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Surgical Endoscopy Series Ep. 4: Endoscopic Management of Complications · Behind The Knife: The Surgery Podcast

• Endo Management of Complications === [00:00:00] Welcome back and thanks for tuning into our fourth episode in the surgical endoscopy series for Behind a Knife. In this episode, our focus will be on endoscopic management of complications, although our team was originally based out of Endeavor Health which is in the northern suburbs of Chicago. We are now spread out all over the country. For a brief reintroduction, I'm Celia uso. I'm now at the University of Texas. I'm a minimally invasive surgeon there and an assistant professor in the Department of Surgery and perioperative care Once again we are lucky enough to be joined by. H Mason Hedberg from Endeavor who also has an affiliation with the University of Chicago and Dr. Trevor Krafts from the Rocky Mountain va and the University of Colorado and Denver. And the last couple of episodes we've also brought on a guest, and this week we are very excited to have Dr. Zachary Callahan join. Dr. Callahan like the rest of us trained under Dr. Michael Uki at Endeavor, formerly North Shore and is now assistant professor and also the Associate Program Director for the [00:01:00] residency at the University of Tennessee in Nashville. Like the rest of us, Dr. Callahan employs surgical endoscopy, regular in his practice. So Dr. Callahan, welcome to Behind the Knife. Thanks for joining us. Yeah. Thanks so much. It's, it's honestly an honor to be here. I've been listening to Behind The Knife for well over 10 years, so to be able to, to be on the shows, it's honestly a bit of a dream for me. So, thanks to Soly and it's, it's good to see everyone else again. Excellent. Travis, do you wanna take it, take it away? Absolutely. So in this episode, we will talk about the endoscopic management of the unexpected, so intra procedure and postoperative complications, and hopefully it will offer resources and options for all of you as trainees and practicing surgeons in these feared and difficult situations. Specifically we'll plan to focus on the different types of tools that are available, endoscopically and how they can be applied. We'll review different techniques, namely endoscopic suturing, clip application, stent placement, and endo vac therapy. Most of the conversations that we're gonna [00:02:00] have will be centered around foregut surgery, since that's kind of a collective shared focus for us. But certainly some of these things are pertinent for the colon and lower GI tract as well. Specific clinical scenarios that may benefit from the use of advanced endoscopic techniques include things such as anastomotic leaks, sleeve leaks, perforations, iatrogenic injuries, and stenosis. Although these techniques are well described and relatively efficacious, it's not always clear where they land in terms of the board or, or safe answer. And as such, the first hurdle to overcome is learning to think endoscopically and be aware of what could be done. Are there endoscopic options that could help us avoid a potential major surgery for this patient? Is it a safe and appropriate technique for the patient at hand? And this is what we hope the surgical community will aim toward as we kind of more globally enhance our endoscopic capabilities as a profession. Operations for patients who have iatrogenic complications or postoperative surgical complications can be the hardest types of operations to perform often with a high rate [00:03:00] of conversion to open prolonged length of stay and significant morbidity. Learning how to perform these different endoscopic techniques allows surgeons to add a tool to the toolbox and potentially decrease morbidity for patients. With all the talk in publications about what type of minimally invasive repair is beneficial for patients, whether it's lap or robotic or what have you, we believe that a focus on endoscopy can make surgeons even more complete caregivers for these patients. Awesome. Trevor. Zach, you wanna start us off talking about endoscopic suturing? I think it'd be really interesting to hear your experience with learning this skillset and then how you apply it in practice every day. Yeah. Thanks Lily. Yeah, so I mean, most of what we'll talk about today focuses on a device called the over stitch. Important to recognize that there are other endoscopic suturing devices. This feels like a new device, I think because endoscopic sleeve gastroplasty is, is, is gaining a lot of steam. But it's actually, it's a pretty old device. So there, the first generation I think was around 2010 or so. [00:04:00] And you know, I, I wrote a paper in fellowship and I pulled up some old pictures of that device and, you know, the new one is. Is definitely a little intimidating. There's a lot of moving parts, but that old one is impressive. You know, there's a lot of like long catheters, long strings, that thing looked kind of miserable to use. And then they also just came out with a, and, you know, all the old ones rely on a double channel scope. But the new one, the NXT is out. And it is on a single channel scope, which is kind of a big deal. I'll tell you that. When I started practice in, in Nashville, there was not a lot of advanced endoscopies, so I've kind of had to. Fight with the hospital to get different things and even getting some, like a double channel scope is extremely difficult. Anyone that's tried to do that is aware that Apollo has stopped making them How long? I mean, years ago. And I've been hearing for like five years that, oh, like, you know, we're, we're coming out, you