Okay, all right, can everybody hear me okay? Great, so thank you for joining this breakout session. I was, I have no relevant disclosures for this talk. I was asked to speak about surgically altered anatomy and what kind of endoscopy and therapeutics you would do in these cases. And I think it's really, you know, I appreciate the course director's invitation because really we're seeing so many more patients who have had bariatric surgery, cancer-related surgery, transplant. And so as endoscopists, we're more and more frequently scoping patients who have had surgery. And there's a lot of challenges that come up. There's conventional landmarks are gone, right? So you're really having to understand the anastomosis, how to access the excluded or afferent limb, specific scopes, lengths, angulation issues, and equipment limitations. So just for this audience, I just wanted to get a show of hands. How many people in the room do ERCP? Oh, a pretty high majority, okay. All right, well, we're gonna cover sort of all types of altered anatomy for all gastroenterologists. So we'll first start with a review of the esophagogastric altered anatomy. We'll talk about post-bariatric, pancreaticobiliary, and colorectal. And again, for most of the post-grad course, things are really heavy data-driven. This is the lunch session. My goal is to do sort of an anatomy review and to give you some tips, some pearls, some pitfalls, and just go through some cases and share experience. So the most important thing to do, obviously, when you're starting these cases, is really to understand before you go into the case what you're dealing with. So anytime you have an opportunity to review the operative note, to review any of the imaging in advance, and if you don't have an operative note and you don't have any updated imaging, it can be helpful to get this upfront. For example, like an upper GI series before doing a case if you really don't know what surgery they had 15 years ago. Choosing your scopes wisely, making sure that you have backup options in the room or outside the room, specific devices and accessories available that'll be specific for this patient's anatomy. And really, team coordination, right? Especially in these post-surgical cases, we're dealing more and more with our colleagues in surgery, interventional radiology, urology, ENT, whatever it may be. So for esophageal surgery, there's two things to usually keep in mind. There's typically some sort of a resection or esophagectomy and then a reconstruction. And again, this is just a review of what you would want to think about for the patient's prior history of esophageal surgery. So what was the indication and what was the reconstruction? So a typical case is post-esophagectomy endoscopic surveillance. So you had a patient who had a Barrett's-related cancer. Typically an esophageal adenocarcinoma would be a distal, so you're anticipating that they would have a distal esophagectomy or an Iver-Lewis. And so when you go in to do your routine endoscopy, you should see the esophagogastric anastomosis in the thoracic esophagus. So in this case, it was at 26 centimeters. Things that you'll want to talk about are the patency. So this is a wide open anastomosis. There's no inflammation. This looks healthy. There's maybe some suture material at the two o'clock position. But this overall looks good. And then if you go right below this, you're in the stomach, right? So this is a gastric pull-up. And so you're gonna see the gastric fold starting from 26 centimeters. And this case, actually, a colleague asked me if I thought that this was recurrent Barrett's. Anybody in the audience think that this looks like there would be concern in a patient with prior Barrett's and cancer? Show of hands, anybody worried? No, maybe some worried. Yeah, and I think it was a reasonable question. To me, this probably just is the neo-squamo-columnar junction but it was reasonable, it was biopsied, but I'm not very concerned about that. So in contrast, if somebody has a more proximal squamous cell carcinoma, you would anticipate that they would have a cervical anastomosis. So this would be much higher up, 19 centimeters. And obviously, this looks very different. It's a little bit narrowed. This patient has had multiple prior dilations. It's ulcerated, a little bit less healthy. So these are the post-esophagectomy endoscopic surveillance things to make sure that you're putting in your note is the characterizing the anastomosis as well as the location. Some of the other things besides surveillance post-malignancy, so post-esophagectomy, you may be asked to treat anastomotic leaks. I should mention actually up front, so this talk is not going to be covering endoscopic management of acute surgical complications. So I'm not gonna be talking about all the stents and endoscopic vacuum therapy and things that you would do right after surgery. This is more about what you would see or need to think about when you're scoping your routine patients. But certainly when you have anastomotic leaks that can predispose to strictures, I just included two studies here because I think there's pretty strong data that not everywhere in the GI tract, but particularly for anastomotic strictures, up front with your dilation to also include a steroid injection. Certainly these patients get reflux and bile