Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Complications in Endoscopy. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording and GILeap as part of your registration. Now it is my pleasure to hand over the presentation to our GI Fellow Moderator, Amulya Penmetza, from the University of Rochester Medical Center. Thank you. Thank you, Marilyn. Welcome everyone to our Endo Hangout session this evening. I'm very excited to be here and to have our wonderful panelists with us as well. My name is Amulya Penmetza. I'm one of the third-year fellows here at the University of Rochester. I'm going to start by introducing all of our panelists. We'll start with our Director, Dr. Shivangi Kothari. She is an Assistant Professor of Medicine and the Associate Director of Endoscopy here at Stroum Memorial. She received her medical degree from Set GS Medical College and KEM Hospital in Mumbai, India, and then completed her internal medicine residency and GI Fellowship training from Seton Hall University's School of Health and Medical Sciences, and then later her interventional endoscopy training at Stanford University Hospital. Dr. Kothari has clinical expertise in interventional endoscopic ultrasound, advanced therapeutic ERCP, esophageal endotherapy for Barrett's esophagus, double balloon endoscopy, and pancreatic biliary disorders. Dr. Kothari's interest in academic medicine has led her to practice evidence-based medicine and conducting multiple research projects. Her research interests in particular include development of EUSFNA techniques, endoscopic ablation and therapy of Barrett's esophagus, and evaluation of new devices and technology in the diagnosis and treatment of biliary and pancreatic diseases. She is an active member of scientific GI societies and serves on several national gastroenterology committees and is a reviewer for various journals. She's passionate about patient care and is committed to providing the highest quality personalized care to each patient. So thank you so much for leading today's session. Next I'm going to introduce Dr. Tyler Berzin. He is an Associate Professor of Medicine at Harvard Medical School and Director of the Advanced Endoscopy Fellowship Training Program at Beth Israel Deaconess Medical Center in Boston. He has authored over 150 articles and chapters on all aspects of GI endoscopy, ranging from anesthesia safety and advanced endoscopy to artificial intelligence techniques for colon polyp detection. At Harvard Medical School, Dr. Berzin has been the recipient of numerous clinical and classroom teaching awards. He is a fellow of the ASGE and ACG and is a founding member of the ASGE AI Task Force. Welcome Dr. Berzin. Next I'm going to introduce Dr. Praveen Chahal. She's a leading expert in advanced endoscopy and interventional EUS. She is the Program Director of Advanced Endoscopy Fellowship in the Department of Gastroenterology at Cleveland Clinic. She finished her training in internal medicine gastroenterology and advanced endoscopy at the Mayo Clinic in Rochester, Minnesota. She joined Cleveland Clinic as staff in 2010 and her special interests include therapeutic endoscopy and innovative interventional procedures, including EUS directed transluminal ERCP in altered anatomy, abdominal fluid collection management, endoscopic management of necrotizing pancreatitis, EUS guided gallbladder drainage, and therapeutic ERCP. She has served as chair and member of several national societal committees and has published over 100 articles and book chapters in reputed medical journals and presented at various national and international scientific meetings. Welcome Dr. Chahal. And then I'd like to introduce Dr. Jennifer Maranke. She is professor of medicine at Penn State Hershey Medical Center in Hershey, Pennsylvania. Dr. Maranke graduated from the University of Pennsylvania with a BA in anthropology. She went on to receive her medical degree at Temple University where she stayed on for residency in internal medicine and then completed her fellowship in GI hepatology and advanced endoscopy fellowship at the University of Virginia, where she also received a master's of science and clinical research. She has been at Penn State Hershey since 2016, where she serves as director of endoscopy. Dr. Maranke has been active in ASGE committees, including the GIE editorial board, where she acted as a clinical reviewer and guest editor. She's presently a member of the education council and involved in developing ASGE webinars. She has served as faculty for ASGE training courses, including the STAR lower EMR program and the first year fellows endoscopy course. She is also active in the ACG, having served as faculty for hands-on sessions and several years in the membership program. She is the current president of the Delaware Valley Society of Gastrointestinal Endoscopy and is active in the Pennsylvania Society of Gastroenterology, where she serves as a regional counselor. Her clinical interests include diagnosis and management of complex pancreatic ovariary disease and GI oncology, including precancerous lesions of the GI tract. She's a self-described endoscopy nerd and interested in all things related to endoscopy operations. Professionally, she's committed to education of medical students, residents, fellows, and faculty with a special interest in supporting the advancement of women in medicine. Outside of work, she enjoys spending time, especially traveling with her husband and two daughters and loves staying active and has recently become a golf nut. Welcome, Dr. Maranke, and to all of our panelists and directors. Thank you, everyone, for being here. As we said at the beginning, please feel free to enter any questions into the Q&A box instead of the chat box, and I will take a look at them throughout the session. We're going to start with cases. We'll turn it over to Dr. Katari. All right. Thank you, Amulya, for that wonderful introduction. Thank you, ASG, for giving us this opportunity to be a part of this endo hangout session on complications in endoscopy. It is a topic that's very close to my heart and I'm sure to all of our hearts, even if we want it or not. This is something we face in our career, and it's good to talk about it and learn from each other, and that's what we're going to do today. We have a lot of complications we're going to discuss today, the most common ones, and discuss some interesting and challenging cases, and hopefully, we can give some tips and tricks to help manage these complications endoscopically. So, some of the most common complications with endoscopy are cardiopulmonary complications, bleeding, perforation, post-ERCP pancreatitis, and one complication we're going to talk about today is stent migration for everyone who does ERCPs. The one take-home slide that I want everyone to take today is to start off, the best practice for any complication is to stay calm and not panic. And I know it's easier said than done, but trust me, when you stay calm, you decide on the tone in your unit and that room and what's going to happen next in managing the issue at hand. Also, the key thing to understand is that it's inherent to what we do. So, at some point, it is going to catch up and it is going to affect outcomes. So, you have to know that it's inherent and early identification is key. Don't ignore the patient's symptoms or discharge patients with symptoms after a procedure. Try not to create a new problem while fixing the underlying problem. Call for help if a senior partner is around, even when you are a new faculty and you go out into the world. You know, asking for help is not a sign of weakness. So, you know, you have to keep your patients safe and that is the most important thing in the room. Multidisciplinary management is key for any complication. So, always go back and think what could have been done differently and if there is anything that you can change in what was done. So, coming to the first complication of the evening, we'll talk about cardiopulmonary complication and Amulya will present our first case. Thank you, Dr. Kothari. So, we had a case of a 63-year-old female with medical history significant for obstructive sleep apnea, not on a CPAP and GERD with a BMI of 40. She came in for an elective endoscopy and colonoscopy with the indication of anemia and abdominal pain. The procedure was planned under moderate sedation. So, prior to the procedure, she received a first dose of sedation with the cedacane spray, 50 micrograms of fentanyl and 2 milligrams of midazolam. At that time, her saturations were 93%, but they increased to 100% when the oxygen was increased to 6 liters and she remained comfortable. So, she received her second dose with 25 of fentanyl and 2 GERD and subsequently had a respiratory arrest requiring Narcan. She received one dose of Narcan and recovered well. Obviously, the procedure was aborted at that time. So, we did review this case at our quality committee because it was an unexpected event. And part of that discussion was because of her OSA and BMI and possible physical exam that really wasn't well discussed or well documented, perhaps this case should have been scheduled with general anesthesia or at least discussed with anesthesia, maybe as a pre-op consult to see what would be most appropriate. Because again, this was an unexpected event that happened. So, we'll kind of talk a little bit more about what to consider from a cardiopulmonary standpoint. And if any of the panelists have any comments on if they've had any similar experiences, because this is definitely a decision that we make on a regular basis. Hi, well, I think this is a type of patient that is at high risk for potential complications. I think it's always really important. You know, a lot of times in heavier patients, keeping them a little bit on the lighter side is sometimes beneficial, but a lot of that is patient dependent and a lot of times dependent on their other comorbidities and what medications they may be on. I have found that, you know, there's