Video Endoscopy Conference 10/16/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 10/16/20 Overview Three cases presented here: • 00:00 – Gastric Annual Vascular Ectasia (GAVE) • 17:51 – UGI in HIV Positive Patients • 33:54 – Endoscopic Management of Chronic Gastric Fistual After Laproscopic Sleeve Gastrectomy again. I'm Jamila Winter. I'm one of the first years and welcome to all the applicants. Okay, so we're gonna start off briefly with a case. Um, so we have a 70 year old woman with a history of non alcoholic liver disease who has evidence of mild portal hypertension on imaging. Who presents to the hospital with Melina? Um, for about two weeks. She does have a history of chronic iron deficiency anemia requiring iron infusions as an outpatient. Um, an intermittent blood transfusions as well. She did have a g d in 2018 for essentially work up of idea that showed a trophic gastritis on past. Um, And on arrival, um, she had a hemoglobin, a 4.2, which was about about three points, uh, around 3 to 5 points less than three months prior. And she had evidence of iron deficiency anemia. Um, consistent with her prior kind of presentations. Despite I ve infusions, um, kind of in the outpatient setting. And so obviously she warranted a e v d. And this was what we saw during her procedures. So on the left, here, you see these red linear striations that are in the Antrim of the stomach leading up to kind of the the pile Or is that people pylori area And on the right here, you see, using from these lesions presumably the cause of her melon A, um and ultimately her. Her, uh, lesions were treated with this little device here called a PC. Argon plasma coagulation, which is essentially it's almost like Katari. And, you know, we buzzed the lesions to essentially stop the bleeding. The lesions were so diffuse, um, that we didn't get everything, but we probably got around, you know, 90%. And so ultimately this patient again was treated with argon plasma coagulation. Um, she was started on pension resolve 40 daily and continued on I V iron as an outpatient, given her persistent, um, iron deficiency anemia. And then the ultimate plan was for her to follow up in clinic for a repeat hemoglobin in about 2 to 4 weeks. Um, and if she continued to be symptomatic So she continued to have melanoma of her hemoglobin down trending. The plan was to repeat the e g d. With possible a PC. And so these lesions, I'm sure most most of you are familiar. But just for a good review. This is called Gastric Angela Vascular Act Asia, or gave. And so we're gonna go into a little bit about what gave is and so ultimately gave his, um, small vessels or Tadic vessels, um, that appear to be multiple multiple red linear lesions at the embassies of the intra folds that radiate to the pile Oris, also known as watermelon stomach. This is actually a path economic for the for the disease process. Um, sometimes it can be punked eight as well. It's not only, um, linear, uh, it's actually quite rare. About 4% of upper GI bleeding that's non very seal will will be gave. And almost always it presents in a woman. Um, at the average age of 70 Similar to, um, the patient that I presented to you earlier. She's actually kind of a classic, um, textbook patient for this particular case, um, it actually commonly presents as a cult leading that manifests, um, as iron deficiency anemia. And so patients, usually about 60 to 70% of them become transfusion dependent. And that's, uh, blood cell transfusion dependent, um, doesn't commonly actually present with overt GI bleeding. Um, similar to, uh uh, my patient. So she was actually kind of a little bit, uh, an anomaly, and not necessarily in a nominally, but she was a typical in that sense, um, it is almost always associated with a common, uh, chronic disease processes such as liver cirrhosis. Um, uh, kind of connective tissue disorders such as programs or systemic sclerosis, renal insufficiency and atrophied gastritis. Um, there have been case reports that do show some connection to other chronic disorders like chronic hypertension and thyroid disease. Mhm. And the pathogen pathogenesis of this disease process is actually unknown. Um, thought to be a multifactorial from mechanical stress, Um, in the sense of strong peristalsis, um, thought to be induced by the prolapse and trauma of the Angela Mucosa Hormonal factors. Um, actually, these patients tend to have increased levels of gas, Trine and prostate gland ID. But they're often, um, seen in liver patients because of, uh, you know, build up and liver processing dysfunction and then autoimmune factors. So about 60% of patients who have gave um have associate auditing disease. Uh, they will test positive for an A or anti central core antibody. So it's thought that there is some auto immunity, potentially