see the patient every day. Even if there is another consultant covering your ward, you need to show your face. So this is why the patient is like become your best friend for hopefully a few days. And the other important thing that not many people unfortunately mention is the second victim. And this, I think, applied mostly to the younger generation, because it is well known now, and that's been described for the first time in 2000 by Dr. Wu, that yes, the patient is the first victim because he is the victim of a complication. But then the doctor, who we usually feel very responsible for the complication, is not as a second victim. And there is all the psychological events that the second victim goes through that are well defined. So there is a first stage where the doctor says how and why this happened, and then how did I miss and what could I have done to prevent it. And then what other people think, what people in the hospital, colleagues would think of me. And then there is the phase where the doctor starts to get worrying, I might get fired, and then he go and seek colleague support to discuss his complication with several colleagues, which by the way, is a good thing. And then there is the last stage where either drop out and say, oh, this is too much. I can't handle these complications. I'm not going to do therapeutic endoscopy anymore. Or, and this has happened many a time, is that the second is the doctor learn the lesson, learn to handle this complication, improve himself and move forward and gain experience. So please, you're more than welcome to check all these publications related to the second victim, especially the young gastroenterologists who are starting performing therapeutic endoscopy. Now, definitions. Definitions are very important. So a complication can be defined as an adverse event and as an incident. The adverse event is an event that prevents completion of the planned procedure or results in an admission of prolongation of existing hospital admission or another procedure like surgery of the patient. So, for example, I'm going to do, I'm doing again, a dilatation, I make a perforation, and then the patient has to stay in the hospital for a week under observation or a patient goes through surgery. And this is an adverse event. An incident is when there is an unplanned event that does not interfere with completion of the planned procedure or with the plan of care, meaning that we perform a colonoscopy, we reject the polyp, the polyps are bleeding, we place a clip, we stop the bleeding. That was an incident. And then we carry on and nothing different happened to the procedure or to the plan of care of the patient. Now, we move now to the complication and the procedures. So I thought it was interesting to start from the diagnostic procedure because yes, diagnostic is diagnostic, it's very easy. Everyone can, all of us can do diagnostic procedure, but still they have some complications, which are very rare. And the majority of time they're caused by sedation and analgesia. So, usually we, those are linked with cardiopulmonary adverse events. So you have a patient in advanced age, most of the time with several comorbidities. So, pulmonary adverse events, they include aposemia and hypercapnia, both caused by sedation, which decrease the ventilation, so hypoventilation. And also the other complication may be aspiration pneumonia. So many times I still see colleagues that perform gastroscopy, there is food in the stomach and they carry on performing the gastroscopy. This is not really advisable. One, because, you know, the food can cover some abnormalities in stomach and two, because the food can come back in the esophagus and then goes down in the eye waste and this can cause aspiration pneumonia. So please, if there is food in the stomach, just stop the procedure, reschedule for the day after. Or if it's an urgent procedure, just give metoclopramide or Domperidone to the patient and repeat the procedure after a few hours. Cardiac adverse events are hypotension, which is usually caused by the sedation or hypertension, a vasovagal reaction. Hypertension can be caused by anxiety or by hypotension. And arrhythmias, it's, someone can think that it's very rare, but actually arrhythmias during the procedure are quite frequent, but they are mostly in keeping with atrial or ventricular ectopic beats or atrial fibrillar or supraventricular tachycardia, which is something that resolves spontaneously. Angina, it may happen, very rarely happen, but it happens when you have reduced myocardial perfusion due to bradycardia or hypotension, but I mean, you manage the angina with nitroglycerin as usual. Now, perforation, I put it in red because it's always a quite stressful situation. So, perforation for diagnostic colonoscopy is extremely rare, 0.3% to 0.01%. And of course, increase with therapeutic procedure. So, how does perforation happen with diagnostic procedure? First of all, when you try to pass the corners of the colon or part of when