kind of a big difference between conscious sedation and general anesthesia. And I think that somewhere in the middle of that, you know, may have been helpful. It may have been helpful to do the case, maybe with anesthesia providers, but not necessarily with general anesthesia. We have found that using IV propofol sedation doesn't always lead to general anesthesia, although it certainly has the potential to do that. And we've also adopted the practice of using high flow nasal cannula with, in conjunction with anesthesia for this type of, you know, obese patient who's at, you know, kind of at higher risk for obstructive, an obstructive airway. Yeah, thanks, Jen. Again, at our institution, we do a lot of moderate sedation and access to anesthesia is limited. In our world, GA is propofol versus general anesthesia. So I think it's anything more than ModSed is what gets scheduled with anesthesia. And then, of course, it's the discretion of the anesthesiologist, depending between propofol or GA. Praveen, you were saying something? Yeah, I think, you know, just a couple of points I would like to mention is, you know, somebody with a BMI of 40, I think physical exam is very important before we embark on moderate versus general anesthesia. Moderate versus deep anesthesia, you know, Mullen-Paddy score, what is your oropharyngeal area, neck, body habitus look like? And I think other telltale sign is when you're given 50 and two of fentanyl, and now the patient is requiring six liters of oxygen when the patient is not on any baseline oxygen at home, I think there's just another warning sign that this patient is probably not going to do well just with a nasal cannula alone would require, you know, some additional oxygenation method. At our institution, we use something called as a palm mask, which allow us to give high flow oxygen. And especially in patients with this kind of a habitus, it works better than just nasal cannula alone. But I think physical exam is a key, and then how the patient does with initial sedation. And that's a great point. This patient was actually a direct procedure. So, you know, in hindsight, you know, it should have raised some alarms. But I think, you know, when the patient showed up for the procedure, that's when we dealt with this. So in summary, you know, minimizing cardiopulmonary events as, you know, both of our panelists alluded to identify the high risk patients pre-procedure and plan accordingly. If patients need an anesthesia consult or you need to delay the patient for, you know, to get optimized, we get that quite a bit where we send the patient for a PrAT or pre-procedure consult with anesthesia of very early high risk. And they'll deem if the patient needs to be done in the OR or needs optimization of their cardiopulmonary status. Have a low threshold to admit the patient post-procedure if you feel like, you know, they are going to be a high risk for any decompensation and make sure the patients have appropriate post-procedure monitoring. So coming to our next case by Dr. Moranke. There was one question in the chat. Just for everyone, does anyone routinely use N-tidal CO2 to monitor patients? Because this can kind of identify inadequate respiratory drive before there's any desaturations. Just was wondering if anyone could comment on that. Yeah, so we use it for moderate. I'm sorry. We use it routinely. Sorry, go ahead. Oh, I was going to say we don't use it for moderate sedation, but of course we use it for anesthesia for all cases. We use it for both. However, when we're using a high flow nasal cannula, there is not a mechanism for getting an accurate N-tidal CO2. So sometimes it's a little bit inaccurate. I do feel that even, you know, sort of watching the patient and seeing if they're breathing and seeing if there's a good chest rise is one of the earlier signs, even prior to the change in N-tidal CO2. And so that can sometimes be beneficial as well. Thanks, Jen. Over back to you for the bleeding during the colon polyprosection case. Great. So I'm going to talk about a case which was done at our institution that was a colleague of mine and he used a number of different kind of modalities and it was sort of persistent bleeding. So I thought it'd be a good case for this. I just want to preface it by saying, you know, there are some recommendations and some guidelines on how to remove large non-pedunculated lesions, right? And so we typically will pursue endoscopic mucosal resection for non-polypoid lesions that are greater than two centimeters. You want to remove all the visible tissue. Using a contrast agent for your lifting agent is important. We didn't always have, we didn't always use methylene blue or indigo carmine and we didn't have the availability of commercial agents such as LVU or ORISE or some of the other ones. That has now been recommended not only to lift the tissue, but also to help delineate abnormal tissue from normal tissue. It's also important not to tattoo, use a tattooing agent for lift, which has in some circles has been recommended. It causes a pretty intense fibrotic reaction that can actually make it kind of tether down the polyp even more. A viscous injection may allow for removal in fewer pieces. We generally recommend avoiding argon plasma coagulation of any visible residual tissue. So we want to resect all the, all of the neoplastic tissue and then use APC or a snare tip soft coag for removal of the margins or, you know, treatment of the margins, which are normal, or at least endoscopically appear normal. It's very important to inspect the mucosal defects to determine the need for clipping on the right side of the colon, particularly if using electrocautery, consider prophylactic clipping, particularly if someone has to go back on anticoagulation and to treat the intraprocedural bleeding with coag forceps, snare tip soft coag, or hemoclips. And then the ESG guidelines have some recommendations on how to, you know, handle intraprocedural bleeding. They note that almost 3% of patients who undergo standard polypectomy will suffer from intraprocedural bleeding. And that number jumps up to over 11% of patients if, you know, you have a patient who needs EMR with a lesion greater than 20 millimeters in size. It's important to identify the bleeding source with vigorous irrigation. And I tend to use a transparent cap over my scope for any known EMRs that I'm going to be doing because that helps pinpoint lesions that are bleeding, pinpoint areas, improves visualization, and certainly the combination of a cap and vigorous irrigation helps really clear out the field. Injection of epinephrine in a dilute form may be used to gain initial control of any active bleeding. Right, if you take off a portion of the polyp and starts bleeding all over the place, it may be reasonable to inject some dilute epi just to sort of slow it down so that you can see the exact site of bleeding more readily. And then you can treat with snare tip soft coagulation for small bleeds. Use the coag forceps for larger bleeds. I typically use 80 watts on effect four or five. And then for refractory bleeding cases, over the scope clips may be helpful. So this is a large polyp, large bulky polyp in the rectum that was sent for, you know, it was referred for endoscopic removal. This is the initial injection. And the initial attempt was really to kind of start with a hybrid approach using techniques of endoscopic submucosal dissection. That was not going well. A number of large vessels were identified. And so, and the tissue appeared quite adherent. And so, as the ESD was progressing a little bit, a decision was then made to switch to endoscopic mucosal resection. And you can see we're now using a snare here to remove the bulk of this lesion. And kind of keeping a close eye, sorry that the video seems a little bit staggered here. But basically, this, you know, kind of shows the resection. It's kind of bloody. It's kind of oozy. It's bulky. It's difficult to see, you know, visualization is generally fairly poor here. But the resection continues. You can see there's, it's kind of a little bit of a bloody field, despite, you know, the use of a little bit of dilute epinephrine in here. And then after that last piece comes off, you can see a little bit of a red out here. So this is when you sort of take a deep breath, you know, make sure you've got, you know, kind of got your tools at the ready and work on identifying the source, right? So you found the source with some irrigation. And the tool that was first used was a coag grasper. You can see kind of a pumping vessel. Sorry for the beams. One of the residents helped me with this video editing. So she took some creative liberties. But, you know, so this is now, you know, going on, it's kind of a long procedure. And now it's complicated by this. But you know, you've got to take the rest of this out. So the initial bleeding was treated with coag grasper forceps. The resection continues. And again, it's kind of not getting any better because the bleeding persists. There is some concern for a deep, you know, kind of a deep tear at one point. But you're committed to kind of removing this, because this is your best shot at really adequately removing this. So it looks like it's all off. The rock net's been used to pull out that pathology, which is going to be very important. And, you know, the main reason that we're here, you can see there's persistent bleeding. So here's the coag forceps. And the tip of that is being used to kind of coagulate that bleeding vessel. And that seems to be fairly effective. There's, it's kind of bleeding again. And there's additional vessels that have also been, you know, been bleeding through this, through this resection bed. And that's not uncommon. We frequently see that, especially with rectal polyps. They tend to be very vascular, have large, larger submucosal vessels. And so this is kind of a frequent occurrence, especially with a polyp that size and with that bulk. And so again, coag forceps is being used here as