to this to know that this is to this kind of finding. And so this is just a brief slide on the difference between gave and portal hypertensive, gastro apathy. And the reason why I included this is that sometimes endoscopic lee, the two disease process can appear the same. And so just for a brief reminder, um, so on the right, right here this is gave again kind of the linear read striations in the Antrim of the body portal. Hypertensive destroy. Apathy is almost always seen, actually, in the body, um, or the fund this of the stomach and not the Antrim. Um, but, uh, you know the demographic or the patient that both of these two disease process can be found in, um are oftentimes patients who have liver disease or are kind of liver dysfunction or some kind of, uh, kind of portal hypertensive process. And so, um, so that's why it can be hard to differentiate. Here. You can see in portal hypertensive guest apathy that the endoscopic li it's actually more snakelike and kind of music pattern. So that's another differentiating factor. Um, it's endoscopic li. It's hard to determine the difference between the two. Actually, we can look at it both the disease that both are kind of disease processes look very different. Histological. So gave actually has this, like, vibrant nous deposits and the mucosal capillary here that starred but the portal hypertensive destroy apathy. Past slides usually show clearing of the capillaries. I'm actually getting histology is not needed for the diagnosis. Um, of gave and actually, for our patient that I, um, presented on the first slide. We actually did not get, um, biopsies for her. And so how do you manage these patients? So the first line is actually endoscopic similar to what we did early on with a PC. Um, the other kind of endoscopic therapies that have been shown to be just as efficacious as a PC include laser Cairo therapy, band ligation, radio frequency and ablation. Um, maybe kind of Later, after the talk, one of our, you know, maybe City Show one of our, um, advanced endoscopy can talk a little bit more about the differences in all of these. But a PC is widely used across institutions because it's more cost effective and actually has been shown to lead to less complications. Um, so medical therapy is actually falling out of favor because there's actually no clear, um, kind of improvement in either re bleeding rates. Mortality, um, hemoglobin levels when using these medical, uh, kind of like these medications, Um, when we look at them in certain trials, and so they've fallen out of favor and we actually don't really use these anymore to as first line in Mandarin gave and then the definitive, um, management. Actually, surgical is in direct to me, but as you can imagine, this can lead to kind of high rates of mortality and morbidity. And so, um, that's also not that that's not used frequently. Um, but, uh, can be can be used if patients have so severe, profound symptoms and refractory symptoms, um, that are not well managed, um, with endoscopic treatment. And so, unfortunately, there's actually no, uh, they're not that many random randomized controlled trials Looking at the different therapies. Forgave. Um, there are several meta analyses and systemic, a systematic reviews, uh, looking at kind of the different therapies that I mentioned earlier. Um, this one that I found in clinical gastro and Hepatology 1014 is one of the larger meta analyses looking at, um, I think about 60 studies standing from 1980 to 2013 and ultimately, what was kind of concluded, um, again, that medical therapies had no clinical role, Um, and gave and that a PC laser, um, and banding are almost all comparable, but a PC, um, winds in the sense of having made potentially having less complications, um and, um, being more cost effective. Um, on average, they saw that patients will need to be treated anywhere from 1 to 4 times with a PC or laser to have, um, for 80% of patients to have about 90% more, um, resolution of their symptoms. So it's actually quite they're quite effective therapies, Um, forgave. But unfortunately, about 40% of patients on average um, will need, uh, kind of another kind of treatment, Um, in 1 to 2 years after their first treatment with both a PC and laser. So this was actually the only randomized control trial that I could find. Um, looking at the difference between endoscopic band ligation versus a PC in treating, gave and about 88 patients who had cirrhosis. Um and they looked at multiple outcomes. Um, a lot of secondary outcomes, including chemical. Been levels, really leading rate mortality. Um, blood transfusion units, treatment sessions, complications. And ultimately, um, there were no difference between the two therapies. Except for what I think is probably probably only the most effective outcome is like