esophagitis, regurgitation. This can be a big issue for them long term. So acid suppression therapy, positional changes, and then if they haven't had a pylori myotomy at the time of the surgery, or if for whatever reason they had their esophagectomy a long time ago and now they're having ongoing, consider additional therapy or a G-POM. So the other thing besides the indication and the location of the anastomosis to know is what was the reconstruction. So typically the gastric conduit is used, assuming it's healthy and well vascularized, and the stomach is sort of pulled up into either the thoracic or cervical anastomosis, but certainly there's other cases. Just a few months ago I was asked to do a colonoscopy for an elderly patient with end-stage achalasia because the surgeons were anticipating that they may need to use the colon as a conduit. So an inner position where they are able to maintain the vascular supply to the colon can also be used. Sort of silly little things to remember, but of course the colon can have polyps no matter where it is, so you would obviously have to continue with surveillance in those cases. So those are more of your malignancy-related esophageal surgeries, but probably more commonly what we're dealing with is benign anti-reflex surgery. So I think we are probably, we could all do better at sort of evaluating the anatomy of the gastroesophageal flap valve pre- and post-surgery. So I'm gonna show you some what it should look like and what things look like when they go wrong. So surgical fundoplication, we also have an endoscopic fundoplication, or TIF, transoral incisionless, as well as magnetic sphincter augmentation. So a surgical Nissen fundoplication is a 360 degree wrap. And so on retroflex view, what you're seeing here is sort of the stacked coils appearance. You should see that white line is really depicting that the gastric fold should be perpendicular to the scope. And then you can see in the posterior, don't believe I have a pointer. Oh, maybe I do. You have the posterior and the anterior groove. The posterior groove is gonna be much tighter, okay? So your next fundoplication, surgical, would be a partial, or 270 degree posterior. This is really that omega-shaped, the lip from this valve. And you can see that the anterior and the posterior are both a little bit looser. And then the door fundoplication, or an anterior fundoplication, is a partial, 180 degree wrap. And the lip of the valve is much wider, sort of S-shape. And you can see that there's really no posterior groove. Over here, there's really no posterior groove. And so, this is what they should look like normally. And we should be reporting on this after they've had these operations. But sometimes things go wrong. So, if you have a patient who comes in post-NISN with dysphagia and food impactions. So what are the things that are already going through your mind before you're putting the scope down? So in this case, the fundo actually looks quite intact. It looks good. Maybe it's a little bit long. But it definitely is intact. But it's probably too tight or too long. And that's because if you look at the barium esophagram, you're not really seeing any emptying. There's tight EGJ at the level of the diaphragm. And then if you look on, this was a nice depiction on manometry as well as on endoflip, that this is really showing you that there's a high interbolus pressure that's compartmentalized at that area between the contraction and the wrap. And this is associated with a high integrated relaxation pressure. So flip is sort of demonstrating the same exact thing. And so this patient may be having food impactions due to having a tight, long wrap. So although the wrap is intact, it can be too tight. And this can also be due to too tight of a crural repair. So we don't get that as often. If you do, you can try dilation. Occasionally, they will need to loosen the hernia repair. But most of the time, what we're dealing with is the disruptions of the fundoplication. So again, just pattern recognition and starting to get better at understanding. So in the first picture, this is a disrupted wrap. So what you're seeing is that the gastric folds are actually more parallel to the endoscope. And again, after a fundo, what you're supposed to see is that they're sort of perpendicular. So this is basically disrupted. In the second one, you still see that there's a bit of a wrap. It's intact, but the diaphragmatic repair is disrupted. And so now you're getting that parasophageal hernia component. In C, you're basically seeing a huge hernia recurrence. I don't think there's really much of a wrap remaining. So this is a case of a patient who has similar symptoms, but the difference is that not just food impactions or dysphagia, but they're also having recurrent reflux. So if you scope this patient, what you're seeing here is grade B esophagitis. And you're seeing that there's herniation. So the wrap is actually intact, at least partially intact, but the stomach has herniated above it. And so that's what's causing the patient to have dysphagia. It's above the diaphragm. So on this image of the esophagram, you can see that and appreciate that, and as well on manometry. So this is a, sorry, so this is a slipped nissen, very common. And the problem here is that they do tend to get recurrent reflux, even