a colon is quite angulated and you try to pass it, pushing blindly, so push the scope through the wall. And you can see that the wall change coloration. It goes from a white, from a pink color to a white color. That's very unsafe because you are basically applying pressure on the colonic wall and this can result in a perforation. Ovarian sufflation and bariotrauma can cause perforation. So, if you see that the colonic wall is start bleeding and there are some scratches, it means that there is too much gas inside the bowel. We're now using CO2. So, this is a very rare event, but because before with the oxygen, it happened more often. But still, if you see that this is happening in the patient's pain, then you want probably to suck the CO2 and reduce the tension. And also, when you pass through the the devices, sometimes we do it very quickly and then it happened that the device come out from the tip of the scope very quickly and might traumatize the wall, the colonic wall, leading to a perforation. It's very rare and extreme perforation. But we always have to take care of these things. For the gastroscopy, the perforation is even more uncommon than for colonoscopy. Perforation rate is one out of 2,500 to 11,000 based on the literature. And the predisposing factors are mostly zanker diverticulum or anterior cervical osteophytes or stricture. Bleeding is, again, a very rare adverse event for during diagnostic endoscopy. It's mainly caused in upper GI endoscopy by malaria-wise or a patient with thrombocytopenia or coagulopathies. Now, something that you might have experienced is that there is a good percentage of patients that after colonoscopy complains of abdominal pain. This is very common, but it becomes a complication if the patient is admitted. If the patient goes home and then from the hospital they say, oh, I have this pain. You recommend some paracetamol or Vascopan and then the pain resolves. It's not a complication. But if the patient comes back to the hospital because the pain is unbearable, then this becomes a complication. And you always think about perforation if you had a resection about post-polypectomy syndrome or, as happened many times, and this is the major cause of abdominal pain, is some air trapped in the bowel. Splenic rupture is very uncommon. So, post-polypectomy syndrome usually starts straight after the colonoscopy, but can happen also a few hours afterwards or a few days after the colonic resection. The patient initially complains of abdominal pain, which is quite intense, I have to say, and it can get worse and it can cause fever and peritoneal signs. You might have leukocytosis and raise CRP, but when you perform the CT scan and we, in our hospital, when we have a suspect of perforation, nowadays we only perform CT scan. We don't perform x-rays because the CT scans are much more reliable. Then the CT scan in this case will be negative. So, you might think about post-polypectomy syndrome. And these happen mostly when we resect polyp on the right colon, when we have a polyp bigger than 20 millimetres in size, although even for a smaller polyp, when you use diathermy, it might happen that patient might have post-polypectomy syndrome. It's more common when you have multiple polyps resected throughout the colon and if the procedure takes longer. And, of course, if the polyps are flat rather than polyp or pedunculated. How do we manage postpolypectomy syndrome? So, we usually admit the patients, IV fluids, antibiotics, bowel rest, and usually in 24 hours, the patient feels better and improve and then you are able to discharge them. Now, I will fire a question to you now, if anyone is keen to comment. This is, what is it? This is the up and after resection. So, if anyone wants to make a comment, I'm not sure if you're able to. If no one wants to step forward, then of course, this is a target sign. We do have a comment at ESD. Yes, this is probably done by EMR because it's a small poly, but this looks like, it's a target sign, so-called target sign, that was described by Michael Burke initially. So, as you can see in the resection, in this submucosal part of the resective specimen, there is this weightish area, which is actually a muscle layer. So, and if you look at the endoscopic images, that this is a defect in the muscle layer. So, what you want to do it here is to place, as it was correctly done, to place some clip to completely close the defect, and it is important that you completely close the, this white area, because if you don't close it, then in a few hours, the patient will develop a transmural perforation and will be admitted to the hospital. So, this is, that means, as we said initially, a prompt response to early signs of perforation. Okay? So, this is actually a full thickness perforation, and as you can see here, around the perforation side, there is still a polyp left. So, the question here is, what would you do? Would you carry on with the perforation, with the resection, or would you close the perforation