treatment session. So, Ben legation on average, um, required one less treatment session about 2.93 compared to 3.54 of a pc. Um, and that was statistically significant. Um, banding also required less blood transfusions For what it's worth, um, about an average 2.5 compared to 4.6. Um uh, a PC. So perhaps banding is more effective in that sense. Um, but I think, uh, and everything else both therapies against again are very comparable. And, um and I think ultimately the same in complications as well. So, um, there are no guidelines for managing. Gave that not not that I could find There are a lot of proposed algorithms that have been kind of, uh can propose in several articles and journals. And this is one that I really like, Um, and one that I think I've seen very few few months that I've been a fellow. But this one is in elementary, uh, pharmacology and therapeutics. And ultimately, what this is saying is I give the patient has been diagnosed with cave upfront treatment is iron therapy transfusions and then treating with a PC similar to the patient that I presented down earlier Repeat a human globe in in 2 to 4 weeks. Um, and the patient continues to be symptomatic, or it's down trending then technically should be repeating the sessions up to maybe four sessions. Um, which I guess this number 3 to 4 is what has been kind of documented in in prior literature. Um, and if there is a response rate, you can follow up with the patient. I think, you know, guidelines and follow up again are essentially non existent. So that's her judgment of the clinician. Um, but, you know, after four sessions, if there is no control of the bleeding, um, or symptoms, then consider banning. And if the patient continues to have a factory, symptoms then can consider more, um, kind of definitive treatment such as surgical and track to me. And so in conclusion. So watermen Mountain stomach is a classic endoscopic finding of gave. You know, I think this is important for mostly border view. So if you think of a patient, a woman who's elderly and has refractory i d a chronic illness such as cirrhosis, connective tissue disease and you know insufficiency gave us something that we should be thinking about. Um, as a differential, histology can help differentiate between gays and portal hypertensive destroy apathy. E p C is, um, kind of widely used as the main treatment option to manage gave, but by an allegation may be more effective based on that one or randomized control trial. Um, and then, unfortunately, there is no set guidelines and the management, So we need more CTS, um, can to help, uh, help us that guide our clinical reasoning and our management of these patients who present with gave. And that is the end of my presentation. Whenever anyone has any comments or questions for me. Yeah, awesome. Thanks, Jamila, um you know, sort of interesting. It's been like the season of game and radiation truck top of the I feel like we're getting like, I consult a week from the General Service for treatment of this, Um, there's every few years. Another study that shows how good our F a is in refractory gave and so ABC often as frontline, partly because it's just easier to access. Um, the thing that caution is that after you, ABC that much of the stomach patients feel horrible like they are because everything it also rates when you go and sculpting a week later. They're just all ulcerated from all of that. Kateri. So it's good to be on assets, oppression, maybe some Cara fate and just really wore the patient that that's not going to feel great. Um, I've never done band ligation again every couple years. There's another study on band ligation, Um, and, uh and there's multiple studies now that show that is quite effective. Um, I think Chris has done it once. Maybe not the best results. Um, you know, it's a lot of scarring. Potentially. I don't know if you're going to share your experience briefly. Yeah, it's funny. I saw it once during my fellowship training, and then I've done it once, Um, since then, and it was a woman who had refractory. She had severe gave in and out of the hospital whole, the whole thing. Symptomatic anaemia. Um, and she was refractory to a pc. Um, and this was really before people started doing our f a. So this was really the only other option. And, um, we banded about 50% of the Antrim. Um, immediately. I knew it was going to be an issue because it included her pie, Loris. I mean, I thought liquids and stuff could could sneak through, but I was really curious as how his food going to get through, which was an unexpected consequence. She had pain. When she woke up, we managed to get her home. And when she got home, she had severe retching and vomiting, and she popped her bands and had more bleeding and had to go to a local hospital for treatment. So that was