Extreme Endo Toolbox. Slide 1. Slide 2. Slide 3. Outline. Endo Toolbox - Requisites

Transcription

1 Slide 1 Extreme Endo Toolbox Pramod Malik, MD, FACG, FASGE, AGAF, CPI Gastroenterology Associates of Tidewater Slide 2 Outline New Tools - Confocal endomicroscopy (Cellvizio) - HD/ NBI/ FICE - Ovesco clip Old Tools - CO2 insufflation - Methylene blue tinted saline - Transparent cap - Management of perforations New techniques - Old tools - Pseudocyst drainage - Rx appendicits Not covering EUS Slide 3 Endo Toolbox - Requisites Preparedness Open mind, think outside the box Have a clear grasp of endoscopic principles Expand use of tools outside their common use

2 Slide 4 Preparedness Discuss the plan BEFORE (fluoro, anesthesia, location of case, surgical back up, endo plan & route) Have all tools ready - Injection, snares variety, MB dye - Wires, contrast, dilators, correct scopes, stents Expectation of the patient & family Slide 5 Think Outside the Box ERCP & stone removal PEG Colon stents Stents for leaks Pseudocyst drainage & exploration EMR/ ESD NOTES Dealing with leaks Slide 6 Endoscopic Principles Never overinsufflate Never push scope against resistance Know where you are going - X-ray & contrast - Soft tip wire Remove lesions completely (DO NOT sample a polyp!) Tattoo - not too close to the lesion

3 Slide 7 Endoscopic Principles Close holes if you can Liquids go to the path of least resistance Any thing that leaks out, needs to be drained out Dilate - not too much Monitor the patient often & closely Plan and be prepared - stock the endo supplies Slide 8 Expanded use - ASD closure devices - cardiology - Wire torque device - radiology - Balloon dil elsewhere - vascular - Stents - PD stents out of biliary, pushing catheter for short x-change - Laparoscopic tools for ERCP - Transnasal EGD - Trans PEG EGD - Speculum Slide 9 New Tools Narrow Band Imaging/ FICE (Fuji) HD and magnification Confocal microscopy Ovesco clip

4 Slide 10 pcle (Confocal Laser Endomicroscopy) Uses: Barrett s Biliary strictures Colon polyps Main Points Probe thru scope microns Permits targeted biopsies/ improves yield Live interpretation of dysplasia Still needs conventional or HD WLE Not used wide spread - general application? Slide 11 NBI/FICE/HD Slide 12 NBI/FICE/HD

5 Slide 13 Ovesco (Over-the-scope) Cap Size (a, t, ag) Diameter Diameter Diameter 6 mm long mm long Slide 14 Ovesco Clip Uses Hemostasis Closure of acute perforation NOTES closure Closure of fistulae - PEG leaks - Enterocutaneous fistulae - Gastro-gastric RYGB fistulae Slide 15 The Ten Commandments (Perforation) Prompt recognition of endoscopic perforation is essential to improvement in outcome. The presence of extraluminal air does not automatically mean the need for surgery. The volume of extraluminal air is not necessarily proportional to the size of the perforation. Extraluminal air per se is not infectious. Extraluminal air under pressure is a medical emergency.

6 Slide 16 The Ten Commandments (Perforation) Extraluminal air can dissect into distant spaces. Residual extraluminal air may persist without clinical significance. Perforations tend to close after drainage or diversion of luminal contents. Oral, rectal, or injected contrast material extravasation should elicit prompt intervention. Failed endoscopic closure of a perforation generally requires surgical intervention. Slide 17 Perforation During Endo - Nurse s Role Agitation - pain, low O2 Low pulse ox - abd or pleural air Subcutaneous emphysema Distension Can t keep luminal distension Low BP, tachy - low venous return (BAD) Pain in recovery area Slide 18 Perforations - Late Signs Systemic inflammatory response (fever, leucocytosis, tachycardia, tachypnea) Acute abdominal pain (peritoneal irritation) Nausea/vomiting Back pain/flank pain Unexpected localized swelling (neck, scrotum) Abdominal distention Pneumothorax Severe chest pain Inability to handle oral secretions Shortness of breath Hypotension Mental confusion

7 Slide 19 Use CT not X-rays Slide 20 Management Principles Endoluminal closure (metallic clips, stents) for immediate or early postprocedure recognition Nasogastric or nasoduodenal decompression Abdominal/chest decompression if there is air under tension Radiographic evaluation IV broad-spectrum antibiotics Fluid resuscitation Pain medication NPO Close clinical observation Percutaneous or surgical intervention Slide 21 Covered SEMS

8 Slide 22 Old Tools CO2 insufflation - CO2Efficient by EZ-EM - By Olympus - CO2 cylinder with adaptor Clips Caps Water immersion colonoscopy Methylene blue tinted saline Slide 23 Why CO2? Less distension, pain and flatus post colon, ERCP May be better in procedures like - ERCP, tough colons, enteroscopies - Pseudocyst drainage & explorations - Closure of perforation and fistula No CO2 retention in COPD patient Slide 24 Transparent Cap Stabilizes position - Botox injection Polyps on proximal side of folds Any bleeders at angle (GE jn, duodenum, tics) Clip closure Suction of FB Anorectal lesions

9 Slide 25 Water Immersion Colonoscopy Great for long, redundant colon (not fixed) Less discomfort, easy telescoping Delineate edge of flat lesion/ magnification Allows good cleansing Accurate localization of bleeder spot Slide 26 Methylene Blue tinted saline Slide 27 Endoscopic Rx Appendicitis

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