and then send the person for surgery? So, does anyone want to respond? I'll give you a few seconds. Ready, let me know if anyone will type something in. I am monitoring it, yes. Resect and then close. Sorry, say it again? Resect and then close. Yes, and that's exactly what has been done. So, the rest of the polyp has been completely resected and then fully closed. But, I mean, this really depends on the patient conditions, because if the patient is under GA, or you have these complications, this perforation, that the patient is fine, then yes, please carry on, finish to remove the polyp, and then close the defect, because you will achieve both the result of complete resection of the polyp and perforation management. But, if the patient is in pain, screaming, and is under sedation, and cannot bear the pain, etc, then you might need to close the defect first and then try to come down. The patient gives more sedation and then try to continue with the resection, if it's possible. And this is a video from Dr. Paul. So, they had this rectal lesion, LSTG. I found it on Video GIA, and then they resected the polyp, and they found the perforation. They finished with the whole resection. You can see this is a transmembrane perforation, and then they place a few clips to close the defect. So, this is a very interesting video, because it shows us that when you close such a deep defect, what you want to achieve is not just having the margin of the resection site closer. You need to clip not only the mucosa, but the muscle layer from the edges of the resection site, and sometimes also the serosa within, you need to catch all of that within your clips, because if you only catch the mucosal layer and close them, then it will be much more difficult. Well, it's not going to be an effective closure, and the patient might still experience pain. So, the learning point here from this video is to achieve a full thickness closure. Now, perforation. Management of perforation, of course, when you are in a procedure where you still have to resect part of the polyp, when you have a perforation, what you want to do is reduce the CO2 content of the colon. So, suck the air, as my Japanese colleagues also told me, and bring the fluids away from the lesion, give to the patient some IV antiperistaltic agents, as vascopan, so that these won't interfere, the peristalsis won't interfere with the resection and the perforation closure, and finally, once resected, apply the clips as we saw. If the patient has a perforation, whether it's a delayed perforation, which many times happened that, as we saw, patient might come back to the hospital with abdominal pain or might develop this pain after a few hours for the perforation, they usually develop abdominal severe pain, distention, tendons, and guarding. Vital signs may be normal or they might have some tachycardia and they might develop fever, and for this reason, you need to give them a broad spread through antibiotics. You need to, again, organize an urgent CT scan and involve the surgical team as soon as possible, because even if the surgeon won't operate on the patient or even if you think that the patient is doing well after you started your, you know, all the antibiotics and you gave them the anti-pain killers, it's always better to involve the surgeon so that at least they are aware of this patient. Now, this is a changing topic now. From perforation, we go ahead with bleeding. This was a sickle lesion that we found in one of our patients at the Royal Free Hospital, so you can see the endoscopic view on your right, and on your left, you have a little diagram, which was drawn by Professor Ianno from Gigi Medical Center, who we had the pleasure to have him with us for three months recently, and here, as you see, is how, when we are injecting underneath the lesion. This procedure was done by my friend and colleague, Dr. Edward Despot. We worked very closely together, so Ed was starting resecting this LSD granular type, and after the first resection, there was some bleeding here. Ed decided to, because the bleeding was not significant, he rightly decided to go ahead with the perforation. As you can see here for the graph, he proceeded with the resection. Now, we found that he had some more space to try to stop the bleeding, so he tried with the coagulation, but it didn't work very well, but he is also aware of the fact that if there's a place to clip, then he will probably make the resection even more difficult, so he decided to carry on with the resection, and so he is carrying on resecting piecemeal, and then you, I move a bit forward, you will see here that, as almost finished his resection, he finds the bleeding point very easily, he has all the space, he put a few clips, he stopped the bleeding, and then he completes his resection. Okay, so everything was handled very well. As we say, this is not a complication, this is an incident, right, but that became a complication the day after, because the day after happened