the first and probably last time I've done banding. And I was we were, um Jim, All that was a great presentation. Thanks very much. But we were actually, um, interested that a couple of us sort of sort of chatting while you were doing it about, you know, have you ever used banding for this? Um, and the four of us decided Chris was the only one who maybe had, um I mean, it's interesting that there's a randomized controlled trial. Our meta analysis, I guess you showed that sort of points toward that because typically, I think all of us use superficial, um, thermal type therapies or cryotherapy, which is sort of a thermal therapy in a different direction. Um, all right, we have two other cases. So, um, like to turn it over to, uh, staff college? Perfect. Thank you. Scottish. Um, let me just share my screen. Yeah. Great. Can you see my screen? Okay, Perfect. So welcome to the applicant's. My name is Stephanie Rutledge, one of the second year fellows. And I am presenting a somewhat selfish case today because I don't know what to do with her. It's a lady that I scoped last week, so I'm really looking forward to hearing people's input. So the case is a 41 year old transgender female meaning male at birth and transition to female last year. Who has HIV and is on antiretrovirals? A viral load of 2000 with an unknown recent CD four. But my suspicion is that if we if she has no known recent CD four count. It may not be that great because most of the patients who have a good CD four count will not will know their city four because they're following up so closely. Um, she presented to G. I clinic with abdominal pain, early satiety and a pretty concerning weight loss of £40 in the prior year, had no dysplasia or rodeina Fadia, which will be important later on. She did not drink alcohol, was a former smoker. Her exam was unremarkable and she was anemic but not really iron deficient, sort of a borderline transparent saturation and then a very normal for Britain. This is what her egg showed when I did her leg during outpatient scopes last week. So here we are, coming into the esophagus and immediately sort of overwhelmed by these sloughing sort of areas of white exit date throughout the mid two distal esophagus. And at the end, you saw there was maybe the sort of the illusion of a perhaps a ring, but lots of exit eight, which was difficult to wash off. Um, and then when we sort of washed underneath it, we saw that it was erythematosus and looked inflamed underneath. Um, let me show you. Oh, and here's the what Looks like the illusion of a ring. There's sort of an abrupt change here to normal mucosa, but it might just be that everything is so inflamed. That is sort of more of a dramatic transition. So these are some of the slides on the left here, you see, just like peeling off of slough it off, exited off the side with, like, an erythema Otis stripe here. And then you just get a sense on the right of how how extensive the sloughing was, although the mucus that underneath doesn't appear ulcerated or to abnormal. So I was eagerly awaiting her pathology, and I was sort of disappointed when it came back. I was phoning them yesterday just to get the final report. She has mild, chronic, non specific esophagitis. We did biopsies and brushing, and the Russians were negative for malignant cells and negative for GMs. So no candida, which was what we were suspicious for. So maybe at the end, I would love people to weigh in on on whether what this might be, whether it still is Canada with the negative biopsies and cytology. Um, what I did was I increased her pp. I try and improve her symptoms. Um and I was planning to empirically treat her with fluconazole, but we'll decide after at the end of this talk. I just wanted to do an overview on upper GI symptoms in the HIV positive patient, which I think is not something that we see all that often with anti retrovirals. It's less common to see the HIV or AIDS related manifestations in the upper GI tract. But I think with the city for a count of over 300 you're really looking at the pathologies that affect the general population. So I think the reflex should be sort of like when we hear there is Melania our reflexes. What does the rectal exam show for HIV positive patient. When you hear HIV, you shouldn't be jumping to C. M. V or Canada. You should be asking what their CD four count is because if it's over 304 100 then you're looking at causes that are as common in the general population. So things like GERD pill esophagitis, especially from things like a CT or doxy altered motility oracle Asia, There is some evidence that HIV itself can affect the nerves in the esophagus and cause esophageal motility. And there are some rare case reports of HIV causing a Kel Asia. And but those are sort of rare. So usually I think pill