best as possible to try to, to try to treat the bleeding. It looks like it's clearing up a little bit. The resection bed looks pretty good. And the decision was made to close up this defect to decrease the risk of any, you know, active perforation or, you know, that's not fully detected or a delayed perforation, given a lot of the electrocautery use that's been done on this case. And so that's kind of, you know, one of the, not all that uncommon occurrences with removing, with removal of some of these rectal polyps. And I'd be interested to hear from the panel on how they might have dealt with this issue. Well, I think one thing that Shivangi pointed out at the beginning is sort of setting the right tone in the room. When you encounter a polyp like this, even before you get started, I think that normalizing for the nurses and the techs that we may encounter some bleeding, that's going to be sort of part of what to expect. That's a conversation I often have before in ESD or a third space procedure where bleeding is really, honestly, there's a totally normal part of the procedure. But if you have a nurse or tech who is not used to that, it can seem catastrophic and terrible. So just, it lowers the temperature right away before you start the procedure to anticipate these types of things. And I think it's easier for people to help you in a calm way. The interesting thing, and that I don't know the answer to, is that at the beginning of the ESD, you mentioned that one of the things that made it difficult was that there were these large blood vessels. And while ESD is technically more difficult, one of the advantages of it is that you're exposing and proactively dealing with these blood vessels, whereas in EMR, we can't really do that so well. So it's a really interesting decision. And I'm not sure what I would have made if I was getting slowed down by really large blood vessels, whether moving to EMR is the right solution versus saying, you know, maybe this is not for me today. And I guess just as one quick final comment is that this procedure completed successfully, but there is no shame in just stopping. And sometimes it's really hard to stop because you've entered the room with a mission. And I think you have to constantly remind yourself that the mission is actually not the lesion, the mission is just patient safety. And so if you can accomplish your mission safely, that's the critical goal. And if it means leaving some of the polyp in there and going to surgery later, that's not the end of the world. I think that can still be a success for the patient. I think that's a very important point, Tyler, that it's not about you or, you know, your ego, what you set out to do. And, you know, there are times when actually discretion is a better part of valor and we back off and you keep your patients safe. And that is the most important thing. And then, so thank you for that input. There's also just one other video that I wanted to show related to hemo spray for rescue. And this was a gastric polyp that was, again, a similar situation. There was a lot of fibrosis that was encountered and it was kind of a hybrid technique. I'm not sure if you're able to go to the next, the kind of the next slide. Yeah. And so this was a video GIE, you know, case report that was published. But basically, you know, the lessons learned from this, and if you go to the next slide, it'll show a brief video. This was a large, you know, kind of a bulky gastric polyp that was sent for endoscopic resection and endoscopic ultrasound in advance had not shown any evidence of, you know, invasion into the submucosa or anything like that. So endoscopic submucosal dissection was initiated. And then it, again, kind of switched to a more hybrid technique. But what was encountered here again is some substantial bleeding after the lesion was resected. So that looks like a nice resection base. We can see at the top here, there's this spurting vessel. And so that was attempted to be managed, again, with coag forceps, a coag grasper forceps a number of times. And that was unfortunately not effective. And so this was attempted a few times. APC was also used, which is kind of, you know, not a standard, you know, therapy because we don't have the, you know, the advantage of coactive coagulation. And then finally, this continued to bleed. So hemospray was used and that was actually very effective. The side effect to using hemospray is that it then made any kind of endoscopic suturing of this lesion a little bit more difficult because it was a little bit firmer. It was a little bit kind of more difficult to deal with. And so it kind of made suturing more technically challenging and potentially not possible. But that's kind of one of the things that you can consider as kind of a rescue method. And then ultimately- What was the pathology of the specimen? Yeah, so this was about a four centimeter T1B moderately differentiated adenocarcinoma. Yeah. No wonder it was highly vascular. Yeah, yeah. So what would the panel do? I know this happened at the end, but if in the middle of the resection and you start getting this spurting vessel, and I know if you put the hemospray, it's going to affect your field to do any complete resection. So most of the times, I think when you embark on ESD, you continue on the ESD path, as Tyler mentioned, you know, because you have the tools available to you to help with the hemostasis. And I think when you are choosing the technology, you know, you have to be careful that you're not burning any bridges for that particular day. So try to have an algorithm in mind, step one, step two, step three, step four, and not just go with what is first available or the nearest available technique to you. Are any of you using the Puristat after any big resections yet? I know there are some trials going on. Yes, there are. I don't have any experience with that. We've just started using it, but I can't say I have any clinical sense yet of whether it's a helpful thing. I think the answer for the vast majority of here is using a cap, getting very close, using tamponade and coag grasper, that solves the problem so much of the time. And the nice part about this is that it really, you can zoom out and it pertains to managing virtually all bleeding, no matter what type of bleeding a fellow runs into in the midst of a case. So much of it can be solved by pulling the scope out, putting a clear cap on, and just getting pressure and tamponade on the site and things that were not visible and not controllable, suddenly become visible and controllable. Yeah, so to move on to the next case, so if you feel like cautery is the root of all evil, I am here to talk about, you know, cold snaring is not risk-free. So this is a polyp that was on a screening colonoscopy found in the rectosigmoid area. And we are going to now have some polling questions. So all the attendees, you will see some questions pop up on your Zoom and we will love to hear what everyone would want to do with this. So do you think this should be resected with a cold snare, a hot snare, small enough for a jumbo biopsy or this should require a submucosal saline injection and a hot snare resection? And so majority said cold snare, very nice. And that's exactly what I did. So I did a cold snare resection and it's in the rectosigmoid, resected it. Inside looked good, patient was in the recovery room. The nurse in the recovery room said that a patient is complaining of passing some blood clots. And I was like, okay, what do you think would be the next best step for this? Reassure the patient that this is normal. A patient looks great, but when he used the restroom, he said he was passing blood clots. Inform the patient that he can go home and if tomorrow this continues and it should slow down, a lot of our discharge instructions say that, call if the bleeding continues. Reassess the patient or even evaluate the toilet bowl if they've left it on flush to see how much amount of blood there is. Or admit the patient and observe them overnight and possibly rescope the patient in the morning because you take the patient's word that they're actually passing blood clots. So over 50% said reassess the patient and evaluate what's going on. So I agreed with that. So I went to reassess the patient and literally on his recovery bedsheet, he had this kind of blood clots. So now the question was, what do we do? And this is where you trust what the patient is telling you. And after seeing those blood clots, I said, okay, we are bringing this patient back in. It was in the rectal sigmoid. It was the only polyp I removed. This thing is probably bleeding. Even though it's small, it's in the left side, it's the ante of what all the guidelines say. And I brought the patient in. His wife was in the recovery room. Now mind you have to reconsent, right? Because you cannot use the same consent I used for the colonoscopy. So we consented the wife to do a quick flexing. And this is what we started with. And after resecting this, this is what we encountered in the recovery room. And then when I put the scope in, there was actually a significant pulsatile bleed from the cold snare site. And this was easily fixable. We put two hemoclips on it and we were able to control the bleeding. But again, the main thing is to not discharge the patient with the symptoms and making sure that you reassess the situation if it's not adding up. We have a whole host of hemostatic modalities. Usually we'll use epinephrine as a monotherapy. We have a bunch of thermal therapies that Dr. Maranki spoke about with coag graspers or APC. And of course, with mechanical therapies, we have endoclips over the scope clips, self-expanding metal stents if you have a post-sphincrotomy bleed. And of course, hemostatic sprays can be used if nothing else is working. Mind you, once the hemostatic spray goes in, it may limit your ability to do further endotherapy in the same session, but it will definitely help slow down the bleeding or even control it in some cases. So