that, unfortunately, the patient came back to the hospital, and on that day, I was in endoscopy, so I took care of this complication, I could see the bleeding point, and which I thought it was there. I put a clip, but unfortunately, my clip didn't work very well, although it was close to the bleeding point, the lesion was still bleeding, and at that time we had Professor Yano from Jichi Medical University at our hospital, and they, Professor Yano worked very close with Professor Yamamoto, and they recently came up with a gel immersion technique where they use a special viscous solution to find the bleeding point, because as you see from this video, with water, we were not able to pinpoint the exact bleeding point, and I'll skip quickly to the important point, which is around here, where we inject some gel, this viscous solution, inside the working channel, and because it's a viscous solution, it reduced the bleeding, and we are able to clearly identify the bleeding point and place one resolutive clips. As you know, when you place a clip, it is very important that you place the clip in the proper place, so I always ask my nurses, I will always double check with them the order, so open, close, fire, release, so I open, I close, I make sure here that the clip is placed in the right spot, and the bleeding has stopped. Now, we release the clip, and eventually, the bleeding is under control. So, this is a very good, I think, demonstration of how to handle the bleeding, and also, I like the fact that the saline immersion using the special gel, which is commercialized in Japan now, but it will be commercialized in Europe, all over the world, hopefully in due course, it's extremely useful for this kind of situation. So, what you do when you have bleeding following a colorectal EMR or ESD, so if the patient is in your unit, first of all, you stop the bleeding. If the patient comes back, as it happens, you check also the hemoglobin. If the patient needs transfusion, we give him transfusion, you admit the patient, you check for hemodynamic stability, and then we tend to, if we know that the patient had a resection, which we tend to repeat the colonoscopy as soon as possible, if, or the other option is to wait and see, because most of this bleeding resolves within 24 hours spontaneously, but I think sometimes when you perform ESD or resection, and you have this kind of bleeding, and the patient came back with a delayed perforation, with a delayed bleeding, it's more sensible to repeat the colonoscopy, because you might have a significant bleeding, which won't stop spontaneously. Immediate polypectomy bleeding are around 2-3 percent, and of course, they increase with the increasing size of the EMR resection, and the delayed bleeding is around 9 to 13 percent for every millimeter in polyp diameter, I found in the literature. Does anyone have any question about resection or perforational bleeding? Dr. Moreno, the video that you showed from Dr. Pohl, the tools that they've used, are those commercially available at all? It was about the resection or about the... I believe it was about the resection, yes. Yeah, I mean, they used a cap, which is commercially available, and then they use a snare, which is commercially available, as well as the clips. So yes, all of them are commercially available. Okay, thank you. Yeah, the other question is, why did you choose clip over coagulation grasper? That's a very good point. So, I remember on that case, I was discussing this with Professor Yano when I was doing the colonoscopy, and I was saying, shall we go for a clip, shall we go for a coagulation grasper? We decided to go for a clip, because the point of bleeding was bang in front of us. We couldn't fail, and it was very easy to place a clip. So that's why I decided to go for a clip. But a coagulation grasper might be also a good option. Absolutely. Actually, the guidelines, international guidelines, usually recommend two kinds of treatment. So usually a combined treatment is preferred, either injection therapy with adrenaline, and then coagulation grasper, or you know, gold probe, or maybe injection therapy, and then clips, but combined is preferred. But in that patient, we were very sure that we would have been curative. So, can I move on? For the complication of bleeding for resection polyps, what intervention can be done for those? Okay, so the question is about how to handle the bleeding after EMR. Correct. Correct, yes. So, if the bleeding happened during the procedure, so during the EMR, you usually, or during the SD, you usually, you can treat the bleeding with the tip of the snare, or with a knife, in coagulation mode. So, you need to really identify the bleeding point, so use the water jet. It's very important. If you have the cup, the cup is also very important, because when you have a bleeding, sometimes it's difficult to find where it comes from. If you have a cup on your scope, you can apply some pressure on the, around the bleeding point. This, because of the