know, and, and they just haven't come up with anything else. So, that's been a, a major limiting factor. So it's certainly come out the NXT where it can be on a single device, a single channel device is a big deal. I do wanna point out that, that the big, the reason this device [00:05:00] was different it has to do with full thickness, full thickness defect closure. So certainly we have our hemostatic clips that we use all the time, but we really didn't have a good way to close something that was full thickness. And the, the first device that came out is the, you know, the Vesco clip. So this is a device that, you know, you'd, you'd basically have an instrument that would go through the device. You could grab tissue edges and then clamp that thing down. And for small defects. That worked really well. And the overt stitch kind of extends on that idea that, you know, through one of the channels you're using a device that's gonna grab tissue, pull that tissue into the overt stitch, and then fire stitch full thickness through that. The the OG fellow that at North Shore Endeavor, Mike McCormick would always say, you wanna feel that Polish pop. And what he's talking about is, you know, when you drive that needle through the tissue. So when you actually are getting full thickness through the cirr, you feel kind of a little bit of a pop, which, you know, being in Chicago, you have a few Chicago doc, et cetera. So we call it the Polish pop. Anyway, so most of us, at least as [00:06:00] surgeons, as bariatric surgeons, our exposure to the device occurred mostly with endoscopic bariatrics. So both the TOR procedure and then endoscopic sleeve. Both of those. Procedures, as you can imagine, really require full thickness bites. I mean, if you're taking non full thickness bites of the stomach to compress it, to make it into endoscopic sleeve, you can imagine that it's not gonna last very long. But it has a lot of uses, another nice places. For those that do third space endoscopy I find it, you know, it, it's way too big to do. For Zener closure, though I've tried in desperation. I think I called Mason during that one. And then in the esophagus it works, but it's also a little bit for GP poem. So GP os really nice 'cause you end up, you know, with the, the stomach it's, it's really kind of like thick mucosa. So, overt stitch can be super helpful. I forget the cost cutoff. It's something like maybe more than. Five clips, I wanna say, or six clips. But once you get above that clip amount on the over stitch it's cost effective. It works in the same way. Certainly if you're in trouble. And I submitted some videos to Sully. There's a great video. I think I stole it [00:07:00] from Chris Zimmerman actually. But there's a great video of A EMR. It is like duodenal, bold, maybe D one, whatever. Get a good lift on it. You know, they throw a snare under and they, they rip it open and you're just looking at pancreas. I mean, it's this like, it's this huge hole and you're just like looking extra per, have you guys seen that video? You haven't seen that video? No. Oh man, I can't wait. We'll share it with the, the viewers. Yeah, you guys gotta check it out. It must have been Chris's year, but but it's incredible. I mean, you know, in someone else's hands, in another part of the country. You're calling general surgery, that general surgeon's giving that patient exploratory lap, right? They're getting an X lap, you know, whereas in, you know, when you have the endoscopic skillset, like we're all so lucky to have, you know, they just threw the overs stitch down, took some bites of it, cinched up and sent that patient home, I think, same day. So it, it's obviously super helpful for things like perforation. The other thing, and I was talking to my residents about this the other day. You know, when we see perforations from like gastric ulcers, we're talking about tissue that [00:08:00] is inflamed and angry and been sitting in pus and bile for all this time. So, you know, closing that is hard, but when there's an atrogenic perforation, I mean, that should heal like really well, right? That is fresh tissue, healthy tissue. The patient isn't, you know, A-A-C-O-P-D or that's on, you know, Eliquis, whatever. So, you know, when he said an hydrogen perforation, honestly, those are some of the. The easiest saves for us. And you're also a total superhero because the person that created that full thickness, you know, defect, that's the worst day of their life. And if they can call you and you can go in there and, and, and save them a big operation, expect, I mean, there's nothing. And I, I, I fondly remember Mike u Geekie doing this a few times, you know, I. They'd call for surgery for like, you know, perforation in the GI suite or something like that, you know, and, and they call us and, you know, they expect us to like, take into the OR and, and Mike would just kind of go up and just like take the scope outta their hands and then just like, go back down, you know, and like close it up and there's just something kind of fun about that. I'll just finish and talk about it. I, I did, we published this paper and the idea was there, there's an [00:09:00] Vesco paper that kind of published the first a hundred, 150 whatever cases, different utilities. The Vesco clip looking at, you know, fistula closure, looking at. Defect, closure et cetera. So we kind of tried to do a similar study looking at overt stitch. So we looked at 150 different cases that that used the endoscopic suturing device. So we had to kind of dance around using overt stitch about a hundred times in that paper. So it goes. And the short story was that, you know, technically