esophagitis should be on the top of the list, especially if they're taking either antiretrovirals or bacterial prophylaxis. With the city for kind of less than 200 you're sort of getting into the realm of more HIV or immuno suppressed specific pathologies. So Kennedy Isis is by far and away the most common cause of death video. Dina Fage in a patient with a CD four count less than around 200. That's extremely common, in fact, so common that in before the advent of antiretrovirals to in the early nineties in France, candidate Oral Kennedy Isis was the second most common aids defining illness there and had if you were diagnosed with um C M v esophagitis back in that time, your life expectancy was, on average about five or six months. So these some of these pathologies really hard back to the before the advent or before antiretrovirals were widely available, although unfortunately in some of sub Saharan Africa. Many of these pathologies are still happening due to lack of lack of access to the antiretrovirals. But the other thing to think about is HPV, or squamous cell carcinoma that seems to be slightly increased in HIV positive patients and can be sexually transmitted. The other thing, which is rarer but can occur pretty much at any CD four count in the like 203 100 below range, would be composing sarcoma, which rarely affects the esophagus as well as lymphoma. They're pretty rare, but something to be on the lookout for. And then when you really get into sort of the AIDS CD four count level, you have cm the which is more common than HSV. Um, and then these idiopathic daffodil ulcers, which are thought to be perhaps related to, um, necrosis of healthy cells around the HIV cells, which can sometimes be found in the esophagus themselves. But we don't exactly think it might be a direct psychopathic effect from HIV on the esophagus. They cannot find any any organism in these ulcers, but they have seen them in HIV positive patients with a low CD four, and then you move into the realm of very rare fungal illnesses, like I've described here on the slide. So again a really idiopathic esophageal ulcers when before antiretrovirals, they were associated with the life expectancy of just 13 months. So really, really poor and C M. V. Just just five or six months. So there are the things that you're looking for in someone who's really immuno compromised. And interestingly, these pathologies are more common in patients with HIV compared to patients who are immuno suppressed on something like, I am like, uh, anti rejection meds for an organ transplant. So we think that there's something directly related to the HIV that may be predisposing people further to these pathologies. Um, here's some of the different salvageable findings that you can be on the lookout for if you're doing an E g in someone with HIV, so that Canada has that classic cottage cheese appearance. The plaques are difficult to wash off, and you can do biopsies or brushing, which I'll talk about a little bit later on. Then you have the HIV HSV ulcers, which are these like small volcano like appearance there, more shallow than the C M V ulcers, which are deeper, more longitudinal. Um, they can be like linear stretching down the esophagus and just to remember C M V. Center. So I remember C would see you should biopsy for the center because you find from the center because you find more of the psychopathic effects in the middle of the ulcer, which is helpful to make your diagnosis on pathology. HSB biopsy from the edge And here's some of the pathology findings. So the HSV esophagitis there's multiplication and there's margin ation. Maybe one of the pathologist would like to comment on this later on. Whereas C. M V. Esophagitis, I think from our U. S. Families we find may be easier to recognize because there's this prominent inter nuclear entry into a nuclear basically conclusion. Typically with this clear halo surrounding so almost like an Els I oral candid Isis is one of the most common was one of the most common aids defining illnesses before antiretrovirals, and you can see even if you have a CD four count of 200 to 400 about a third of those patients will have some mild candida in the mouth. And if you have AIDS, it's 90%. 