pressure, will stop, or partially stop, the bleeding. You will be able to spot where the bleeding is coming from, and then while you put in pressure on that area of the mucosa, you can then use the device to stop the bleeding. So, you can use, as we say, tip of the scope, the knife in coagulation mode, or the coagulasper, and nowadays you use the coagulasper during the SD. If you fail to control it with the tip of the knife. The other, other things that might be useful, of course, the clip, and the worst, worst case scenario, when you're not able to handle a bleeding, is HEMO spray. At least it gives you a transient control of the bleeding, as a bridge, and then you could re-scope the patient the day after. But, to be frank, I never had to use the HEMO spray to stop, to stop a bleeding related to EMR or ESD. Never happened to me. Shall we move forward? Yes, thank you. Thank you, Dr. Moreno. Okay, so this is a video, interesting video, of a dilatation that I found on internet. You can, it's, it's a dilatation of an esophageal estrusion in a patient with akalasia, that was treated with Rigiflex balloon, which, in general, has an increased risk of perforation. And you can see here, compared to the CRE value. And you can see here that there is a perforation on the left side of the esophagus. So, now, esophageal perforation is something that is extremely stressful to handle. And so, here the question is, what do you do after you have an esophageal perforation? And I go straight to this slide because, first of all, if you recognize this esophageal perforation, you might want to try to close it with an Ovesco or with Eclipse, but it's quite difficult, especially if the patient is not on their GA. And please bear in mind that in Europe, in majority of the hospital in Europe, we use still conscious sedation. So, if this is the case, it's more difficult to place the clip or to close it with an Ovesco. If you fail to close the perforation, and that one that I show you was quite a large perforation, then you need to perform, to give to the patient straight away antibiotics. So, starting on antibiotics, and then he needs to have an urgent CT scan of his chest with oral contrast, so that you are sure that is a transmural perforation that looked like a transmural perforation, but you might have smaller perforation that you're not sure. So, CT scan with transoral contrast and start the patient on a painkiller. So, it's like codeine or fentanyl or, because I'm afraid, but paracetamol won't be enough. Of course, you need to involve the surgical team as soon as possible. And then you also, but this is very, it varies. So, someone place a nasogastric tube so that all the secretion are aspirated. And also in many hospital, a nasoesophageal tube is inserted with a continuous aspiration so that all secretion and saliva are sucked. But it's also important that, that's one of the most important thing actually, the patient needs to fast. So, kneel by mouth, nothing. You might want the patient, if you cannot place a nasoesophageal tube with a continuous aspiration, you can ask the patient to spit out the saliva and try not to swallow the saliva. Bear in mind that this is, for the patient, a very, very tough situation because the patient will stay in the hospital at least for seven days because he needs to take antibiotic for seven days and then he needs to have a repeat CT scan with barium, sorry, with oral contrast after seven days to check if the perforation has healed and is closed. So, again, we come back here to the best friend rule. So, no matter if you're covering the world or not, go back to the ward and see the patient every day. And usually in this case, we, he needs to have gram, sorry, a full broad spectrum antibiotic cover. Now, always ask the surgeon to review him every day as well. The other point here for this patient is in some hospital, they place stent after a perforation, in other hospital, the stent is not placed. I think, and the guidelines here are a bit contradictory. So, someone suggests the stent to be placed, other guidelines do not recommend the stent. So, this is a grey area. I can tell you that, for example, in my hospital, we don't place stent in these cases anymore because the surgeon don't recommend it. But it's always better to double check with that. Now, let's move on from the esophageal perforation and quickly go through the PEG. So, PEG is a very common procedure that we do basically every day in the hospital. It's quite straightforward, but it has many risks. And the risk rate is around 5% to 10% and can be serious in up to 9% of the cases. Those include aspiration, bleeding, injury to internal organs, perforation, barry bumper syndrome, wood infection, necrosite emphasitis and death. So, it is very important specifically to avoid any infection and for the necrosite emphasitis, which can cause death, to give the patient a prophylactic antibiotic therapy. And this is extremely important. And also, you need to make sure that all the anticoagulants