This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Again, perforation, you know, it sort of depends. There's different types and sort of how these are managed. Sidewire or instrument perforation can occur in the bile duct, the pancreatic duct. It's typically induced by, you know, the wire sort of scooting out of the bile duct or the pancreatic duct. Oftentimes these can be managed with stents, especially in the bile duct, if you're aware of that when it occurs. There's sphincterotomy-related perforation, which is typically retroperitoneal. It's usually at the apex of the sphincterotomy, usually by the sphincterotome, but can be due to accessories post-sphincterotomy. And then there's duodenal perforation that is usually caused by the endoscope, and that's usually intraperitoneal. So luckily they're pretty rare. You know, the important thing is, again, is to try to get up into the duct if you think that you're outside the duct and put a stent in. These can occur with stricture dilation. Again, picking a balloon that maybe is a little bit too big, you've got to think about that. You can cause a perforation there if you use really stiff guide wires, which I tend to not use in the biliary tree. Sphincterotomy perforation is pretty uncommon. And, you know, the one time that I had it with the sphincterotomy, it was a biliroth 2, and I was in there, and in the heat of the moment, I kind of forgot that I was in a biliroth 2 anatomy, and I cut the wrong way. So I realized it after I did it, and I put a stent in, and the patient had a small fluid collection in that area, but because of the stent kept NPO and antibiotics, the patient did well and did fine, and I never did that again. So patients can also have duodenal strictures that you may want to try to dilate. I would caution against dilating strictures due to malignancy just to get in and stent an obstructed duct. I don't think that is wise. That is nothing that's ever going to heal, no matter what kind of thing you try to put a stent in or overstitch or whatever, you're going to be in big trouble, and I would not recommend that. You know, you want to think in those times about EUS guided rendezvous or stenting through the duodenal bulb or something like that. With regards to perforation, again, with a guide wire, you know, you may go outside the duct, and you realize as you're injecting that it is not really looking particularly ductile. So you realize, and this can happen with tumors, so, you know, the guide wire can go kind of cattywampus, and next thing you know, you're in the wrong place. So you want to make sure your guide wire is in the duct and put a stent in, and just make sure that you're in the duct that you know you're in, that you're not in a pancreatic duct and out a side branch and up into the peritoneum. You don't want to stent something you think you're in the duct and it's not clear, and then you stented the peritoneum, you're going to be in big trouble. Give antibiotics, make the patient NPO, and call your surgeons who you trust, who will follow along with you and make decisions together, because that's, I think, really, really important. Because a lot of these can be managed expectantly and with supportive care. Sphincterotomy, perforation, again, you know, be aware that these things can happen. And if you see it, you want to try again, get the guide wire across, work really hard to do it, because you can fix this if you put a stent in. You can put in a plastic stent, or you can put in fully covered metal stents. That can help, you know, with tamping on, sort of sealing the perforation. Be a little bit careful if they have a gallbladder. You could try and get a transistic gallbladder stent. That may be challenging in the setting of the sweat that is pouring down your face as you're trying to stent your perforation. You want to admit for observation. I think it's reasonable to just put a plastic stent in or put a short, fully covered metal stent in. Even if you did it short-term, you may be okay if the patient has a gallbladder. Admit for observation and keep the patient NPO. Again, IV antibiotics, surgical consult, and, you know, watch these patients, see how they do. Duodenal perforation, most of the time, oftentimes requires, well, I shouldn't say that, can require surgical intervention. We have new devices. We have over-the-scope clips. We have endoscopic clips, which may work with very small defects. If the whole scope went in, that's probably not going to work. We also have endoscopic suturing. And, you know, at our institution, I have not done much endoscopic suturing, but I have surgeons who do. So we oftentimes will call them, and they can come and stitch it up, which is a really nice thing to have. You can also put covered stents in, but that's a little challenging, depending upon where your perforation is. If it's in the duodenal bulb, it's pretty hard to seal off with a covered stent and hope that it stays in place. So these are areas where you would think about an over-the-scope clip or suturing. Again, you know, we all want to put our head in the sand and just get out and hope that the patient does okay. But these, you know, if you don't recognize it right away and take care of it right away, those patients are going to have worse outcomes. So if you have to call your surgeon and they go in and do surgery, that's far better than sending the patient home or sending the patient out, and two hours later, they come in with peritonitis. So it's really important to have a high index of suspicion. You know, you're right there, you have contrast. You can always, if you're not sure, put contrast through your scope channel and down and look to see if there is a perforation, if you're talking about luminal perforation. Thank you very much.

perforations

endoscopic procedures

duodenum

stents

complications