managing bleeding, make sure you manage the anticoagulation in collaboration with the cardiologist or neurologist. Don't just tell the patient to stop the anticoagulation. There are recent guidelines that were published on management of anticoagulation in patients for endoscopy. So read those, they are very informative. When doing resections, try to use blended currants compared to pure cut currants and carefully select the patients. Prophylactic clipping, Dr. Maranki spoke about that for large polyps, proximal lesions, if patients are going back on anticoagulation and observe the patient and observe the site before pulling the scope out, make sure you've achieved adequate hemostasis because that is your window to fix that complication. If you're in a hurry to pull the scope out, patient keeps bleeding, your colleague is coming back in the middle of the night to fix it, so be mindful of that. And sometimes severe cases may need IR or surgery, so it is okay to understand that, you have to escalate therapy if endoscopy is not fixing the problem. So coming to the endoscopist's worst nightmare, perforation, we all hate this. And I will talk about a case of 57-year-old guy, history of PSE, prior bilirubin of 10, has a dominant stricture in the left main hepatic duct that was dilated and stented. And the patient's bilirubin started improving and he came back three weeks later with right upper quadrant pain. The jaundice that was improving had now recurred and he had fever for two days. So what do we think happened here? Did the stent get clogged? Did the stent migrate distally? Do you think the patient have scoliosis titus? Or he developed a new stricture? Three weeks from his prior ERCP. So it's a 50-50 between stent clogging and stent migrating distally. It could be a combination of both. Now, mind you, it was a three-week-old stent and he had two stents in. The likelihood of the stent clogging is a little lesser. However, in three weeks for the stent to migrate is also a low probability. So we brought the patient in that, okay, let's assess what's going on here. And what we encountered was that one of the stents was in good position, but the second stent had migrated distally and was perforating the lateral wall. So we tried to see, and again, this was a case where I was an advanced fellow at Subhas Banerjee, my mentor was scoping the patient. And so we tried to move it to see if we could move the stent upwards and out. And mind you, the stent had now migrated below the stricture. So there was no pushing the stent back into the intrahepatic duct and there was no pulling the stent out. It had like wedged in place. What should we do next? At this point, do you send the patient to surgery? Do you get a CAT scan to get a lay of the land and assess what's going on on the other side? Get an upper GI series to see if there is a leak around the stent? Or do you feel like this is, we can send the patient home, this is not the source of his complaints. So majority said get a CAT scan and that is right. We wanted to assess and see if there is an abscess on the other side. And there was no fluid collection on the other end, but what we did see was that the stent, you can see the arrow pointing at the duodenal wall and the stent had migrated out and perforating through the lateral duodenal wall. So now how do we manage this? We have the CT information. Do we send the patient to surgery at this point? Do we refer the patient to IR to push the stent from above? Do we cut the stent and pull it out? Or do we treat the patient with antibiotics and put a new stent in and leave the migrated stent as it is because there's no collection and see what happens. The stent is wedged in place, mind you. Now this is a young patient. So again, we are split between A and C. So half of the attendees feel we should send the patient to surgery and half said cut the stent and pull it out. So we actually decided to cut the stent and pull it out. This was after discussion with surgery and seeing if we could cut it and we know there is no fluid collection on the other end, if we could remove the stent and close the pulverization. So what we did was we went in prepared, again, you're doing this with CO2. We went in with a double channel scope. So we had our clips ready to go and we cut the stent with endo scissors right in the middle of the shaft. It took a while because again, it's a good caliber stent. It's not easy to cut through. But after a couple of tries with the endo scissors, we were able to keep working at the same area and cut the shaft of the stent. The first thing you wanna do is you wanna remove the shaft because that migrated portion is keeping that perforation closed. So once you pull that, you're gonna have a hole and then the cut portion of the stent can come in your way. So what we did immediately after cutting was remove the shaft of the stent first and then tackle the perforating part of the stent. So here you can see with the snare, we're first gonna remove the shaft of the stent so it's out of the way and you have a clean field. And here we have a clip ready in the other channel. We pulled this piece out using a rat tooth forceps and then the perforation was closed using endo clips and the patient actually did well. So here we pulled this out and here's your perforation and with a bunch of endo clips over the side, you were able to close it and that's the final view. Now the thing is you still have an underlying problem. What do you do for the stricture? Do we place a new stent but now a double pigtail stent? Do we not place any stents because we know there is a risk of migration? Do we place a straight CBD stent again hoping that this doesn't migrate? Or at this point, do we refer the patient to interventional radiology? So majority said, actually everyone said that we should place a double pigtail stent and that's exactly what we did is we removed the straight stents and we put double pigtail stents across his stricture and this was two months later and the patient did well. And now we avoided a big surgery in a patient with PSE who's gonna need further ERCPs and you've not burnt his bridge to his endotherapy. So open up to the panel, anything you would have done differently for this patient? The tight situation, literally speaking. Yeah, I think you demonstrated it very elegantly, Shivangi. I think I probably would have approached it a bit differently. So I think first and foremost, when we are dealing with the PSE patients, I think it's important, first of all, to have a clear indication. Patient with worsening LFDs or if it's a new diagnosis or if there are worrisome signs and symptoms, worrisome imaging, as you showed this, there's a stricture. There was non-filling of the right system and generally speaking, there's a lot of research that supports. Balloon dilation is better than stenting in these patients, reduces the risk of infection and whole bunch of complications, cholangitis, et cetera, from stent insertion. And if it's not draining after balloon dilation, then yes, stenting. I think personally, in this case, if the stent had migrated down and caused the perforation, patient didn't have any clinical sign or symptoms of abscess or soilage of the abdominal cavity. He just came in with a recurring jaundice. I personally, so the upper end is free. I personally would have used a rat tube to grasp and pull it out and in a non-elegant fashion, yank it out with a raptor and close it. But you've demonstrated it very elegantly by cutting it. You have been the case, yeah. I would also add that I think that because of the nature of how GI endoscopy has developed in the last five and 10 years, perforations are now so much part of sometimes therapeutically what we're intending, that the amount of devices and choices we have over perforation closure has really expanded. And our comfort level with dealing with it has also expanded to the point that I think, even if you see a perforation endoscopically, I don't necessarily think there's an obligation anymore to pause and get a CAT scan. I think in many cases, you may just be able to see it, close it and be done, maybe get a CAT scan afterwards. But I do remember even in my own fellowship, I finished my fellowship in 2011, that our way of dealing with complications, perforations in particular, felt very, very different and much more fraught than it does now. Yeah, I totally agree. And I think that I have come across these a few times in the past several years, where a stent's been in there for at least a few weeks and it looks kind of embedded into the wall of the duodenum and generally removing them, it is a little, sometimes have a little bit of a lump in your throat, I'm not really sure what's gonna happen, but of the times that this has happened, kind of over the course of several weeks, they have not been a full through and through perforation. And I think even if they are, we're able to manage them much more readily endoscopically now. I did, I looked into this a little bit because I recently had a case where I placed a long, I placed two plastic straight stents in a case of suspected COVID cholangiopathy. And so I put it in a right-sided and a left-sided stent and they were fairly long, but appropriately long. And one had migrated perhaps the next day and the patient was admitted with abdominal pain and the following, I guess later that day, an endoscopy was done, which showed that the stent had perforated the duodenum and it was a nice, frank, clear perforation of where the stent had perforated. I'd never seen that before. So I kind of looked into it and I think there was a Turkish study that assessed their rate of plastic stent migrations and complications and stents that are placed into the left side tend to be more readily associated with perforations, longer size stents, things like that. But the timeframe was generally a few days to within a few weeks. None of them had occurred prior to two days and none of them had really occurred beyond three weeks. And so