has been stopped and the INR is less than 1.5. You want to check that there is a transillumination and also adequate finger indentation. I have a video here about barry bumper syndrome. So, this was a patient that the, this is the bumper of the PEG, which was buried in granulation tissue. And here we use new devices with this. We recently published on GIE a multi-centre study about that. So, you insert this flamingo device, which is like a sphincterotome like shape through the PEG externally through a guide wire. And once it is inserted, you will see now coming in the stomach from the endoscopic view. And we're doing this procedure under sedation. So, you handle this device externally. So, you need two operators, one that controls endoscopically the scope and the other one, then control the flamingo device. The flamingo device is here. You bend it. There is here a cutting wire device and with the wire you cut following a stellar, a star shape in order to cut the granulation tissue and then to release the bumper. And here I move forward. At some point, you will see that the bumper became visible. Here you see that the bumper became visible and externally you push the bumper in the stomach and then remove it with the scope. And this was a very, it's a very useful device. Now, I'm going to finish in a few minutes, just to say capsule endoscopy, very safe procedure. The only risks are retentions and aspiration. Retention usually is caused by strictures that many times happen in IBD patients. Many times the capsule pass through the stricture with laxative or spontaneously. In IBD patients, if the strictures are inflammatory, then medical management should be given to the patient so that the stricture heal, the inflammation reduce, and then the capsule can pass through the stricture and, you know, naturally excreted. Aspiration mostly happen in elderly patient or patient with a swallowing disorder. Remember, if you have an aspiration, the first thing you want to do is a good interscapular gloss to promote cuffing and expulsion of the capsule. But if this doesn't happen, then you need to organize a bronchoscopy. Device-assisted enteroscopy, I'm referring mostly to balloon assisted enteroscopy, are extremely safe. You have the complication usually when you do resection of large polyps or dilatation of small bowel-width strictures. Other complications are mucosal damage, abdominal pain, which are mainly very, very mild, and acute pancreatitis. There is always this thing on top of our head, or what about acute pancreatitis? I can tell you that it's extremely rare. In literature, it has been reported as 0.3% of the complication. In my personal experience, and I've done hundreds of enteroscopies with double balloon, I've never had it, but you would. But it's extremely safe. Okay. So, conclusion. The conclusion is, remember, complications occur. So, please be ready to face the complication, because no matter what you do, you will have some complication. Complication is important, and you need to recognize it very, I mean, as soon as you can, and have a plan in place and promptly react. Communication with the patient is important. Before the procedure, once he had the complication, and after, when you are treating the complication, if the patient is hospitalized. Learn from complication, because this will give you a lot of learning point. You will grow a lot as an endoscopy while you manage your complication, and share your complication. Share your complication with your colleagues. Share your complication with your fellows. It's an important teaching point, both for you and for other colleagues. So, share your experience as much as you can. Thank you. Thank you, all of you, for listening to this webinar. Again, many thanks for inviting me, and a big thank you to all my endoscopy team here for the amazing work that we've done in endoscopy during the pandemic, from the porters, to the fellow, to the nurse, everyone involved, to the front desk. It has been a dreadful year, and thank you to all the endoscopy staff and endoscopy unit staff out there that, many times, have been redeployed in other wars to help during the pandemic. Thank you. Wow, Dr. Moreno, thank you for the excellent presentation. The audience is ready with some questions for you, but I just want a quick reminder, if you have any questions, please use the question box in the GoToWebinar panel on the right-hand side of your screen. Dr. Moreno, that last picture that you showed with your staff was amazing, and earlier, you mentioned that best friend role and the second victim concept by Dr. Wu. The question is, how important is the support in staff in managing complications? So, it's crucial. It's crucial, but this is something, if you, by supporting staff, mean if we have the proper support as a physician when we face this complication, I'm not sure if we have it, to be frank, because it's something that has, you know, we are now discussing about these things, but before, it has been very