Commentary

When we talk to our patients about a planned procedure, we explain the risks of complications, yet try to calm their concerns. However, complications do occur, particularly with advanced endoscopic procedures. The three selected video cases in the current issue of Endoscopy describe complications and how they were managed, and highlight what is important when they occur.

In the first well-illustrated case, endoscopic ultrasound (EUS)-guided gallbladder drainage with a lumen-apposing metal stent was attempted in a severely ill cirrhotic patient. At insertion of the stent, “torrential” bleeding (as the authors put it) occurred, that quickly obscured the view and led to misdeployment of the stent. The stent was not fully deployed and was removed. Doppler imaging identified the source of bleeding in the gallbladder wall. A new lumen-apposing stent was placed to compress the bleeding vessel while establishing access, and this successfully stopped the bleeding.

The second case also relates to EUS-guided placement of a metal stent, this time for palliative biliary decompression in a patient with pancreatic cancer. Longer stents are often used to reduce the risk of stent migration. This case illustrates the risk associated with using a longer stent. Here the proximal stent end caused an esophageal perforation within 3 months after initial placement. The perforation was closed and the stent was trimmed and shortened, and the patient recovered. This case highlights the balance between two possible risks (migration vs. traumatic injury) and underscores the need for novel safe transgastric biliary drainage solutions.

The third case describes an inadvertent complication of placing an over-the-scope clip (OTSC), namely, complete colonic closure. A patient presented with a rectal fistula after surgery for rectal cancer. Immediately after deployment of the OTSC to close the fistula, the endoscopist noted complete obstruction of the lumen. What to do? The authors were well aware of the physical properties of nitinol, the OTSC material: it loses its memory of shape at a temperature of < 4 °C. They instilled cold water and were then able to safely remove the clip. Subsequently a new clip was successfully placed and the fistula closed.

These cases highlight that as endoscopists we need to be ready for complications, yet when they occur we must stay calm, think on our feet, stay creative, and have a plan B (or C) in mind should the current approach to addressing the problem not work. In particular the last case shows the importance of recognizing a complication and knowing our “tools and tricks of the trade.”

Publication History

Article published online:
27 May 2020