speaking, it worked well, it's like high, like 90, 97%. But in terms of actual clinical success, meaning the thing we were trying to do actually being successful, it very much, very much depended on, you know, what was the indication. So, you know, the overt stitch is a great device. It's not a silver bullet. So if someone's had, you know, a. GC fistula for the last 30 years from their malignant whatever cancer. Yeah. If you overt stitch that close, that's not gonna work. But certainly in, in appropriate uses, it works very well, especially with things like stent fixation. I see a lot of migrated stents that could have been prevented just by a few [00:10:00] stitches. Alright. That's pretty much all I can think about. That's excellent overview. I think that's just such a versatile tool to close both, you know, planned and unplanned defects. But you gotta get facile, facile with it before you widely apply it. Which is way easier said than done. I mean, there's definitely, you have to get past the phase. Youre thinking like, oh hey, do I push, do I click, do I, et cetera. So right when you have a lot of area. Stomach, et cetera. That's probably the best way to kind of learn the tool, you know, rather than try to close some my atrogenic esophageal perforation late at night. But yeah the applicability is wide for sure. So, yeah. I'm excited for this next part 'cause Dr. Hedberg, I think, you know, and think about surgical endoscopy as well as anybody that I know. Talking specifically about clips and stents and how you use them in your everyday practice. Very interesting to hear. Yeah. Yeah. Thank you very much. I wanted to piggyback on Zach a little bit in terms of, you know, hero moments in the OR if that. Overt stitch can go in either end of the body. So I had somebody it was an aqua ablation, rectal [00:11:00] perforation, same thing. We just put the endo stitch up there, one figure of eight stitch. And you know, ML looked good. Okay. I went home the next day. So, you know, it's a, it is a great tool to have. So in terms of clips, you know, we all know the little hemostatic clips. There's a lot of different varieties of these different widths and different kind of grabbing tips to grab the tissue. These are, you know, good for kind of superficial mucosal tears. You really don't want to. You can, some of these clips are designed for full thickness defects, but in general we're, we're using these to stop bleeding or close little mu mucus autotomies, not full thickness injuries. You know, we'll use anywhere from four to eight of these when we're doing poem to close the mucus otomy, depending on how big that hole gets. It works really well. The mucosa heal quickly. The clips just fall off. I will say there is a, a newer clip, I think it's called a mantis clip, but it has these really gnarly, you know, hooks on either side. It opens up really wide. And this is actually, you know, there they marketing it as a closing closer device, not a clip not a hemostatic clip. And there's, I dunno if it's out yet, but I was reviewing sage's abstract [00:12:00] videos and I saw somebody close a. Rectal stump blowout with 11 of these clips and it, it healed great. It was after a hartman's in an acute setting, and it worked fantastic. You know, he is in there in the per watching out the, I used You use the mantis clips? Yeah. You guys have you guys? I have. I don't know why we would have that. We don't have anything, but for some reason we have mantis clips, but it is sweet. It's a little tricky though, like, you know how with the. With the over the scope clip devices, you can kind of grab one side, grab the other side. With the mantis you have to be a little creative and you kinda like pinch one side and hold them in it, and then you have to kind of drag it over to get the other side. So it, it works well. I don't know if I would do it for rectal peripheral 11 clips, but it's a neat tool for sure. Yeah, it, it seemed good in those little tight spaces. I mean, this rectum didn't look fun to be in, in terms of the video and trying to get an over the scope clip and really get the whole rectal perforation in that clip would've been tough. So that, that was a, you know, unique circumstance. But I think we'll be seeing more of these technology. The technology will advance, there'll be better clips. We did already go on those over or talk about the, over the scope clips a little bit. The other tool that I [00:13:00] don't know that we mentioned, is it, you know, again, you gotta use the dual lumen scope for this, but there's a grabber thing, like Zach mentioned. Grab one side on the other and there's another one that just kind of shoots out Barbs radially. So you can put that into a small defect or, or fistula tract and really pull that whole track into the clip before you deploy it. Before I get to stents, I thought I didn't see it in our agenda here, but I think we have to shout out to internal drainage. So some of these, you know, defects, you can close either suturing or with clips. Sometimes there is a indication specifically for internal drainage, like a sleeve gastrectomy leak that is now the preferred way to manage these. So when you have a relatively small defect and an abscess cavity on the other side, rather than going to the OR and washing out, try to close this thing, we just put these little double pigtail drains into the abscess cavity. So one end of the pigtails in the cavity, one end in the lumen, and it just allows the abscess to drain and it solely collapses from the outside in. So I've had a couple circumstances where I use these and it is. A lifesaver, if you know, to think about it in the right [00:14:00] circumstance. You put it in, the patient can go home, they eat, you know, they don't even know it's there. They, you know, you get a CT two months, you know, two months later. So the cavities collapsed and the drains are still there. You just go in and pull 'em out. Sometimes they just fall out and pass through. So that's a good tool to have and you can stent around these. I, I have not done that. But if again, you have kind of a big defect and you're worried about more food or something getting in there with the, those drains, you can put in a couple drains and then. Stent to really occlude it. The pu will kind of drain around the stent. It'll deep pressurize, but you're also keeping other food debris and stuff from getting in the abscess cavity. So there are all multiple kinds of stents and they have different indications. The most common one at least in my world, is the wall flex esophageal stent. So these are pretty big. They're 18 millimeters wide, up to 23 millimeters wide, about 10 to 12 centimeters long designed to, you know, cover at least a third or more of the esophagus. They come in a couple flavors, so fully covered. That's for what we're using most of the time. It's something you intend to come back out. Then there's partially covered where the, the ends, the distal [00:15:00] and proximal ends of the stent do not have a coating on them. So I'm using that and mo most often in a palliative kind of setting, if there's a bulky tumor that's obstructing a lumen you put in the, the partially covered so the tumor doesn't grow into where the. The coverage is, but also that stent's not gonna migrate. So that's less so for our complications or acute settings. The fully uncovered or the uncovered stents, I've never really used, there are some duodenal stents that are uncovered and actually go through the scope. So in you know, particular kind of circumstances that may be useful if you're in a tight spot and you can't get a big stent in there. And then. There is a different kind of esophageal stent I learned about recently and they come in shorter sizes. So I used a six centimeter one. And a patient had a kind of a small sleeve gastrectomy actually. I put in a 10 centimeter one first and the distal end was occluding the lloris. So we pulled that one out, put in a six centimeter for this stricted area that was healing. And that one worked pretty well. So. You know, they're, they're coming out with more and more varieties of these for specific, you know, specific circumstances that can be useful. And then finally, one, you use using fluoro every time or how often you use [00:16:00] fluoro. Do you, do you sometimes use it? Yeah. Yeah. Good question. I think I always, these things are expensive and if you don't get 'em in the right spot, it's hard to move. So. I'll describe the deploy process just briefly, but they come on kind of a big rigid catheter, so you come down with your scope first. Put a wire across. I'm usually using fluoro, so I make sure the wires really deep in there, back of your scope over the wire, and then you advance this giant catheter down and there are markers on the catheter that are radiopaque, so you can see your distal and proximal into the stent. And then usually. You know, with the scope down in there, you're clipping some hemostats or something on the patient, so you know where your stricted areas and where you want your landing zone for the stent. And then you deploy it. So once it's in place, you got the distal end in first, then you're pulling a sheath back over the stent. So you see it start to expand and open distally first. Then you're trying to adjust that distal landing zone as you continue to pull the sheath back. And so for that process, I do like to have fluoro. I've done a couple just with endoscopic visualization like in the distal esophagus. You can get a, a scope down next to it and just watch it. [00:17:00] But generally I'm using fluoro for these. And then the last kind of stent is a kind of specialized, it's called Axios, but it's the shape of a dumbbell. We're not using these in too many acute settings. They're designed to, you know, connect the stomach to a pancreatic pseudocyst. They're using 'em to do gastro ostomies and drain the gallbladder under the duodenum. So it's connecting to spaces generally. But sometimes the shape lends themselves to particular strictures. So we've used them in esophagal, gastro ostomies or esophagal ostomies where it's kind of a tight space at the GE junction or something similar. And that little dumbbell shape kind of holds it in place there. Speaking of being held in place, I didn't mention fixing stents as well. So especially those big, fully covered esophageal stents, they can migrate up to 30% of the time. And then they get lodged in the small bowel cause a perforation. So it's, it's a big deal. I usually try to put two overs, stitch sutures into the proximal end of these. I had one case where I did one and it migrated, so now I do two. I think the literature may say three is better, but that's not surprising. The more you [00:18:00] do, it's gonna, you know, migrate less. But these are kind of hard to get out. Two I've started actually not cinching them down all the way. If you really cinch those down, that thing's gonna be buried in the mucosa when you come back in a month to get it out, and it's really hard to find the suture and cut it. So sometimes I think a little bit of an air knot. Might be helpful to get 'em out later. Awesome. That was an excellent overview. The last kind of thing that we're gonna talk about last but not least is the Endo Vac, right? So there's probably some resident or