that's kind of the timeframe for these. But so I agree with your slide up here, which is that they are, the migrated stents are not always so benign. Yup, and there have been reports of fatal outcomes from this. So I think being mindful and what Praveen said, you know, if you can just dilate the stricture or here the patient had gone prior dilations and had persistently elevated bilion, that's when he had that dominant stricture, which was treated with further endotherapy and stenting, which was holding him intact till of course the mishap with the stent perforation happened. We have a whole bunch of tools that are available to close perforations from endoclips to over the scope clips, to endoscopic suturing, self-expanding metal stents to for esophageal perforations or bile duct perforations. And now endoscopic closure are part of guidelines. And if you look at the ESG algorithms, the endoscopic closure is recommended like Dr. Berzin said, as far as possible. If you see it endoscopically, keep your calm and close it then. And it has been shown to be the need for surgery. And only if the patient has severe sepsis or inadequate closure or peritonitis, those are the patients or large perforations with active leaks, those are the patients that would need surgery. But if it happens during a procedure, identify it early and try to close the perforation there and then. Coming to post ERCP pancreatitis, briefly there are risk factors that are technique related, such as difficult cannulations, precut pancreatic sphincteratomy, pancreatic duct contrast injection, large balloon dilation of the biliary sphincter. There are patient related factors, such as patients with prior history of post ERCP pancreatitis, female sex and younger patient age. The main thing to be mindful about this is once the post ERCP pancreatitis sets in, the course can be very unpredictable and can be life altering for the patient and the physician. So you wanna make sure you have a strong indication for the procedure. This was a 60 year old female that was sent to me prior history of gangrenous cholecystitis and had a subtotal cholecystectomy five months ago. And they were unsuccessful at removing the large obstructing cystic duct stone, which had led to her gangrenous cholecystitis. After her subtotal cholecystectomy, she had persistent pain. CT three months later showed the cystic duct stone with dilation of the upstream remnant of the gallbladder with mild residual inflammation in the gallbladder fossa. So she was referred to me because the surgeon literally picked up the phone and said, Shivangi, I cannot go back in this abdomen. If you can get into her cystic duct and perform EHL or break up the stone somehow, we really don't wanna take her back to surgery. She had underlying comorbidities, coronary artery disease, obesity. So after a detailed discussion with the patient and the family and the surgeon, I bring her in for an ERCP. You can see the choledoscope is actually inside the cystic duct remnant. And we just couldn't reach the stone because the duct below the stone was also so collapsed and inflamed that I just couldn't access the stone. And so we had to pull out. She did fine. We gave her indomethacin. She got two liters of LR. Watched her for two hours after the procedure. She went home, tolerated liquid. Six hours later, she calls her on-call fellow with pain. Comes to the ED. Of course, amylase and lipase are elevated. She was treated for post-ERCP pancreatitis. However, day three, she spiked some fever. So a CT was obtained. It didn't show any obvious fluid collections, but did show, you know, of course, that she had the underlying pancreatitis. Her length of stay was six days, which as per the definition is a moderately severe pancreatitis. So she was discharged. Again, you know, there were no other complications. She was discharged on an oral diet at day six. And now she has been referred to hepatobiliary surgery for tackling that stone and that remnant cystic duct that's being blocked by the stone. So again, open to the panel thoughts. So I always, Peter Cotton's words run in my head is that ERCP is most dangerous in patients who need it the least. So I think having a strong indication is important, but any thoughts or words of wisdom on this case? So I think that, you know, this happens. We know it happens. It's, you know, the most common complication after ERCP is, you know, post-ERCP pancreatitis. And so, you know, all of the points you have up here are pertinent and, you know, very important. I tend to use wire-guided cannulation, and I also prefer to control the wire myself. I feel that that, you know, that helps. I use all the tools that, you know, that I have. So in difficult cannulations, I will sometimes take a look at my fluoroscopic angle if I'm not really getting where I want to get to and make sure that I'm kind of in a biliary orientation. I do, in terms of pancreatic duct stance, if I have used, if I have cannulated the pancreatic duct inadvertently more than once, I will leave my wire in place. And I use that as a way to help facilitate biliary cannulation, but also to, you know, prevent me from continuing to cannulate the pancreatic duct, you know, inadvertently. And so I'll use that wire in the pancreatic duct as a way to straighten out the papilla. It sort of guides me fluoroscopically as to where the pancreatic angle is, and I can use that to get into a more cephalad angle into the biliary tree. And then it also allows me to readily place a prophylactic pancreatic duct stance. I use rectal endomethysin liberally. Virtually every native papilla will get a rectal endomethysin dose intra-procedurally unless they have a contraindication to it. And I agree with a very, you know, aggressive hydration, especially in young women, you know, with a non-dilated pancreatic duct. Those are, you know, some high-risk features or risk factors for the development of post-CSU pancreatitis. Yeah, you know, and that's when, what I took back from this case was we did everything right. We'd gotten in with the wire guided, first attempted cannulation, watched her, she got her rectal endomethysin, she got her two liters of fluids after the procedure. And unfortunately, even after being fine in recovery, tolerating her liquids, she came back in the evening. So, and you know, and this is one of the complications I feel is very humbling because as I said, once it sets in, the course can be very unpredictable. So you have to do your due diligence and all the things that Dr. Maranki in our slide says in terms of best practices and minimize the risk as far as possible and hope for the best. Great question for the panel before we move on. It's much more rare, but have you seen cases of pancreatitis post another advanced procedure like an EUS with the pancreatic biopsy and would you manage that any differently? I think we have seen it a couple of times here and there. Yes, it can happen. Pancreatitis is one of the complications that we discussed with the patient during the informed consent, especially if you're doing FNA or FNB softer pancreas, you know, we estimate risk to be one in a hundred. And I think as Shivangi alluded to and Jen, we handle our EUS, especially if I'm planning on an intervention, same as ERCP, load them up with the fluid. And I personally actually, if I give them endomethysin, not everybody gets it. You know, if you feel like the mass was deeper in the uncinate, you may or may not have been closer to one of the side branches or PD, et cetera. So there's no data to support this, but I do that. And most important is the fluids in those patients. Yeah, I think it's very important as Dr. Berzin is going to, I'm sure get into to consent these patients, right? So, you know, even with my ERCP consent, I kind of use a baseline of around 7% for all comers, but it, you know, it can be as high as 30%, you know, or more depending on the situation. And so it's very important that patients are aware of what that risk is and that you inform them that you're doing everything to try to mitigate that risk. In terms of EUS, I also quote about a 1% risk of getting pancreatitis after an FNA. And I think a couple of points I would like to make with the previous cases, you know, like cholangioscopy, we know that the risk of pancreatitis is probably slightly higher because you are using this 10 French accessory and you are sitting at the papilla probably for such a long time to get the stones out and doing lithotripsy, et cetera. So be mindful of that. And finally, I think if you're using a wire to cannulate the bile duct and if the wire gets into PD, even if you didn't inject contrast, I personally always, always leave a stent in. I don't pull the wire out and try to redirect because pathophysiology of pancreatitis is still a mystery and enigma. The patient may or may not be on the checklist of the procedure or patient-related risk factors, but all of us who've been doing this for years come across patients who we thought were low risk and they end up getting pancreatitis. So if you get into the PD with a wire, always utilize that opportunity to leave a stent in. That's a great point, Praveen. And even coming to the informed consent part of it, that is exactly what I told the patient is you're risking pancreatitis versus any surgical complication. And when your surgeon says, try this first, they really don't wanna go in. And it was a discussion with the family as well. So you wanna document the discussions, and especially if you're doing something out of the normal ballpark and trying to help the patient. Over to you, Tyler. All right. So I'm glad we're talking about informed consent because I think this is a technical skill that in a procedural field is frankly more important than some of the hands-on skills that we learn in the endoscopy suite. And I think this case hopefully demonstrates some of those points. So this is an 82-year-old male who is in generally good health. He had a three-year history of dysphagia. He had a workup by