90% of those patients will have Oral Kennedy Isis so very, very common. Salvador Kennedy Isis is considered an AIDS defining event, or it was in the past, less so now. In endoscopic surveys, however, you can find a salvageable Kennedy Isis in about 40% of asymptomatic patients with HIV. Interestingly, as we have used more fluconazole, we're having the emergence of these non Albertans candida species, and they can cause refractory, mucosal and even invasive Kennedy Isis. And there is more of a resistance to fluconazole, although they have all been shown to be sensitive to your console. And one third of patients with Candida esophagitis don't have thrush. So I think it's important to look in the mouth when you're worried about Candida Esophagitis. But just remember that only two thirds of those patients will have oral thrush. The others may not have any abnormalities in their oral firings at all. And just to think about it, that actually, when there's a safe Radio Canada, I said you can have committed infection with other viruses like CMD in just over 20% or HSV just in 2%. Or you can have bacterial super infection of the ulcers or the esophagitis, so there might not just be one pathology important to think about. The study that I pulled up was the biopsy versus brush cytology in a savage open to the Isis because I have done E g. D s with different attendants who have advised doing different things. So I've heard before that if you take the biopsy, the Canada might fall off the biopsy specimen, um, inside the formula. So then you won't get your diagnosis, But then brushing is a little bit more tedious, Um, and isn't just a little bit more time intensive in the endoscopy suite. I don't think we ever have a brush in the room and you can take a little bit longer. But in her case, neither came back positive. So I did a quick literature review of what is recommended. And there is very, very little evidence recommending either. There was this retrospective review of patients who underwent an e g e d evaluation for suspected esophageal cancer be isis, and they had to have suffered real symptoms and this Coptic evidence of Canada and have had both biopsies and brush cytology done. They include 55 patients who had both and they define the strategy attended the ISIS as the pathology I. The biopsy is positive for Canada with esophageal symptoms, and all of them had the macroscopic appearance suggested about Canada. The age and average was around 51. They were roughly half male, female, and just over 40% were immune suppressed. And 11 of those were positive for Canada. So 11 out of the patients, 55 patients who had an E G suspecting for a suspicion of Canada and so looking at the table that they put together, the sensitivity of brush and biopsy are both pretty high. But the specificity is much lower for psychology for the brushing, whereas the mucosal biopsy has a much higher specificity. What I don't understand, though, is that the biopsy was the gold standard. So it is going to be It is 100% sensitive, and I just wondered if it's possible that the cytology was actually picking up cases, that the biopsy was missing, and they're calling it less specific. But maybe it is actually catching cases that the mucosal biopsy isn't. I guess if both are positive, it's it's helpful because then you then you feel sort of comfortable with the diagnosis. In her case, I would have taken just one being positive, because that's what I that's what it looked like and we don't know what our CD four counties. So I was suspicious for Canada. Um, but unfortunately, we don't we have both Negative. So to summarize. Mucosal biopsy is the preferred endoscopic sampling for diagnosis because it's more specific. But the sensitivity of brushing and biopsies are both high, and I would love if anyone has any thoughts about what I should do with this patient. I was going to give her a call today, so any of your ideas would be much appreciated. Thank you. Thanks, Steph. That was a really thorough and good overview of the upper GI and HIV, and you don't see this often. It's good to be reminded of it. There's a few people in the chat box talking about maybe that they looked a little bit like like, um, discriminated esophagitis or esophagitis as it can superficial list, which is a little bit what that like peeling swimmers because it looks like, But the problem is it doesn't help you with what they have because it's sort of a reactive. Hi, I'm sick. Kind of process. Um and so but we already know that, Um, some of those. I mean, it's hard in the video, gets little choppy on Zoom, but I didn't know they almost look like squamous papilloma as some of the sort of solid lesions. But maybe that was all just bunched up because, um, certainly not reasonable to empirically treat Canada little downside to that. And it's so common. Is there a sampling error here? Uh, and then you can repeat your scope and sort of see what happens after it clears. Other comments. The audience. You have one. Go ahead. Now go ahead. No, I everything's Batista said as I agree with, um, you know, the the deep ulcers that you described that they are, they were shown on electron microscopy, um, the idiopathic ulcers in HIV and those of us who are a bit older. I mean, we used to see this constantly, Um, and it went away with much better treatment for HIV. So all of this is much less frequently