though the wrap is intact. This can often happen from a hiatal hernia recurrence. So more pattern recognition, and I'm just gonna go quickly through these, which is, so we talked about the disrupted fundoplication, where the fold does not involve the endoscope. This is a twisted. You can sort of see those oblique gastric folds that aren't parallel. Herniated and slipped just has to do with if the stomach is herniating up or if the fundo has slipped down, and then a parasophageal hernia. And I think this is all very important because whenever you have a patient post-antireflux surgery who's having recurrent symptoms, even if you're gonna repeat your pH testing and send them for recurrent surgery, it's important to understand what exactly is the problem. If the hernia repair is intact, but they just need tightening up of the fundoplication, it's a very different operation than repairing the hernia. So I'll move into the endoscopic version, transoral incisionless fundoplication. So this is what TIF looks like. So this is a normal sort of hill valve three, open GEJ. This is the esophagus device that you use to create these plications in the esophagus, and you recreate the gastroesophageal flap valve. These are what those little fasteners look like. We also have the ability to now do TIF with a hiatal hernia repair, or so-called C-TIF. So the surgeon will do the hernia repair, whatever they need to do, put in the mesh, put in the sutures, and then same session, you can then proceed with your TIF. You can see that even the endoscopic view pre-hernia repair to post-hernia repair is quite different. So even just from tightening up that hernia, you're seeing that now it's like a hill valve grade one, and so you are seeing that the mucosa is snug around the scope, but still there's no wrap. And so then once you do the TIF, it looks like sort of mirroring a partial fundoplication. Just a few pictures to demonstrate that this is durable, and so if you're scoping a patient who's had a prior TIF or C-TIF, you'll probably see these fasteners, polypropylene fasteners that will remain in the esophagus forward and retroflex view, even up to like five years. And then the last anti-reflex surgery is magnetic sphincter augmentation. This is an intraoperative view, this sort of band of beads that's placed around. They're sized correctly for the patient. And what could go wrong, and what might you be asked to deal with as an endoscopist? Well, this was a really great case of an eroded lynx through the distal esophagus. And so somebody who's had a prior surgery, I think many of us have experienced going into a stomach, sometimes you see coils from a prior IRM bow, sometimes you see all kinds of funny things, and so just being creative about how to remove this in a way that would mean that the surgeon doesn't have to necessarily enter into the esophageal lumen, so this was a great case. I'm not gonna show the video, it's like 10 minutes long, but really clever sort of using a wire and a lithotriptor device to break the lynx device. So there's all kinds of ways that these things can be sort of removed endoscopically. Okay, we're gonna move on to gastric surgery. So for gastric surgery, we'll start by going through the anatomy. So typically with resection, whether it's for a gist or a cancer, or used to be for sort of peptic ulcer disease that was refractory, the important part is after the resection, do they reconstruct with a Biliroth I, more likely now a Biliroth II, or a Roux-en-Y? And this has obviously implications for your endoscopy. So Biliroth I, it's pretty easy, it's pretty straightforward, it's minimal impact. So you can pretty much put your scope down, the antrum has been resected, but it's been reconnected, still can get most of your EUS views, you can do an ERCP, pretty much the same. So that's what you would like to see. Biliroth II, so for EUS, you're gonna have some limited views potentially of the pancreas and liver. You know, you may be able to go down a little bit into the afferent limb, I guess it depends how necessary and important it is. Again, because you don't really wanna be putting a sort of stiff EUS scope through a difficult, angulated limb. ERCP, so ERCP is challenging, but certainly feasible. It's not the worst of the altered anatomy. The big thing to keep in mind with ERCP and a Biliroth II is that your ampulla is typically inverted, and so it's the opposite of what you might expect. So there's a few different tricks and things to do. So there's dedicated sphincter tomes that can be used. You can use a regular sphincter tome and rotate it, because basically when you're cutting, you're gonna need to be cutting sort of down instead of the typical up. And this is an example of rotating a sphincter tome and being able to cut and then do, I don't believe a dilation was done here. Dilation has a, you know, can be done as well. Sphincteroplasty, there's small risk of pancreatitis to be considered, and so typically if you can accomplish a sphincteromy, you can do your stone removal as needed. So Bruin Y reconstruction, basically this is gonna be your most challenging, and EUS is gonna be hard, and ERCP is gonna be very challenging because of the long jejunal limb. And we'll talk a little bit more about that when we get to the surgery, the bariatric surgery. So a few cases, melanoma