one of our close colleagues in GI, including an endoscopy, manometry, barium study, all very compatible with type 2A kalasia. Next slide. And his case was formally reviewed at our motility conference. Our advanced team is part of that motility conference. Several different options were discussed. His gastroenterologist ultimately discussed the advantages of all these various options. And in the end, the patient preferred to move on with an isofliptidylation. I had not met the patient. He was offered a clinic visit with me, but he preferred in this case, because of the distance traveled, which was about two hours, to just go ahead and directly book the procedure. So he arrived to us and we went through the consent. And so the first poll question is, he arrived alone. This was actually towards the beginning of COVID. So the patient or the family were out in the waiting room somewhere, or maybe in the car. So if they're not present during the advanced endoscopy consent process, I'm interested in everybody's approach. Do you typically ask the patient that we should reach out to them? Do you wait for the patient to ask? Are there only very specific high-risk scenarios where you do that? Actually really interested in the poll responses here for everybody. So only when the patient is not consentable or specifically requests a family call. And then some offer in every opportunity. So actually, before I move on, I would love to hear Shivangi Praveen, sort of how you think about this for high-risk procedures. So I prefer to always ask like, who is involved in their care? So if something were to happen or if there is a complication, who can I call? Who would be coming that day with them? And if, again, I think the answer is anywhere between A and B, I would feel. Like I don't ask for the family for every procedure, but sometimes if I feel like the patient is not really there for like a true informed consent for something high-risk that I'm planning, I will voluntarily ask to, like, you know, I wanna speak with your son or daughter or partner or someone, whoever's involved in their care to discuss this further. Or, you know, sometimes I've called for family meetings that before we do this, you know, let's everybody come together on the same page and see if you wanna go ahead with the intervention. And sorry to pick on you guys, but Jen, I will ask you for a patient like this, do you always, always see them in the office for a tele-visit beforehand, or might you encounter somebody like this for the first time in the endoscopy suite? No, so we have a pretty robust open access advanced endoscopy program, and it is really only functional because we have dedicated care coordinator nurses who, where we, you know, we sort of get the packet of the referral asking for a, you know, an advanced endoscopy procedure. It's reviewed by one of the six interventionalists, and we sort of go through the pertinent information, the CT scan, all their, you know, whatever outside records they have, and then make a decision about what procedure is ultimately going to be done, and, you know, how much time is needed, and what's the timeframe during, like, how soon should we do that? And then our nurses actually spend a good bit of time educating the patient and their family members over the phone so that they have some idea. We send them a lot of patient information about the procedure that they're going to have. So usually by the time they end up in the endoscopy suite, they have had some knowledge about what to expect and what the potential complications are. If they have any questions, we, you know, if they're sort of confused or not quite comfortable with things, our nurses then set them up for a clinic visit, although it does sometimes delay things a little bit. And then we, you know, for higher risk cases, ESDs, things like that that are, you know, have a potentially higher rate of complications or any kind of, you know, just more invasive things with a higher rate, a duodenal EMR, those are all going to be seen in the clinic first. So I think for the fellows listening, it's interesting to sort of think about what, where, that full spectrum of things that absolutely require a clinic visit first, things that probably never do, and sort of what, how you manage that middle ground, which I think in a lot of ways is the hardest. So this patient was evaluated, he was consented by me in the advanced endoscopy suite. His family was not present. Again, they were out in the car. He had an esophageal dilation to 30. We had an adequate post LES diameter. It was some mild mucosal trauma. On inspection afterwards, looked okay. We got him out to the recovery suite. Next slide. And in the recovery suite, he looked comfortable and he was getting ready for discharge. And then he had some clear fluids. And after about an hour, he started having escalating chest pain and rigors. So what is the next clinical step that you would choose? So repeat urgent endoscopy, gastrograph and study. I think those are actually both pretty reasonable answers. We are certainly, I think everybody is concerned about the possibility of acute perforation. And again, we're getting to the point where acute perforations, we can probably manage acutely, just going back endoscopically. We did not do that. And we ultimately got a gastrograph and study, if we go to the next slide. And in fact, it was negative for a leak. And just as a quick comment, because this comes up all the time, if there's a concern for an esophageal leak, the story in general is that it's probably reasonable to start with gastrographin because water-soluble enemas, if there's a gigantic mediastinal leak, water-soluble enemas are likely, enemas, water-soluble contrast agents are likely safer. But if the gastrographin leak is negative, is negative for leak, a barium provides more sensitivity. And if the leak, if the gastrographin study is negative, it probably means at minimum, the leak is small. And then it probably is safe to use barium because a small amount of barium in the mediastinum is probably not a high risk thing. So that's our sort of typical approach. Long and short is that this gastrograph and study was negative. I was still pretty worried. I discussed with the patient and their family that we were gonna plan to admit him, get a thoracics consult. I had a continued concern for perforation. We actually ended up getting a CT scan with barium. And on the next slide, you'll see that there was a contrast in air adjacent to the distal esophagus tracking into the mediastinum. He actually looked quite a lot clinically worse even as we were getting the CT scan. And he went to the OR actually that evening for a left thoracotomy, a primary repair. They did a little bit of more of an extended myotomy just to make a hundred percent sure he wasn't gonna come back with achalasia symptoms. He ended up staying in the hospital for about a week, did well, but what I really thought about is the next morning I met with the family and that was my first time meeting with them. I had discussed with them over the phone what was going on in the evening, but they asked me what went wrong. He had had four prior endoscopies without any problem and why would this one be different? So if you go to the next slide, I think that this really made me think a lot about, I think we adequately consented the patient. I absolutely explained to him the perforation risks, but he had four family members waiting outside in a car who really, really, really thought he was having just a regular endoscopy. And navigating that successfully and developing any level of trust with the family when they walk in with that expectation and this outcome is a really tricky thing to navigate. I think that all of those processes of dealing with complications are much more easily navigated if there is already a thread of understanding, connection, communication with the family to start with. And so this type of case makes me more and more apt to say, hey, this is a really complicated procedure. My norm is to have family, partner, friends listen in. Is that something you would be comfortable with or do you not prefer that? So I actually generally start with that as the norm nowadays for higher risk procedures, ultimately always still giving the choice to patients, but I'm really interested how the other panelists handle these types of things. I think you bring up several good points, Tyler. I think in our center, our practices, if we are doing some high risk outpatient procedures, I personally meet with them in the clinic either virtually or in person, go over everything. And when it's virtual, most of the times family member is available. And if it's an inpatient patient is admitted to the hospital and they come down on their own, oftentimes patients' family member are down by their side. If not, they're volunteered to have us call them and be on the phone call. So especially for high risk procedure, yes, I think a clinic visit is absolutely mandatory to establish that kind of a relationship and to discuss the risks and benefits. And one additional point I would like to make is, not only before the procedure, during the procedure, I think it's very important when the patient is admitted to the hospital after complication that you go in and personally visit them as long as they are in the hospital till they get discharged. Yes, it's very uncomfortable visit, but I think it goes a long way when you show up there and tell them that you are there with them and explain to them or iron out any concerns or questions they have. Yeah, great, great points. And I totally agree. I think a lot of lawsuits, if you look, are not because a complication happened, it's because the patient feels abandoned after the complication if you don't follow through and see them through and make the patient feel like they're still cared for and that you're still vested in their care, even though some unexpected and unexpected or a complication occurred with the procedure. We'll go to