see now. But the CME VHS V were the two main also closing things Canada cause dysplasia as well. But the deep ulcers that you described that you ascribe to HIV. You know, if you looked on electron microscopy, you found HIV in it and they responded to thalidomide. Interestingly, another treatment. But that's not relevant to your patient at all. Interesting, though. Yeah, I'm just going to make the point that the reason you biopsy the edges of the, uh, ulcers in these in these, you know, rule out viral or viral ulcer. The reason you biopsy the edges with HSV is because the herpes virus infects epithelial cells. And the reason you by up to the center of the ulcer with CMB because CMB causes a more vasculitis and it's more involvement of the vessels. And my understanding is that the pain associated with C. M V, we CCMP colitis and we see CMB ulcers is kind of like an ischemic phenomenon from the from the infection. So that's the reason why you take the biopsies from those specific sites. All right, um, Nick, you have, uh, case for us as well. I do. Luckily, I am well practiced and presenting it in exactly six minutes, so I think we'll be okay. Hold on. Let me pull it up. Okay. So Hello, everyone. My name is Dick. I'm the advanced endoscopy fellow here at Mount Sinai. And today I'll present everything plus the kitchen sink and this topic management of a chronic gastric fistula after laparoscopic sleeve gastric. So first for the case presentation. Our patient is a 34 year old female with the history of obesity status. Post left skeptics leave at an outside hospital in 2013. She did have an early postoperative leak, although we don't know all the details of the interventions because we just didn't have the records. But she came to a message six years later with fever and left upper quadrant pain presentation. She was a federal but tachycardic exam was notable for abdominal tenderness in the left upper quadrant and labs notable for a mild anemia. Initial imaging showed up Paris Planet collection, which was actually drained by IR. And she went an upper GI series that shows this very abnormal looking slave with extra visitation suggestive of a leak. So we took her for endoscopy for closure of that leak and initial endoscopy upon entrance past the G junction being apparent. Her sleep was very abnormal. So the opening to the sleeve is here on the bottom and on the top there's this proximal ulcerated out crouching with a fistful is tracked and the track was investigated with the wire, and it's actually a complex fistula. It communicates with the sleeve itself and you can see the wire popping out through the sleeve opening here, Uh, and on Flora Skopje. Okay, It actually also communicates with an extra Luminal fluid collection. So that picture on the right is the wire going through the foot, shell it into an extra liminal space on the initial endoscopy. The treatment modality chosen to close the fistula was fiber and glue injection, followed by placement of a covered metal stent and esophageal stent across the fistula to sort of seal it off and allow, um, allow it to heal. And the stent was featured in place. And here's the final flora from the stent placement and after a 10 day intervals, she had follow up imaging. The responded collection approved with IR drainage, although she did have a new Perry gastric collection with air in it. And unfortunately she didn't tolerate the stent, so she had a lot of pain and the decision was made to remove the step and try a different mechanism of fiscal enclosure. So on her second endoscopy, the track this whole out patching was treated with circumferential a PC. As you can see here, the idea being that this would aid in tissue opposition for fiscal closure. So this whole track is a pea seed and then again, endoscopic featuring is employed to close this hole area off. So this is the tissue helix pulling tissue within the suit training device. And then this suitor is fired through the tissue. There are several more steps that are not well documented here because it kind of goes in fast motion. But that's what you're there to interrupted sutures placed, Um and this is the searcher being synched down. But the final result is that that area is completely closed off. So they're the only opening. Is the sleep opening there? So after this, she had repeat imaging at a two month intervals, responded collection completely went away, the pair of gastric collection got better, and she did great for a year. She went home until a year later than she had recurrent pain. So she came back and she still had a leak. She had an enlarging Perry gastric collection and persistently got Upper GI Series. So she was taken for a third endoscopy. And at this one, instead of attempting another fischel enclosure because we had tried multimodal