training on this call who has participated in the care of a patient that has required an Endo vac. And I think the good thing is that one patient probably provided you the skillset but it is an incredibly useful tool. So essentially when we are saying Endo Vac. Putting a black sponge specifically on the end of a nasogastric tube. Again, this can be done through either orifice most of the time when, when we're doing this, this is in the foregut setting. And then actually placing the black sponge attached to the NG tube into a cavity or defect. It's particularly helpful for areas where there's significant [00:19:00] amount of contamination and it can help to provide source control. So things you know, where it's used, anastomotic leaks, perforations I'm part of a team that does or takes the esophageal kind of perforations at our tertiary care. And for, you know, anything, this is kind of a standard part of our protocol because it's a temporizing measure that has very good clinical success and actually healing wounds over time. The thing to talk about and it's worth mentioning in counseling patients is that. There's really no telling how long you are gonna have to require endo luminal vac therapy prior to this actually healing. I typically will tend to favor doing one more exchange than you need. So when the area is granulated and it looks like things are sealed to do an additional change just to make sure that you're in a good place. I don't personally perform contrast studies on table. Though I know people do that and do that successfully. There is a lot of data that has emerged on this technique especially over the last [00:20:00] five to 10 years. Steve Leads will shout him out. He's a kind of a friend of the family, and Dallas has published extensively on this. And his series where he was looking at different areas of the geo eye tract and applying in a vac therapy it took seven to 61 days to, to heal these different defects. And so this is something that you have to commit to and, and patients need to understand that oftentimes this is the only option, right? There is a, a could be a hole or a perforation or a defect that's too gnarly to close with endoscopic suturing or clips. And then this is an area that takes a commitment over the course of several changes to actually provide a durable result. And so, you know, there are a variety of protocols that have been described with this. Typically what I do is I'll change the endo vac twice a week. I think that's pretty standard protocol. So have set days where you go back. Remove the sponge, look at the defect and then cut a new sponge and replace it. Importantly, this is all done under general anesthesia just because you want to protect the patient's airway. So that's definitely worth [00:21:00] saying. And again, can be applicable to, to different areas, things like sleeve leaks and hard to reach areas. But it's certainly a, a commitment. I'm not sure if anybody else has any further tidbits on this technique, but I know that this is one of the things that I rely on frequently in my own practice and I think the be the best tidbit ever is. Don't put the sponge on. Before you put it through their nose. Did, did everybody hear that? Make a stick one time because you can't put a, you can't put a tube NG tube with a sponge, you know, down like a normal NG tube. So you pass it into the, OR pharynx get the tube. I'm pretty sure I've done this with Dr. Hedberg. Every, everyone has like tied the perfect knot and you got this sponge in there. Look what I did. Actually, he'll remember this fondly too. First one that me and him were supposed to do. I was like trying to, you know, have everything prepped and I had sewed the sponge on the back table and I was like, let's go. I don't wanna waste your time. So good dude outta here's good's so good. And he was like, yeah, nah, not so fast my [00:22:00] man. Yeah. But anyway, it's a very useful tool. I was just gonna say too, you, you may have mentioned this, but you gotta keep feeding access in mind. I mean, if you're doing this in the esophagus or something, they're not gonna be able to eat. You gotta leave a tube beyond it. And to go back to my stent process, I was looking into this stuff recently and there is a company now that's making a stent with a sponge wrapped around it. So you can deploy this in your perforation and then suck on it and they can still eat through the stent. Wow. So that's kind of a nice development. We may see that coming up the chain at some point. Yeah. Well, speaking of the chain, I'm pretty sure they're commercializing Endo Vac, right? Yeah. I think this is that company. They have a couple products, I think. Yeah, yeah. Yeah. Very neat. So the, the best part of these types of episodes is doing case-based learning or at least side things. So, so then we can kind of apply a lot of the things that we've talked about. So we're gonna go through a few cases that hopefully can give you all a chance to see how we employ some of these technologies. In everyday practice. So I'll take the first one. Again, this is for Dr. Hedberg. So this [00:23:00] is a scenario that we actually dealt with. So there's a patient who came in from, you know, the famous outside hospital. The guy was found down overnight started having projectile emes. Went to this outside facility and got a CT scan that showed esophageal perforation. So the thoracic surgery team accepts this patient. He also had a pretty significant infusion in the right chest and took him to the OR for first and an endoscopy. And I was the, I guess the fellow, so they wanted me to come down and check out this area. It seemed to be the