Dr. Chahal for cognitive ERCP. Quick interruption. There was a question in the chat just about, there is a mention of a standard protocol that some institutions have for a CT chest to rule out a perforation or particularly with the gastrographin protocol. I was wondering if anyone could speak to that. If everyone has that or if it's a patient level decision about what to use. Yeah, and our center is mainly patient level, what you did and what you're expecting in a patient. We don't have any CT protocol for perforation. Thank you. All right, Praveen. All right. So, I think the take home point from this case is, all of us when we are performing these kinds of procedure, and especially people who are going into advanced endoscopy in their third year or fourth year, everybody is just so caught up in learning how to cannulate. We forget about the cognitive part of the ERCP, which in my mind is extremely important. In fact, more important. Everybody knows how to do ERCP by the end of the year. So, it's when to do, how to do, what to do is I think more important. So, I'll share this case with you guys. This was a 56 year old man who presented with painless jaundice, and he had a CT scan done at outside institution. They found a pancreatic mass, no additional information was available. And at the local institution, he underwent endoscopic ultrasound guided biopsy, which confirmed adenocarcinoma. And in the same session went ERCP and they placed a plastic biliary stent. The note said that there was a distal biliary stricture. So, patients subsequently three weeks later had a CT scan done for staging purposes, a repeat at our institution, chest and abdomen. And at the same time, he was seen by oncologist and they repeated some basic labs and they found that his LFDs were worsening. So, this is the CT scan that was found. You see the coronal image on the left of the screen and axial on the right. LFDs are worsening, otherwise patient is asymptomatic. So, I would love to ask the panelists, what are some of the thoughts that would be going through your mind? What would you like to know about this patient? And if you embark on ERCP, would you have an algorithm in your mind and how you would tackle this case? Well, it looks like the stent has migrated proximally. And so, I would imagine a pancreatic mass is going to cause generally a distal biliary stricture. So, things kind of watermelon seeded in the wrong direction. And so, typically I would, I guess, manage this by doing an ERCP. I would, you know, kind of re-cannulate the biliary tree. I would need to potentially dilate that inter-pancreatic portion of the bile duct to kind of open it up a little bit. And then there's a number of things that we can try to do. If I can get a wire through that stent, then I can use a Sohendra stent retriever and try to screw into that to try to capture the stent that way. And then, you know, I may need to grab it with a rat tooth forceps that are fluoroscopically directed. I can't see how long that stent was initially placed. Generally, a pancreatic duct stent that gets a plastic stent or a pancreatic, I'm sorry, common bile duct that's stented for a pancreatic tumor is not generally going to be a very long stent. So I'm worried that it's a short stent that migrated all the way up. And I'm wondering if this is going to be achievable through a trans-papillary route. So you bring up several good points, Jen. I think the most important thing in this patient is you notice the stent is abutting the liver capsule. So, and plus this patient has biliary stricture. So can we move on to the next slide, please? So this is a, you know, one of the devices that Jen mentioned. So this is a question for the audience. Which of the following tools can be used for removal of migrated biliary stent? Grasping device near Sohendra stent retriever, dilating balloon or occlusion balloon, or cholangioscopy assisted stent removal. Probably as we're thinking about the options, was this patient, I didn't catch the stage. I didn't see any metastatic disease. Are they a candidate for upfront resection? So we don't have to do any of this? Yeah, so that was my next question for the panelists and audience. When you are planning any kind of an intervention or procedure, what are the questions that you would like to ask or know about this patient? Is this resectable? Is this unresectable? So how does that make a difference for you, Tyler? Well, even though the threshold for neoadjuvant chemotherapy has gotten earlier and earlier and earlier to the point that maybe it should always be given, this particular case may be an exception because the reality is getting a stent that high up in the liver out and through a potentially extremely tight stricture is just a lot of intense endoscopic work that could be made quite a lot simpler if the stricture is removed surgically and the stent can be dealt with in a variety of ways. So I think the role for neoadjuvant might need to be really seriously thought here for the patient and maybe just straight to surgery, Whipple, and then we sort of figure out the stent with the surgeons. Yes, so great point. And this patient was unresectable. And so now you, and most coming back to the question, most everybody answered it correctly. So you have different tools in your toolbox that you can use. And somebody who is unresectable, you are obligated to palliate their jaundice. So when we deal with a migrated biliary stent, you can use any number of devices. And as Jen mentioned, started with ERCP and this is what you see. So in the cholangiogram, you see the stent, I think it was a 1010. It is the proximal end as we saw was near the liver capsule. Distal end is sitting in the common hepatic region. Not only one, this patient has two strictures. So there is stricture extending right to the bifurcation, the common hepatic region, and then there is this tight distal biliary stricture. So now you have to tackle these two different scenarios in this patient. Now this is where the cognitive part of the ERCP arise. And you notice the wire is into the right anterior system. Can we use any number of these devices for migrated biliary stent? Absolutely. But in this case, I think you have to be careful in advancing any accessory. If the stent is not such close to capsule, we can advance the wire, try to get the wire in the stent miraculously and you can advance a four millimeter dilating balloon inside, dilate the balloon and try to pull it out. But since this is so close to capsule, even a centimeter of pushing it up, now you're risking a major catastrophe in a patient. Similarly, advancing a raptor device or a snare, which are not wire guided across these two stricture would be extremely difficult. So hand through a stent retriever for the same reason, pushing it upstream, going with the occlusion balloon or dilating balloon next to the stent, inflating this dilating balloon next to the stent and pulling it down again carries a risk of further capsule injury. So can we move on to the next slide? So what I did was what Jen mentioned, we balloon dilated the stricture, both of them dilated it to six millimeter. Again, you're careful in choosing the size of the balloon dilation based on the duct size. As you notice, it was a small duct above the stricture and high grade stricture, six millimeter, both the top and the bottom stricture. You can tell this is a high grade stricture because the waste is not effacing. This is fully inflated balloon. Next slide, please. So both the strictures, as you notice, the balloon is not effacing, which goes in with the severity of the stricture. And then finally, would anybody care to guess how we would retrieve? And the answer is there. So I think what I felt was, this is where you need to think it through the procedure. I felt the safest was balloon dilate and go in with direct cholangioscopy. Fortunately, we were able to dilate it enough where we were able to advance the cholangioscope over the wire. Next slide, please. So initially I tried to grasp the flap. As you see, the stent is nicely embedded above the stricture and the flap is visible. I tried to grasp the flap with this small snare, mini snare that goes to the cholangioscope. That was unsuccessful. And then finally we advanced those micro forceps through the cholangioscope and under direct cholangioscopic guidance, we were gently able to pull it out. Question for the panelists. Now that you have pulled the stent out, it's across the stricture, would you remove it and put a new stent in, metal stent in? What would be your thoughts? This is three week old stent. It's 10 French. So I would, you don't have huge ducts to deal with. So, and you have two separate strictures to deal. So I'd have to look back at the cholangiogram to see if a fully covered, maybe an eight millimeter fully, I'm sorry, uncovered metal stent is appropriate. I'd be a little bit hesitant to put in a bigger stent given the size of the ducts. But ideally, for this unresectable patient with pancreatic cancer, a metal stent would be better to minimize the need for additional procedures. I agree. Any other thoughts, Tyler? Yeah, that's probably what I would do as well. If I did not do that, then I might think about doing a double pigtail just so that it wasn't gonna slip one way or the other until the dust settled. So, I mean, this, yeah, it's in, this is where you see how people can approach the same scenario in different ways. So this was palliative patient had unresectable cancer. And this was a 10 French stent, three weeks old. I chose to reposition and leave it alone. Patient did well for three months, brought him back, and then he just needed another stent exchange and unfortunately passed away after that. So in hindsight, anything was different why it migrated so proximally? Usually, like Jen said earlier, shorter stents have a higher tendency to migrate. For a 10, tend to migrate this high into the liver. Yes, extremely unique. It's hard to come up. I looked at the first ERCP pictures. The