in a prior Biloxi patient for cancer. So the first thing you're thinking, if this patient has melanoma, is what's going on at the anastomosis, and do they have recurrence? So this was what the anastomosis looks like, kind of beefy red, didn't look great. We were concerned that there might be recurrence. Actually, it came back negative for cancer. And so I think there was some hemostatic agent that was applied to this. Patient stopped bleeding, went home. Then the patient was readmitted with melanoma just a few weeks later and had ongoing anemia, a repeat scope. So here are the importance of really evaluating both limbs from your GJ anastomosis and making sure you get a really good look. So this was further in, and you can see that there's a big ulcer at the, I think at the afferent limb. The third picture is, this was really hard to treat. There's something in the center of that that needs to be treated. So we were able to retroflex, which is a little unusual, but that was really the best way to treat this. So always remember to kind of look, not just at the anastomosis, but down both limbs in these situations. And this got better on its own. These can tend to be ischemic, but they will often improve. So this is another case, an inpatient, that a patient had a subtotal gastrectomy for cancer with a Roux-en-Y reconstruction. And so a patient has nausea, vomiting, and inability to tolerate PO. So the question is why? Why are they not tolerating everything in the immediate post-op setting? And so if you think about sort of where the issue can be, that helps you guide your management. So probably the issue was, although it was not with the sort of small stomach, but basically down into the jejunum, where that green circle is at the jejunum. So this patient had a push on heroscopy. And so you can see here, this is the gastrojejunal anastomosis. It's immediate post-op, a little bit ulcerated, maybe slightly narrowed. But then they made their way all the way down to the jejunal-jejunal anastomosis. And you can see here that this is at your JJ. You're gonna have the afferent biliary limb and then the efferent alimentary tract. And this was stenosed a little bit. This picture is actually on a subsequent time, but it was initially slightly sort of narrowed. Again, probably just post-op edema. And so if your goal is to try to feed the patient, and I should say that was really the goal of looking, is how can we give this patient post-op nutrition, you're gonna need to get your feeding tube into that limb. And so that's exactly what was done. A wire was passed, followed by the feeding tube, and this patient was able to then get enteral nutrition and then leave the hospital. But sometimes you have to really go to the site to be able to understand why they're having these symptoms. Okay, we're going to move to bariatric surgery. Sleeve gastrectomy, so we can talk for hours about all the different things post-sleeve, like twisted sleeves, stenosis, sleeve leak, what kind of stents do you use? I'm going to skip over all that sort of acute surgical complications and just say that, you know, usually US and ERCP are doable and are not that affected unless you have a very, very tubularized or angulated sleeve. But I think what we see more commonly is post-bypass challenges. So typically melanoma pain, of course, you're thinking this is going to be a marginal ulcer, usually on the jejunal side. You'll give your open capsule PPI and say to stop smoking. So that might be the easiest one. This is a case that I had that was a little bit less typical in a patient post-bypass, also with melanoma. So the patient had a normal pouch, but oftentimes they can have strictures. And so, you know, there's a stricture, meaning you can only get through with an XP scope. But still there was really no blood, no fresh, no old blood. And so we did supportive care, couldn't really appreciate an ulcer. This went on for a long time, though. The patient continued to have anemia with multiple admissions and scopes, and it was a little bit unclear. So any other ideas where the bleeding could be coming from? Why a patient would continue to have melanoma? So it's not that common, but you do have to think about the excluded stomach, right, in these bypass patients. So this patient had bleeding into the excluded stomach. So if you think about how to get there, anoroscopy or retrograde is, you can't do it when there's a stricture, and you can only get an XP scope through. Potentially, could you, you know, do sort of a EUS guided intervention to reconnect? That would be an option. And actually, a subsequent CTA finally identified a splenic artery pseudoaneurysm that was bleeding into the excluded stomach. And so this patient had an IR embolization and everything resolved. So less typical things, but always to keep in mind. If you have a patient post-bypass who has nausea, vomiting, you're thinking it's an anastomotic stricture. So I think many of us start with just typical dilations, plus-minus steroid for these cases. Some of them respond quite nicely, and then you could do a few sessions, and you're done. But oftentimes, the refractory ones can be really challenging. This was a case where I think I just kept, I just kept dilating this over and over and over again. And then this time, I felt like I pushed it a little far, and I