perfect storm, and I unfortunately knew it, and I don't even think Dr. Hedberg was on call, but there was a linear tear in the distal esophagus, clean edges. We kind of knew the timing of everything, and so my thought at the time was this might be a candidate that was amenable to endoscopic suture repair, so for an acute four hops perforation. But I don't know if you, you remember that or want to comment on what we actually ended up doing. No, I do remember the case. I think, you know, the [00:24:00] main thing to keep in mind with these is can you adequately wash out the space endoscopically? You don't, you don't wanna leave a bunch of crap in the chest or mediastinitis. So I think the thoracic surgeon had already decided he was gonna do a vats. And wash out the chest, leave some drainage. I think there was concern about being able to get to the space well, to have a really good closure or a good two layer closure without doing a thoracotomy. So I think it made good sense, man. I got a good mucosal closure on my side and he threw some stitches on the muscular side, lost some drains, washed everything out. If I remember correctly, the patient went home after a couple days. There was no leak. Same kind of scenario. You know, you don't want them eating right on top of that closure immediately. So he left some drains and left dobhoff. And then, you know, just watched it. Contrast study looked good. So I think it was an inappropriate case. I mean, you know, you don't need to do the endoscopic closure there if it's. Smaller or very early tear, then you may feel comfortable just washing it out, endoscopically and not doing the vats. But you know, this guy had been sitting around for several hours and I think that was the, the safest way to handle it. Yeah, it is a win spirit of [00:25:00] thoracotomy. So, you know, that's not the everyday scenario. A lot of times by the time patients get to you it's been, you know, several hours or days and that really becomes less good option. But Trump, do you wanna take the next case scenario? Well, yeah, sure. Well, I had the, the soap box. I was thinking I could just go through another case I had recently. It was actually that patient I mentioned with the six centimeter stent. So she was a 20-year-old woman, had a sleeve at a children's hospital and it's strictured. She had a Dobhoff tube in place for like four months. When I met her, she really did not want bypass. So I had done one like heineke, mic style, uroplasty. Which actually worked pretty well. And there's some precedent for that. So we talked about doing that. The stricture did end up being kind of long. There was this very tight fibrous band and that was kind of twisty and a little small after that. So it's kind of a wide Heineken micex. And it did break down stricture of the sleeve. Right, the stricture of the sleeve. Yeah. Presumably at the angularis. I see. Correct. Yeah. Kind of classic fixture picture. [00:26:00] Yeah. So part of the suture line broke down when it was recognized. I mean, she didn't really get ill for a while. It was kind of this kind of smoldering picture and when we got imaging and there did seem to be a contained abscess cavity, so going by the, the numbers, we did an internal drain first. I think in this case it did not work very well because that is more dependent so than where we usually have our staple line leaks, which are pretty proximal. So I think her oral intake was kind of going into this abscess cavity. It ended up blowing open into a free flowing perforation. So it went in, pulled out the internal drains 'cause it's no longer appropriate in that setting. Did a washout. We stented the, the perforation on the inside and had drains on the outside. So that was more like an anastomotic leak kind of picture. This is the stent that migrated distally and caused an obstruction of her pori. So then we had to pull that stent out even though that plan, you know, technically could have worked. Well we did at that point there was the perforation had kinda opened again. I had closed when we put the stent in, I closed it around a peg [00:27:00] tube, and that was kind of interesting. So we went through the mouth of the endoscope, passed a wire laparoscopically into the abdomen and pulled it out through a pork, and then we pulled the peg through through her mouth. Or the peg tube through her mouth, and it was just sitting right where the perforation was and it was kind of, the stomach closed nicely around that. Then we still had our external drains. I put a J tube in. So now we finally had a controlled situation where we could vent the stomach, feed her through the j and we had the external drains. We were able to remove the external drains pretty quickly. I went back after a month when things had settled down and removed the peg tube. There was still a pretty good gap in the stomach. It didn't look great and it's still in this dependent area. I was worried about it leaking again, so that's when I was ready with that six centimeter stent. So you're able to cover that area. Let it heal. We're going back tomorrow or Wednesday to remove that stent and then I think hopefully she'll be done. We'll be able to get the J tube out the, she has not tolerated the stent very well. That is another issue with these things. They can cause quite a bit of discomfort and nausea. So yeah, we try to use 'em sparingly when you need to. Yeah, I think, [00:28:00] go ahead, Zach. If that leaks though, you're, it's leaking out the skin, right? Yeah. It would've been a controlled fistula, but I wanna try to avoid that. You know? I want that track to heal. So I figured cover, cover it up one more time and