stent was appropriately positioned. The flap was outside the orifice. So, yes, it's difficult to nail down what led to the migration. I have seen stents actually within past three months. I've had one patient come back with a delayed capsular perforation that ended up with major bleed, body peritonitis requiring surgery, which was almost eight weeks after the stent was placed with the interim CT scan, which showed the stent was in the position. So, yeah, it's unclear how they gained legs and start moving upwards. I don't have an answer for that. Right, and I think that's where we said, plastic stents are not that benign. I mean, they can cause really bad things by proximal or distal migration. So, we'll wrap up our session here. And the take-home points are, you know, understand that all these complications are inherent to what we do. Make sure you have an appropriate indication for doing the procedure. Have a good, detailed, informed consent. Discuss the alternatives with the patient and family or the identification is key. Make sure there is an appropriate infrastructure, resources, backup, whether it's IR or surgery. Monitor the patients closely. You saw how many cases were picked up in the recovery room. Have a low threshold to keep the patient overnight if you have to get the next imaging. But you wanna make sure you identify the complication early and do what's right for the patient. Keep your cool, work as a team with your unit. And the main thing is learn from the event. And Amulya, over to you. Thank you so much, everyone. I know that, Dr. Moranke, thank you. You already answered some questions specifically in the chat and in the Q&A. So, if anyone else has any questions, please send them over. I think we had one that was mentioning that they had a case of an uncovered metal stent that migrated above a malignant stricture immediately upon placing. So, they tried to pull that down with a balloon, but were unsuccessful. So, if anyone has any tips on what to do in that kind of a situation? Yeah, I think if it's just freshly deployed stent, it's above the stricture, same thing. You can balloon dial it. And I think flangioscopy guided grasping it with this, it's uncovered, so it's easy to grasp and pulling it down would be your best bet. If the, since this is uncovered, even if it's across the bifurcation, you haven't burnt any bridges, you can put another stent in the area of the stricture and call it a day. So, I think both the options would be okay in that case. Thank you. While we're waiting to see if any other questions come through, just kind of going back to some of the polypectomy discussions that we were having. One of the other questions we had is, obviously, we're all going to be, as we start our careers, we're going to be scoping at different centers. And is there a size threshold if you're doing a screening colonoscopy and you're doing it at an ambulatory center of a polyp that you would encounter that maybe you would hold on resecting and bringing someone back for the kinds of decisions we're trying to learn how to make now independently? It's a good question. I, so this comes up fairly regularly with us because we have an ASC that we scope at across the street, which is for routine EGDs and colonoscopies. And many of us are comfortable doing endoscopic mucosal resection. And so we've modified our standard consent form so that even for a screening colonoscopy, we have components of EMR in there as well. So we can, they are consented for an EMR and we kind of incorporate that into our spiel so that if we do find one, we're able to remove it. That said, I would say for the vast majority of, you know, lesions that we come across that are bigger than standard polypectomy, you know, a 15 millimeter sessile serrated polyp or a two centimeter one, there's a couple of factors that are involved. Number one is, you know, the schedule, right? So, you know, typically, you know, at an ASC, things are built to move efficiently and you have a time slot. And if you're already running behind, you may not want to embark upon or have the, really the time to embark upon an EMR that may take a little bit longer. So for our EMRs that are referred to us, those are in 60 minute time slots, whereas the colonoscopies at our ASCs are 30 minutes. So number one is, do you have the time? Number two is, do you have the expertise, right? So do you feel confident doing it? You know, the ASC is probably not the time to really like kind of stretch your wings. You want to be doing that more at the hospital where you have a little bit more backup, maybe a senior partner in case you get into trouble, things like that. At the university center, our nurses are more in-depthly trained and experienced in complex endoscopy and EMR. So we have a variety of snares. We have a variety of, you know, tools for treating bleeding and things like that. And that's not always available at an ASC. Typically there's like one or two snares that we use. You know, there's, you know, a couple of different things. And a lot of times, you know, the staff is not trained to do them or to deal with the complications. And so you sort of have to assess your room and be like, all right, like, are we doing this? Is everybody comfortable with this? Do we have what we need? Or is this patient really better served coming back, having a discussion and set up for a formal EMR? I think great points, Jen. I think if somebody is looking for size of the polyp that they are able to tackle at ASC, I would say, you know, anything less than two centimeter probably. But then again, if you're dealing with the pedunculated polyp with a thick stop, you really have to be cautious because those are the ones that can bleed if you haven't done a proper resection or secured the stop adequately. But the key is, I think, again, doing these kinds of polyp resections, EMRs in a more secure setting where you have a backup, you have a trained techs available. And if something were to go awry like perforations or bleeding, you are able to handle those with assistance. Thank you so much, Jen. Thank you so much. It's very helpful. And I think we also talked a little bit about using hot coagulation forceps. Are there any specific risks associated with that? I feel like we don't talk about that as much generally. And there's a risk of deep muscle injury, but I don't honestly think it's any higher than if you use a bipolar, at the site of an EMR. I think it's actually a really, really nice technique. And I think the use of coag graspers has started getting broader and broader again as sort of ESD has taken off. And I think there's just a recognition that these are really nice focus tools, potentially even for ulcer bleeding. I use it sometimes for that as well, because it's just so specific, so precise, and you can effectively get coagulation in this direction without having to do a lot of coagulation. And you can get coagulation in this direction without having to put forward pressure. So I think they're nice devices for fellows to ask about and get comfortable using, even if you're not doing ESD. Thank you. Very helpful. So I think so far, those are the questions that have come in. And I know we've had a lot of really great discussions already. Some of the take-home points that I just wanted to highlight based on this discussion, just stay calm. That's something that I know we're all working on as fellows and not be afraid to ask for help. And I know, I think all of you mentioned this as we were presenting that it's okay to back off, never push against any sort of resistance and keeping in mind that the patient's safety is always first. I think we always get a lot of questions about anticoagulation management. And we consider patients with any pre-existing anticoagulation higher risk in terms of their pleading. And so multidisciplinary management in terms of reaching out to the prescribing physician and having that discussion is very important. And I think we all have a lot of different processes for that, but just something to remember. And then absolutely the importance of involving family members in the consent process, particularly with a complex procedure and consideration of adding on an office visit, definitely something to think about going forward. And then identifying complications early, as we said, there were many cases that we identified right in the recovery room or in the procedure itself. So I think that leads to better management overall. But despite all of this, GI is still a lot of fun. I hope we all feel that way still, including everyone that's listening. So I wanted to thank all of our wonderful panelists for such a great discussion and all of these really informative cases. This is all very helpful. Thank you so much. Thank you. Thanks for having us. Thanks, Emilia. Thank you. Thank you again to our moderator and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure you check out our upcoming educational events. Registration will be open. And these programs are available complimentary to ASG training members. Visit the ASG website to register. The next ASG Endo Hangout session will take place on Thursday, October 6th from 7 p.m. Central Time on Endoscopic Evaluation and Management of Anorectal Diseases. Registration will open next week. At the conclusion of this course, you will receive a short survey and we would appreciate your feedback. As a final reminder, ASG membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to make sure to sign up. In closing, thank you again to everyone for this excellent presentation. And thank you to our audience for making this session interactive. We hope this information has been useful to you and with that, I will conclude our presentation. Have a good night. Thank you.

endoscopy procedures

complications

risk assessment

patient safety

cardiopulmonary events

bleeding

perforation

post-ERCP pancreatitis

patient selection

sedation techniques

hemostatic modalities

endoscopic interventions

careful monitoring