was a little bit concerned with how it looked at that bottom right corner. There was no, you know, perforation or free air or anything. I think they get, they have a lot of sort of scar tissue in the area. So thankfully, it's actually hard to perforate these, but I was getting nowhere with these. And so I've sort of moved towards doing lumen opposing metal stents earlier in these patients. I think you get better results up front if you can just tell that it's not making a difference. Try to leave it at least three months if you can, but follow up on it frequently. These can migrate, so you have to warn the patient. And I did not secure this in place. So we have marginal ulcers and anastomotic strictures, and then instead of strictures, sometimes the opposite problem can happen. So you can get weight regain or dumping syndrome from having too large of a dilated gastrointestinal anastomosis or even a GG fistula. So you want to get a really good upper GI series to rule out a fistula, and then you have two options. Basically, you have a weight loss option, which is a transoral outlet reduction or TORI, and this is a video of TORI, and these are pretty effective for these patients. They can get 10, even up to 15 percent total body weight loss. So you want to use some approach to sort of denude or deepothelialize the mucosa around the outlet. In this case, APC is probably the simplest and easiest. You can also do ESD to sort of expose the muscularis, and then once you've made that one to two centimeter ring around the gastrointestinal outlet, which in this case was at least a few centimeters, you can use suturing to create either a purse string or a zipper, and you're really just trying to bring that GJ smaller. What we do is close it over a six millimeter balloon, so that's sort of the magic number that you want to aim for, and these can stretch out again over time, but this is a pretty effective approach. If you have a GG fistula, you can even do it in the same session, and you would do something similar where I would probably ablate the surrounding mucosa and then close it either with some type of an over-the-scope clip, or you could suture it as well. And then the last one, and it sounds like a lot of people here are doing ERCP, is how do you do altered anatomy ERCP for Roux-en-Y? So there are certain Roux-en-Y cases where it's a reconstruction, but there's been a gastrectomy. So important to first ask, is there an excluded gastric remnant that can be accessed, and also what's the length of the jejunal limb? So some people have a Roux-en-Y reconstruction after transplant or in certain cases, and it might be very short. Of course in weight loss when you have an excluded remnant, this is going to be a long jejunal limb, and so that's going to be more challenging. So there's a few options. Maybe we'll have a show of hand. Who likes to do balloon enteroscopy for these patients? I didn't think so. Yeah, these are brutal. These are painful. This is a video showing the endoscope that made it all the way into retrograde into the gastrocnemius, and then you're pulling back, and you're basically seeing retrograde views of the pylorus. And then once you're there, you know, you have to figure out where's the ampulla, what devices can I use to get into the ampulla. Actually, there's been a good amount of meta-analyses since newer things like EDGE have been used more, and this is definitely the lowest technical success and also quite painful. Laparoscopic-assisted. So I think that this is a great option if the gallbladder is in place, because if they have to do surgery anyway, and the gallbladder is there, it's great. You want to make sure that the surgeon is going to give you access in sort of the right location of the stomach, so you have sort of a good angle. But keep in mind, this is surgery, so the patient has to be a candidate to have, you know, even if it's just sort of a gastric port almost. But, you know, things can happen. And then, of course, the newest, and it's not even so new anymore, would be EUS-directed transgastric ERCP or EDGE, and this is a clever way to access the excluded gastric remnant, seen here on endoscopic ultrasound. A 19-gauge needle is used to puncture the excluded gastric remnant. You can fill it up with methylene blue, contrast, and then you can deploy a lumen-opposing metal stent, first the distal phalange, into the excluded stomach, and then this, now you basically have reconnected the stomach, and you can then put your ERCP scope through the LAMs and do a ERCP, just like as if the surgeon gave you access. A few things that are still being sorted out, a one-versus-two-session approach. So an EDGE is great in somebody who sort of needs an ERCP, but they don't need it tomorrow, and you have time to do a staged procedure, staged approach. You can do part one. You should really, you could really, I shouldn't say you should, but I think there's benefit, there can be benefit in waiting at least two weeks or so. The, really, the risk would be just dislodging the lumen-opposing metal stent, so I think in people who want to do a same session, if you have jaundice, and you have to move forward, I think the best option in that case would be to secure it, probably by some sort of a suturing device. There's a question of whether or not these patients have weight