recently described, although 2000 is 21 years ago, but that was the first time, but now people are starting to talk about this more and more often, and when I had my first complication, it was an esophageal perforation, and I handled the complication myself, I felt very guilty for the patient, and I was lucky enough to have colleagues with the hospital to discuss about it, and colleagues also that I really, you know, take into consideration where I was discussing over the phone, and this is important for your mental health, but also to check if you've done everything right for the patient or you need to add something to his therapy or his management. Thank you for sharing that experience, and which brings me to my next point, you mentioned mental health, and this is more a question, a personal question for you, what are, you have to have a strong mindset to handle these complications, what are some of the techniques that you use to have this strong mindset and this mental health to be able to stay composed during a complication? That's not easy, I think it's something that you gain with experience, so first of all, the first things that I have on my mind when I need to deal with a complication, when this occurs, is that if I get worried or stressed, this won't help with the complication, it won't resolve the complication, so there is no point to freak out basically, so that's one. The second thing, it's important, as we say, to have a plan in place so that you know that you're doing this procedure and you have organized everything even for the complication, so you know that the surgeons know that you're doing this procedure, you are in theater, if this procedure were extremely risky, so you are in a protected environment, the patient is under GA, if it was a risky procedure, that you have your team with you, so dedicated nurses which are experienced and they can help you with this complication, and of course, knowing that you have other colleagues, experienced colleagues with you and your team also help you, because many times, as I said, I work very closely with that despot, we work closely together, when we face complication, it face complication, I face complication, several many times we call each other to support, so also this thing is very important, the working team, it's extremely important. Thank you, I totally agree with you that you do need a strong support, supportive team, so I appreciate you sharing that feedback again. Going back to the esophageal stricture dilation, one question that came through the chat box was, what is the ideal time to start radiotherapy for squamous cell carcinoma after esophageal perforation is treated with FC-SEMS? Well, I'm not an expert in radiotherapy, so it's difficult to me to give a precise answer to that. I guess that you at least need to resolve the perforation first, but you have to keep in mind that when you have a perforation of an esophageal cancer, it has very poor outcomes, so many times the patient ended up having surgery or in another kind of, or maybe a stand place, because conservative management, it's many a time not very helpful in this patient. So, I think you need to, the perforation needs to be fully managed first and then probably you need to discuss with your radiotherapist when is the exact, the ideal moment to start radiotherapy and if it's safe. Dr. Mignot, thank you so much for being here with us today. Your experience is invaluable and I'm glad that you shared it with all of us. And as another reminder, please do check ASGE's calendar of events as we will continue to feature relevant sessions to our global spotlight series. Our next webinar for this series is entitled Manejo Multidisciplinario de la Obesidad y el Sindrome Metabólico, Más que un Concepto, and will be live in about 10 hours from now or so. This presentation will be entirely in Spanish. It will be presented by Dr. Victoria Gómez and Dr. Juan Carlos Karames. The moderator for this presentation will be the chair of the ASGE Latin American Special Interest Group, Dr. Hernando González. We hope you can join us tonight. Furthermore, another interesting free event from ASGE is the New Frontiers in ERCP and EUS on March 5th and 6th. This event will take place on our new virtual platform and you'll have the ability to interact with your colleagues, leadership, industry, and we'll add some gamification to it as well for you can compete for prizes. In closing, thank you again, Dr. Mourinho, so much for this excellent presentation and thank you to our attendees for making this session interactive. We hope this information has been useful to you and your practice. And with this, we'll conclude our presentation. Thank you again.

ASGE Global Spotlights webinar

Adverse Event Luminal Endoscopy Prevention and Management

complications during endoscopy

managing complications

clear communication with patients

the second victim

common complications in endoscopic procedures

handling complications

learning from complications