just let it know. Yeah, sure. Yeah. I think another important point that you brought up kind of globally is. Stenting. When you stint an area, always think about what's on the other side of that, right? Like, how can you get adequate drainage? Because if you stent an infected area and it's not being drained, obviously that's a setup for failure. But if people think, oh, there's a hole, just stent it. But it's, it's not always that easy. So anyway, thank you for the bonus scenario. Trev, you wanna take the, the next case with Dr. Callahan? Absolutely. So, Dr. Callahan, I got one for you. And this is a I guess, collective, real and recent scenario. I will say that my caveat is I'm not in the esophagectomy business, so, not my particular case, but this is a patient who is now seven days post-op after an Iver Lewis. The patient had been discharged that morning and had previous upper gi, which was negative for a leak [00:29:00] and negative drain amylase. They then presented to the er the night of discharge with shortness of breath temperature of 101 Fahrenheit and lethargy, CT esophagus is performed, which reveals an esophageal leak with, and a small effusion into the right chest. Yeah. Yeah. I'm a, I'm out of the esophagectomy business myself, but it's a good case. Yeah, I think there's a few different. Ways to go about this. I mean, first and foremost, I, I, you kind of have to decide if the chest is something you have to go after or not. Similar to kind of what Mason was talking about before. I mean, if it's not a lot of fluid, if the patient's, you know, not super septic in front of you. You know, you can get away without washing out that chest. But otherwise, that's something to look at. But, you know, for me, you know, so what we said seven days postop or, so, the other big, you know, point here is how big is this disruption? And in this case it, it's 50% recognize that there's probably some sort of ischemic issue here. So even if it's [00:30:00] 50% now, that, that, that could grow. So I think it's a good use for an Endo vac. Because Endo vac, I mean just like wound vacs, we know that, you know, they shrink cavities. They, they help with granulation tissue and wound contracture, and this works endoscopically as well. So yeah this patient was taking the operating room did upper endoscopy. And as I said, we, you know, there's a, a 50% disruption in the anastomosis, so Endo was placed. Excellent. And so a fairly common thing that can happen after these, and we'll say for the sake of argument, that this is what happens is that the patient then strictures down at that site where kind of that disaster happens. If they were to present to your clinic, let's say, a couple months after discharge with a profound dysphagia, how would you handle that? I mean, I work it up. I probably get a, you know, swallow study, a double contrast es gram, get a sense of where the problem is. That being said, common thing being common, you know, there's problem with this anastomosis before, not surprising, there's just stricture now. Ultimately, you know, take this to the endo suite and evaluate, and if it's endo and if it's [00:31:00] anastomotic stricture, which should likely is, I would, I would balloon dilate that. I've steered away from the savory dilations lately balloons worked well. I like to be able to see what I'm dilating as I go, so that's probably what I do. How long do you hold your dilations for Dr. Callahan? I do. One minute. One minute. Okay. Yeah. So what Dr. Kras is getting last, we got that on record. Well, historically people would hold it for like two seconds, and I, I found an article in Fellowship that's. Suggested improved outcomes with three minutes, and I ruined basically the fellowship and all the efficiency at North Shore Hospital after. So the guys haven't forgiven me yet, but. What do you guys do? You're not doing, are you still doing three minutes? I do Three minutes. Because of you, you do three. I often do. I have, I've started being a little more selective where I actually watch to see how much the gauge is dropping. You know, if you have to keep chasing the pressure because you're actually stretching something, I, I keep doing that till it's done. Sometimes that's five minutes. You know, if it, if it stops stretching after a minute, I [00:32:00] stop. That's such a smarter way to do that. Mason polling the group. Does anybody do Kenalog? No, no, I saw that in pediatric surgery in residency, but no, makes sense. Hyper. I was gonna ask about that too. I, I've done it once. I think the data says you're supposed to do it early. You know, you got these fibrotic, anastomotic stricture. Your best bet is to do it the first time you dilate it. I have not been doing that yet, but I think that, you know, the one I did was very easy. I think there's no reason not to do that. Just like sub muco, just get a needle inject kind of thing. Yeah. You wanna get into the fibrous band, you know. Then the other one I was gonna bring up is the stricter otomy. Anybody's doing that? Yeah, I haven't, I haven't done, I've heard about you talking about about it. Yeah. No, I mean, that's pretty easy too. You know, I, I've tried to be pretty favor or selective of those as well. If you have one of these strictures where it looks like a thin band, like a, you know, like a shots ski ring or something coming into the lumen, then I'm very comfortable whacking that with an eye knife or you know, some kind of needle knife in a couple spots. You're [00:33:00] trying to just disrupt the fibrotic band. And then in theory, you should have a more controlled dilation than with a smaller risk of perforation actually. 