regain. Basically, based on the size of the LAMs that's used, you can typically close, often they close on their own, the GG fistula, but you can also just close them with an over-the-scope clip or other approaches, and usually they're fine. So, those are all the different challenges that you might run into post Roux-en-Y, and I think that wraps up the bariatric section. So, now I'm just going to get into the pancreatic obiliary, so mostly for pancreas, we're seeing post-whipple. Some depends on your institution. Your surgeons probably have a specific way of doing, having been to several different institutions now, I really noticed that sort of where they put the anastomosis, whether they do pylorus preserving, the link between the pancreatic and hepatico-jejunostomy, and the approach is just really different depending if they're doing a robotic or not for the whipple. And then we also have hepatico-jejunostomies. Again, I'm trying to keep this sort of most common general, but obviously that we've seen all types of reconstructions, biliary reconstructions, colodoco-duodenostomy, all types of things sort of depending on the indication. This was a case of a patient who had a whipple for something pancreas related. I think it was an IPMN, not an adeno, and they were undergoing routine surveillance. One might ask, like, what are you doing on surveillance? If it's post whipple for, you know, something in the pancreas, what's the role of EGD? But in 2020, in 2022, this was normal-ish. I can't really tell, but it was reported as normal. And then in March of last year, there was noted to be a subepithelial nodule. So this was referred to me actually as a subepithelial nodule at the anastomosis. And so I think the first question is, like, where is this arising from? Is this jejunal? Is this gastric? Is it subepithelial? What is this thing? And so I looked then myself, and actually I thought it was mucosal, and I actually, it came back as a carcinoma. And it's coming right off of the anastomosis, but it's gastric. US is a little bit challenging in these cases because you just have error and artifact from the other side. It looked somewhat superficial, but you really can't tell the depth because, as you can see on those pictures, it's sort of already tangentially growing from the anastomosis. So patients who have already had post-whipple, you can imagine the surgeons weren't thrilled to operate knowing that this looks like, you know, if this was a native stomach, you may just want to try to ESD this. A little bit of a tricky location, so tried to do an EMR, came back as invasive gastric adenocarcinoma, which was helpful for a staging biopsy. And then actually on closer look, the whole stomach had intestinal metaplasia. So I just include this case for a few reasons. Number one, I think, you know, sometimes we are so focused on, okay, we're just here in a post-whipple for the pancreas, but it's still a stomach that has potential to develop malignancy the same way. And so we just have to still be very, like, mindful. I pretty much biopsy anything at an anastomosis that doesn't look pristine. And and that's what this case was. Okay, a few other typical things that are, that was a little less typical, but what's typical after a whipple? So a 67-year-old male who had a whipple for pancreas cancer, jaundice, weight loss, rising CA-99, and imaging shows a new soft tissue mass at the porta hepatis, an intrahepatic biliary dilation. So this is probably a typical consulate you might get, and this is tumor recurrence, usually. And so in these cases, you probably, you definitely, you would like to get tissue, and you probably need to decompress. So if you can accomplish it via altered anatomy ERCP, you would probably find that there's a stricture at the hepaticogenostomy. If you're able to biopsy or brush it, then you can get tissue all-in-one and stent it. Alternatively, you can consider EUS drainage or external drainage. This is a little bit of a different scenario, but this patient also had a whipple, not for a pancreas cancer, but for an ampullary adenoma. And on surveillance, because the patient had a syndrome, you can see that at the hepaticogenostomy, there is something abnormal. It does not quite look right. And so this was biopsied and confirmed to be tubular adenoma, which is a little odd because it's sort of now the jejunum in the bile duct. It's a little unusual how an ampullary tissue be there. So luckily in these post-whipple, you can often get there with a therapeutic upper scope or colonoscope, and then you can, if it's a shorter limb. And so in this case, you can see in the video that they're basically advancing to the hepaticogenostomy, to the anastomosis. And this patient's going to be under surveillance. So also something that you're hoping the surgeon takes into account before, you know, that the surgeon would know that it's a patient who might require ongoing ERCPs, and so they may help to make that limb shorter. So you can see at the hepaticogenostomy, first, that was a balloon that's going in now. Balloon dilation is performed of the stricture. I think part of this is that prior to this, because of that ampullary adenoma that had recurred, there was some intraductal RFA, which caused scarring. So now they're dilating that and then going back in. And so then you can use cholangioscopy in these cases still to really see what's happening. And actually, there's adenoma, this tissue inside the bile duct. So things like cholangioscopy and most of your tools can still be really helpful in altered anatomy. I'll show you another case of doing it for a post liver transplant stricture as well. So here's the biopsies, and this is going to confirm adenoma. What to do, this can be challenging. So intraductal RFA does have a risk of ongoing stenosis, short of recurrent resection. But it's adenoma. It's not high-grade. It's not cancer. But certainly with syndromes, you have to be mindful. In the green box, the next typical case that you might get, same exact 67-year-old post-whipple, now coming in with ongoing recurrent pancreatitis. So this is where you want to think about what's going on with not the biliary anastomosis, but with the pancreatic anastomosis. So MRCP is showing you that there's a dilated PD with recurrent pancreatitis, and so you're thinking this is probably a pancreatic jejunostomy stricture. So again, these typically can be reached. They can be dilated, stented, and managed endoscopically. Non-pancreas, but in a post-liver transplant patient who has jaundice, again, anastomotic stricture, altered anatomy ERCP. You can see this is a nice demonstration on cholangioscopy of what these strictures look like. I think many of us will dilate and try to put in a few plastic stents, depending on the location. If it's well below the hilum, occasionally you can use metal stents for these, but these are common post-transplant. And typically if somebody has it, and you think there may have been a little bit of ischemia, you may be stuck dealing with these for some time. And then other things that can happen after a Whipple. So the same patient, let's say now they're coming in with cholangitis and dilated loops of bowel. So also a recurrence, like a mass near the surgical bed, but now they're also having bowel obstruction or afferent limb syndrome. So afferent limb syndrome can also pose an issue. And so we can, these are a nice example of also sort of being clever with our luminoposing metal stents. So if you cannot reach the biliary anastomosis because it's in the obstructed small intestine, in this example, we put a luminoposing metal stent into the dilated afferent limb. And then using rendezvous, we're able to do a ERCP. Ultimately, the patient will then have the luminoposing metal stent from the small intestine, as well as the two metal biliary stents. Okay. Lower GI tract. I'm not doing much on the lower GI tract because there's not as much that's relevant post-op, and but I think there's just a few basic things to keep in mind. This was the case that I got called in literally just like two weeks ago that the fellow was scoping and couldn't find the lumen. And they kept saying like, it's blind, it's blind, both limbs are blind. And everybody in the room, no one could figure it out. And it's true, both of these limbs are blind. And so it's just important to look at the op notes, know what an end-to-side might look like, and to understand that there might be a third option somewhere, and that it might be angulated and behind you and up to the right or whatnot. So that just happened. And then finally, this is a case that can be after a ileal pouch So if a patient presents with acute onset pain, vomiting, this is your classic swirling of the medicinetary. If you do your pouchoscopy, this is where you're going to be having a volvulus of the pouch. So this would be an emergency. This is when you're going to get in in the middle of the night, and these are nice images of what this might look like. Otherwise, I think in the lower colon, a lot of the principles are the same in terms of anastomosis and using your dilation techniques, including steroids, needle knife, all the typical things. So takeaways. So in endoscopy and surgically altered anatomy, always look at your records, always review the anatomy, think about your imaging, be clever, use novel devices. I think so much of what's being done now is really based on innovation and using tools to access excluded limbs. Collaboration is important. I didn't go through some of the cases, but oftentimes if you need to do something like cholangioscopy or certain things in the bile duct, you can get access externally from IR. And so there's a lot of collaboration, I think, that's important here. Ongoing innovation. So what does the future hold? So potentially AI navigation, personalized planning with 3D reconstructions in advance of doing these cases, robotic platforms to help us in endoscopy will hopefully help and change what we do. And I think these are scenarios where sometimes we just see the tree when we're thinking of, you know, a specific post-surgical case. But really it's about thinking about sort of the bigger picture and where is the rest of the GI tract and what isn't in continuity that can be brought in and how can we sort of accomplish the goal and also continue to do routine surveillance for all of the rest of the GI tract that is in continuity. And that's it. And thanks. I had some colleagues and friends who gave me some great cases as well.

endoscopies

surgically altered anatomy

bariatric surgery

therapeutic procedures

anastomoses

endoscopic innovations

interdepartmental collaboration

AI navigation