Mistakes in... 2022 - 8

ueg education
Mistakes in... 2021
a
b
Figure 5 | A swollen oedematous Barrett oesophagus segment with exudates. After every ablation session,
sufficient time should be allowed for the mucosa to heal, so that it is flat, with no exudates or swelling (as per the
images in the top row). If the mucosa is not completely healed, it will be too thick for ablation to be effective and
visible lesions will be missed. Endoscopic images courtesy of BEST Academia [www.best-academia.eu]
Remember that you have already resected the
mucosa and a significant part of the submucosa
and that applying too much pressure may lead
to a perforation. A careful snare tip coagulation
generally suffices, but if the bleeding continues
despite two or three applications you need
to switch gears to coagulation forceps. This
switching will require you to release the
remaining rubber bands in the stomach to allow
passage of the forceps.
Most bleeds can be adequately managed with
just snare-tip coagulation. After the bleeding is
under control, remember to clean the surface
area and to evacuate all fluids and blood from
the stomach before you embark on your next
resection.
Mistake 10 Making things worse in case of
a post-resection perforation
Perforations after MBM in patients with Barrett's
oesophagus are, thankfully, rare, occurring in
0.8-0.9% of cases (figure 6). They are never life
threatening unless you make them.
If a post-resection perforation occurs while
you are insufflating the oesophagus and the
mediastinum, avoid spending too much time
'thinking' without actually 'doing'. Such
delayed action can cause pneumothorax and
pneumediastinum, and that indeed can be life
threatening. If you are not already using CO2
insufflation, then immediately switch to it. If you
do not have CO2
insufflation available, then
you should not be performing therapeutic
endoscopies.
In these circumstances, there are several
steps that should be followed (figure 7). First, you
should remove the endoscope with the resection
specimen. Second, question how certain you are
that you will cure the patient with your
treatment. If you think you may have resected
38
5
6
a deep submucosal cancer, it may be best to
transfer the specimen to the pathology laboratory
for immediate evaluation. Taking this action can
make you switch gears to the surgery that's
inevitably required to manage both the neoplastic
condition and the perforation, instead of
managing the acute complication first and
having to send the patient to surgery anyway.
In the acute setting, your surgical colleague
has the best chance of performing an optimal
oesophagectomy. If you have to knock on their
door after a week because your pathology
specimen has come back with an irradically
(incompletely) resected submucosal cancer while
the patient is still in the intensive care unit for
treatment of the mediastinitis you will rightfully
be criticized for having compromised the chances
of effective surgical treatment of both problems.
Third, decide whether you and your nursing
Figure 6 | Post-resection perforation. a | A perforation
is visible inside the endoscopic resection area. b |
The perforated area after closure with an endoloop
and clips. Endoscopic images courtesy of BEST
Academia [www.best-academia.eu].
team are equipped to manage the perforation if
you go in again. It may be wise to optimize the
endoscopic support available and/or to hand the
endoscope to a more experienced endoscopist.
For significant complications, we always insist on
having an additional pair of endoscopist's eyes
in the room to reveal any blind spots we may
have. Revealing blind spots is not necessarily
related to experience, so even if you are the most
1
2
3
If you are insufflating the oesophagus and the mediastinum, switch to CO2
Remove the endoscope with the resection specimen
insufflation
Are you certain that you will cure the patient with your treatment?
* It may be best to transfer the specimen to the pathology laboratory for immediate
evaluation
Are you and your team are equipped to manage the perforation if you go in again?
* Optimize the endoscopic support available
* Consider handing the endoscope to a more experienced endoscopist
* Ask for a second opinion on whether your planned approach makes sense
4
Have circumstances been optimized for the patient?
* Intubation can avoid the most serious complications occurring
* Start intravenous antibiotics
Know what stage of the procedure you were at when the perforation occurred
Consider transferring the patient to a unit with more experience with oesophageal
perforations
* Before the transfer, place a suction tube above the defect to keep the oesophagus dry
* Delaying management for 24 hours will not compromise outcomes
Figure 7 | How to approach a post-resection perforation.
http://www.best-academia.eu http://www.best-academia.eu

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