'cause you're like forcing it to dilate in five spots instead of like fracture in one spot potentially. So you, you still do a, you know, big dilation afterwards, which feels scary, but it, it should be safer actually. Yeah. I think one of the primary data points on that is decreasing the time to reintervention. So it gives you, you know, a little bit more time for patients to be symptom free or lessen their symptoms. But that's great. And you're just, you're eyeing mucosa theoretically, stopping at No. You wanna see the fibrosis. You, you're trying to see the fibrotic band and like actually cut into it. So you know, these like kind of long, you know, tapered strictures. It's not a good option, but a very short one that's coming into the lumen, you can just whack it and actually see the fibrosis. And you don't have to close that or anything. Mm-hmm. No, just leave it. Excellent consideration. All right, Dr. Hedberg, our, our last [00:34:00] scenario. You want to take it with Dr. Krafts? Yeah, this is for Dr. Kraft. So a patient is referred to you for endoscopic mucosal resection of a two centimeter gastric polyp. You complete the procedure in standard fashion. I might want to hear how, what fashion you chose to remove your polyp. However, after the resection, you do have a small full thickness perforation. So there's a sub centimeter wound. It's fresh, clean edges. So how do you choose to remove the polyp and how do you close the hole you're left behind? And I've, I've done this myself. There's, there's a couple options. Sure. I know this is, this, my, my whole response to this may be like, heretical for this group of people here, but I would probably hot snare this. And you could totally EMR it. And I think that's not unreasonable, but I think you could do lift with like an epi, like a dilute epi solution and just hot, narrow it. It would probably be totally fine, but then we'll fast forward to the point where it's not fine and there's a hole and, and I think the first, the first thing to point out is that, you know, it's always good practice to examine your kind of resection bed, not only for a perforation, but also for bleeding. That would be the other thing, [00:35:00] particularly when you're into the submucosal where you can run into trouble. Like it was specifically with delayed bleeds. So, presuming you would find a hole, there is actually some guidance to this and I, I will totally take the heat if I'm the. The first person on behind the knife to quote gastroenterology literature, but there's an a GA clinical practice update on from 2021. And so admittedly, these, there is, you know, expert guidance on this, but in reality these are very kinda location and, and scenario specific. You know, management practices, but for small defects or basically those that are smaller than two centimeters in size, you could consider either it, it would say that you can consider either through the scope or over the scope clips. And I will say personally that we do sometimes if you have a full thickness, you know, hole in a myotomy or something, occasionally we'll close a mucosa with just through sick through through the scope clips and, and that is generally fine. But if I had just made an iatrogenic perforation probably the most, the way you would be most confident in closing this full thickness would be with an [00:36:00] over the scope clip. And that's probably what I would reach for first. For larger defects, particularly those kind of approaching and beyond two centimeters. That's when you wanna think about endoscopic suturing and that way you can get primary closure for these as well. You can also consider stenting in in, in location appropriate scenarios like the esophagus and things, either as an adjunct to suturing it closed or if you can't get full primary closure, although that is definitely less ideal. And plan B. And then after the patient's off the table, there isn't really a defined correct way to manage them. You certainly can consider performing an upper GI depending on your level of. Comfort and confidence. But I would definitely personally keep this patient for overnight observation and, you know, give them liquids and kind of slowly progress their diet and make sure that, you know, clinically they weren't having any issues before letting 'em go home. Very thorough answer. I love that. Anything else anybody would add here, I would handle it the same way. If not, it's Dr. Zach Callahan, it's time to do the quick hits for [00:37:00] Behind the Knife. I can't believe I'm doing quick hits. I can't, I don't know. I dunno what I did to deserve this, but I'm absolutely thrilled. Thank you. All right. Quick hits. One, endoscopic solutions to surgical complications can often mitigate the need for more surgery. Two endoscopic tools for managing complications include but are not limited to endoscopic suturing, endo vac stent placement, and the use of clips. Three endoscopic suturing, particularly versatile skill. It can offer the management of a wide range of defects, particularly those without significant contamination and are clean and viable. Four Endo vac therapy is done by applying black black vac sponge to the end of an NG tube and endoscopically, and is very beneficial in the setting of contamination. Five. When considering endoscopic stenting, it's important not to stent in, isolate an infected area. Excellent. Thanks everybody again for tuning into this episode of Behind the Ninth. It's our fourth in a series of six episodes. I will make some videos to accompany this podcast. But for now, this is the [00:38:00] BTK Surgical endoscopy team reminding you to dominate the day. Thanks so much.