therapy. At this point, which was unsuccessful, we attempted a different mechanism and which is called endoscopic internal drainage. And I'll explain that. But again, she has this abnormal sleeve opening on the right and then the little out crouching on the left, there are two visible officials tracks. One has puss coming out of it, and wire again shows a complex fiscal are communicating with the sleeve here, and actually the two fistfuls connect with each other. So this is a wire going in one to an extra liminal space, as you can see on Flora. And then the wire comes out the other fiscal, Um so the officials tracked is dilated to allow for a combination of stents and then to dull plastic double pigtail stents are placed through the fistula into the collection and the idea being that the collection can drain internally through these stents and then the stents will allow the track to heal. And this is the final Flora Skopje showing the stent in place and follow up imaging Just documenting the sensor in that collection where we expect them to be. She actually did. Well, unfortunately, actually not last night, but the night before, after I had already prepared this presentation, she actually came back about a month after this last endoscopy and she has recurrent pain and enlarging collection. So this case is still a little bit unfinished. We're trying to figure out what to do. She might end up going for surgery, but I think the learning points our overall endoscopic fiscal management. We can talk about especially relevant to gastric sleeves because they have a highly great up to 2.4% in a large meta analysis and acute fischelis have a pretty high success rate of closure with endoscopy. So a variety of methods have been tried. We demonstrated a few there. The fiber injection future and extending a PC, sometimes over the scope clips would be appropriate, although in this case it was just too large to accommodate a clip. But the delayed closure of chronic facialist is much more difficult and often requires multiple sessions or multiply model therapy. So endoscopic internal drainage is one emerging therapy for chronic pistols, and it's been applied to sleeve leaks. In this large case series of 67 patients, 78% of patients were cured by endoscopic internal drainage, although it did require prolonged treatment and often multiple sessions. All of the failures in this study were, as expected, chronic fiscal is, although they did succeed in closing some chronic fiscal is, um, they did fail in several cases, and the main complications were normal peritoneum, which was managed conservatively. One patient had inter procedural sepsis, which required surgical drainage. And then several patients had stenosis after treatment, requiring pneumatic dilation. And that's it. So I'll take any questions, um, again, like unfortunate that she's actually back and we don't have a great solution, but I think it just demonstrates the complexity of this problem. Uh huh, this work. I mean, you know, the problem is that there is no easy solution here. I mean, if surgery was an easy no brainer, that could have been attempted quite a while ago. But with these chronic tracks, it's going to be investing their surgically as well. So, um, I'm curious to sort of see what the next step is for her. She's gonna lose her pouch or they're trying to just staple it down. I didn't have a new staple line isn't even leak risk. So So I spoke with the surgeons, uh, last night about her case. Um, you know, the thought process on how this El Pao Ching and fistula chronic official end up forming was probably a result of an incest or a stricture years ago when she had her initial sleeved on. And then we're dealing with all the chronic complications with the out patching and the fistula. But the plan tentatively, is for her to have the stents in place to allow drainage of that collection where we saw Puss coming out. And then the surgical plan is, um, in a week or a couple weeks to do a sleeve conversion to a roux. Um, they just don't think that there's enough for them to try to staple across to salvage the, uh, this sleeve anatomy so they'll convert it to a roux. It's gonna be a complex surgery, but, um, I don't think we have any additional great options for her Endoscopic Lee. One of the ones that we had talked about as a team was Endo Vac therapy. But, um, it's a challenging case in her position because of that sort of out Pao ching that's there. And then their official is within, um so I think surgery will ultimately be the best for her in this case. Published December 7, 2020 Created by Featured Faculty Jamila Wynter PGY4 Icahn School of Medicine at Mount Sinai Stephanie Rutledge GI Fellow, PGY5 Icahn School of Medicine at Mount Sinai Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai
