E118 Eric Pauli On Surgical Endoscopy And Endoscopic Management Of Leaks & Fistulas
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human. We're so thrilled, Eric, to have you on the podcast. We followed you for a long time and you're well known in Canada for a lot of the things that you do, and we certainly know how busy you are, so thank you again for joining us. I'm curious, maybe for some of the listeners who may not know you as well as we do, tell us about where you grew up and where you did your training and how you ended up where you are now.
Eric Pauli
So I'm currently in Hershey, Pennsylvania, which is kind of in the southcentral part of Pennsylvania. It's the town where Hershey's chocolate comes from. If you like Hershey's chocolate, that's great. If you don't like it, I apologize. It's not the world's best chocolate, I swear. But I grew up about two hours northeast of here in a small town called Scranton, Pennsylvania, which many people know because it is the setting for the NBC show The Office. So, I grew up in Scranton; I stayed home for college; I went to a small Jesuit school there called the University of Scranton. And then I came all the way here to Hershey to do medical school. And then I stayed here for residency. I did two years of research in the middle of my residency, also here in Hershey. And then I made it all the way to Cleveland for my fellowship. I spent some time at university hospitals with Dr. Jeff Marx and Jeff Ponsky. I went there to work with those two guys, I was lucky enough to work with both Mike Rosen and Yuri Novitsky while I was there as well. And then, the plan and leaving residency to do fellowship there was to come back here to Hershey. So, I've been here as a faculty member at Penn State Hershey Medical Center since 2012, was when I started as faculty. So I'm going nowhere fast as they say.
Ameer Farooq 02:37
That's such a neat trajectory. We obviously know some of your mentors that you named there; they're like the who's who of laparoscopic surgery and abdominal wall reconstruction. So that's an amazing training pathway and mentors that you had. Obviously, one of the reasons that we wanted to bring you on the show was that you have such a neat career and you manage to blend some disciplines in a way that I think not many people have, in their practice; you have this neat blend in your career of combining both a full surgical practice with abdominal wall reconstruction and minimally invasive surgery as well as surgical endoscopy. How did you get into this career path and what motivated you to go down this kind of unique trajectory?
Eric Pauli 03:30
You make it sound like it was planned and I had some forethought. I remind everybody that I am in many ways the Cosmo Kramer of surgery, you know, I have fallen backwards at times into good luck. I went to Cleveland specifically to work with doctors Ponsky and Marx to become a surgical endoscopist. If you asked me in my heart of hearts, like what am I, I'm a surgical endoscopist. When I was interviewing, there was a guy there named Mike Rosen who I - I had literally never heard of the guy. I didn't know who he was; I was there for Marx and Ponsky; I was there to be Pomsky's fellow. And Mike was an abdominal wall reconstructive surgeon, and I had done some of that in my residency training. But my experience was mostly with complex post-trauma patients getting open external oblique releases, heavy use of biologic mesh, patients who were poorly optimized, lots of complications. And I actually said, coming back from that interview, that I would be willing to do those kinds of disaster surgeries and put up with the year of wound complications and fistulas which was, again, my experience with those kinds of surgeries, if I got to spend time with Marx and Ponsky. But when I got there, obviously, Mike and Yuri had joined in the year in between my interview and the time that I started. They turned hernia into a science, I mean among other people, but those two for sure were turning it into its own specialty at the time. And while I learned all of the cool surgical endoscopy stuff that I think a lot of people know me for, I also left with this understanding of how to do a good abdominal wall reconstructive operation. And when I came back to Penn State, there was really nobody who I had trained with left who was doing those operations. And what I saw was an opportunity to build both a surgical endoscopy program and a complex hernia program. My boss at the time said, point blank, he's like, "Eric, you can't be Jeff Marx and Jeff Ponsky and Mike Rosen and Yuri Novitsky all at the same time, like it's just not going to work; you need to pick one of these things and kind of focus." And he's a naysayer, and he's the first person to admit that he's a naysayer. And so I just kind of ran with it. And I said, "Look, the practices balance out very nicely. Those open abdominal wall operations, they're physically very taxing that you spend all day doing one operation. And then the next day I can do 8-10, smaller endoscopy procedures; it uses different muscle groups, you stand differently, use different equipment. And so, if I was sore one day, the next day, I'm using different muscles." From a financial perspective, a lot of the things that I do endoscopically are unlisted procedures; if I close a leak endoscopically there's no CPT code for that, and while I can show value because my partners like the fact that there's not a leaking sleeve anymore, the department is like, "So you just do diagnostic endoscopy and a little bit of fluoro[scopy] - where's your productivity?" And so the hernia stuff definitely has high RVUs and high reimbursement and the endoscopy stuff does. And so for many years, that balance of mental, physical, financial taxation on myself, it balanced out very, very nicely. And I was able to then grow over the course of time, those kind of two separate surgical practices, but none of it was intentional; it just seemed to work out particularly well. That's actually a fascinating voyage and a great insight. Just speaking personally, I fuse hepatopancreatobiliary and trauma, which was also initially met with a lot of naysaying, and I understand that, you know, people pick each of those jobs for very different reasons and generally hate the other and it's really, really neat, as Ameer said, how you fuse that. I'm curious, how do you define surgical endoscopy? Because I think that maybe that 30 000-foot term is really quite confused and certainly means different things to different people across the continent. That's a really great question. And I thought about it when you guys sent me the list of things we might talk about. And I thought about it overnight and I don't know that I have a very good answer because ultimately anytime a surgeon picks up and uses an endoscope, that really is surgeon-performed or surgical endoscopy, and even within my own division - there are 7 surgeons within my division - all of my partners utilize flexi [inaudible] to some extent, but the degree to which they use, it even within our own group, varies quite dramatically. Many of my bariatric colleagues use it for on table endoscopy only. They do a lot of diagnostic endoscopy. They're inspecting their work, they're using it to leak test. That's obviously surgical endoscopy, but other people look at it and say, "That's just kind of routine surgical practice and everybody should be doing that, man." And I agree with that opinion. What I think sets surgical endoscopy apart from medical GI endoscopy is a few things - number one is a high-level understanding of surgical principles and surgical anatomy. Everyone can understand normal anatomy and good GI folks understand abnormal, you know, understand post-surgical anatomy, and even the common variants of abnormal post-surgical anatomy. I think where people who specialize as surgeons doing endoscopy can excel is kind of the understanding of abnormally abnormal anatomy, right? Being able to realize when something is outside the normal patterns and be able to figure that out endoscopically. The understanding of surgical principles and where you can kind of push boundaries is also I think, very helpful. Because I am my own surgical backup for many of the things that I do, I'm willing to push the boundaries, some. I have surgical colleagues who send me patients who they already understand that somebody is looking at getting another surgery, if I can't fix the thing that they're asking me to fix, and so that gives me a little bit of freedom to push the envelope some, it also allows me to partner very nicely with my surgeons. We speak the same language, obviously. And we oftentimes share patients in a way that I don't think you get from a medical GI consultant - a majority of the time, let's say. If I meet a patient on my colorectal surgical team service, who has a leak, I'm going to go I'm going to talk with that patient and the message that I'm sending them and speaking with them about is very similar to what they've already heard from the colorectal surgeon, right? So patients are getting message repetition. This is the problem. "This is the textbook answer to the problem that you have. And this is what my colleagues are already doing, you are getting best care for this process right now. These are some options for managing this endoscopically. And I'm going to with your permission, try these." That language, that backup, that repetition, it allows patients to understand that they are getting high-quality care from the person who is already managing their problem. And be that there are other options that we can offer as surgeons. I oftentimes tell people that I'm that - you guys know what a pilot fish is? Those are those fish that live on sharks that keep the sharks clean, keep bacteria from growing in their eyes and stuff like that. In many ways, my surgical endoscopy practice is, you know, I'm a pilot fish. I keep the surgeons swimming and moving efficiently so they can go out and do what sharks do. But at the same time, if I wasn't around, they'd have some problems that they would have to deal with. So surgical endoscopy is different from person to person and institution to institution to institution, all politics are local. And so you're going to get a different answer from different people, but for me, I think at the end of the day, anytime a surgeon is picking up a scope, whether it's for diagnostic purposes in the operating room, preoperatively, postoperatively, or doing therapy, that's surgical endoscopy; it's only surgeons who are uniquely situated to do endoscopy routinely in all 3 of those circumstances: pre-op, intra-op and post-op. I love how you frame that. That's a wonderful description and sounds like an amazing practice. I'm curious, maybe just to go a little bit deeper. What would be your top most common, say 5 procedures-ish that you do in your local surgical endoscopy practice? And then what are some of the ones that maybe are a little bit more exotic? Yeah, that's a great question. Common things happen commonly; we do a lot of preoperative endoscopy for our bariatric program, it's a high-volume program. And so we do high volume, just pre-op diagnostic endoscopy. It's helpful though, because again, the language when I do a report, for a pre-op bariatric patient, the language that I'm using is all aimed at the person who's going to read that report, which is my bariatric surgeon. So they've got a good understanding of exactly how big the hiatal hernia might be, exactly where the gastritis is and what we biopsied. My partners and I also do a lot of just diagnostic colonoscopy, we have a partial community practice at a local hospital that we just absorbed. And the surgeons there we're doing a lot of high-volume colonoscopy, and that's important, not so much for me and my partners, you know, if I didn't do colonoscopy, I wouldn't lose a lot of sleep over it. But for our surgical residents and our trainees and our colorectal fellows, having access to those high-volume colonoscopies is super critical. For my fellow in particular, who is a minimally invasive fellow, I can't teach you how to close the leak at an ileocolic anastomosis. If you can't, safely and efficiently, get to the ileocolic anastomosis, right? And so, we think about those diagnostic procedures as procedures themselves, but for me, the repetition and just doing those things over and over and over and understanding the motions blindly. You know, it's all muscle memory at some point. It is critical as we move on to more advanced procedures. My next most common procedure is probably endoscopic management of leaks. It's the thing that our group in particular is sort of known for locally. We are a tertiary care medical center in the middle of a corn field. And so we have lots of small community hospitals that surround us and we see leaks like anybody else might see except that if they come to our practice or they're referred to us, we try to manage them endoscopically. And so that includes a variety of different tools and techniques. Our group preferentially tries to close defects if they're closable, utilizing over-the-scope clips or endoscopic suturing devices. We offer endoscopic vacuum therapy for leaks that are less well controlled. You know, we do long-term internal drainage procedures with double pigtail stents for more chronic leaks and fistulas. Most of the tools that are out there for leaks are in our armamentarium. What that means is that if you come to us with a leak, it's not a kind of 'hammer and nails' sort of philosophy. You know, 'leak gets stent' is what happens at many places if you have, for example, a leak after a bariatric operation; at our facility leak gets diagnostic endoscopy with on table fluoroscopy and a comparison with the preoperative cross-sectional imaging and then kind of a timeout in the operating room for us to draw up the anatomy of what's going on, you know, where is the leak? How long has it been here? How much contamination is there outside? And then we go to our list of therapeutic options and we pull the one off the shelf that we think at the time is the right answer for the patient. What also comes with that is a plan for follow-up; this is not, we're gonna bang a clip on it. And if it works, great. And if it doesn't, then just go back to the surgeons and get surgery. If we try to manage a leak and it fails, or when we rescope you there's still a leak, we're going to move on down the algorithm to our next step in the series of steps that we can offer. So that understanding that multimodal therapy at the first go-around, planned endoscopic reintervention with the second look, endoscopy down the road. And then sometimes we know for endoluminal vacuum therapy, obviously that's 2 scopes a week for a couple of weeks while you're here in the hospital. So that plan to do the therapy over and over and over is, I think, part of managing leaks endoscopically. More exotic procedures that we are actually doing at little bit greater volume include actually maybe something in your wheelhouse, Chad, endoscopic management of gallstone disease, but percutaneous management. So, about 2 years ago, we started offering a procedure that is, I think, a little more commonly done by interventional radiologists in some places. I think the group in Toronto recently put out a series of taking choledochoscopes down drain tracts into percutaneous drains in the gallbladder or the biliary tree. And we've begun to offer this as a more regular service for people who have cholecystostomy tubes in and who have been told that they are no longer candidates for any surgical intervention. So, their options are: live with the drain that gets changed for a while, which most people really dislike; pull the drain and hope you don't get coli cystitis again, which is probably a bad idea; and, we have some internal drainage procedures that my GI colleagues offer, like using lumen-apposing metal stents to make an intentional stent-based fistula between the gallbladder and the duodenum. I like the duodenum a lot and I really don't like putting holes in it. And if you're so sick that you're not going to tolerate a gallbladder surgery, I think that if that process becomes a problem either for bleeding or for leak, you probably have a mortality on your hands. And so these are really high-risk patients. You know, draining these patients percutaneously is pretty straightforward. My interventional folks do it with a little bit of sedation on people who are fully anticoagulated. They're pretty amazing at getting drains in these folks. If they can get a drain in and upsize it, then we can easily take a small choledochoscope down the drain tract, and spend an hour under sedation. In some circumstances under no anesthesia whatsoever. I've had an entire conversation with a guy about the restaurant scene in Cleveland, comparing the 70s to the 2000s while removing gallstones from the gallbladder. As sort of niche as that procedure sounds, once word gets out that you're willing to do this, people find their way to your office. One of my former lab residents sent me a picture. He was in an outpatient clinic with our emergency surgeons. The guy came in for a gallbladder surgery with a drain in place, but he had a little note that said, percute. So we call that procedure pebl I guess I should say - percutaneous endoscopic biliary lithectomy. And so that guy had a little post-it note on his paperwork that he brought in. It said: "Pebl Dr. Pauli," and the resident said, "How on earth could you possibly know about this?" And the guy said, "Oh, the farmer who lives next door to me said that he had one and that I should ask for it too." And it's just like, you know, word-of-mouth advertising amongst the farmers locally, I guess is going up for this procedure.
Ameer Farooq 20:26
You know you've made it when farmers are talking about.
Eric Pauli 20:33
It's funny. We get people sent us for that procedure, and we look at it and we say, you know, "Sir, or Ma'am, you're totally fine to get a gallbladder surgery." And I'm surgeon, so we just take out the gallbladder. But we oftentimes meet people who are extremely, extremely ill and are not going to tolerate really anything else. One of the people who comes to mind was on full-dose anticoagulation and antiplatelet agents, she had a very small stent that my neurointerventionalist put somewhere deep in her circle of Willis. And they were like, "Her blood pressure cannot go down, she should not get anesthesia." And they were like, "She probably shouldn't even really be NPO for that long, because even the dehydration might make the stent go down. I was like, "Okay ...". So she was also another patient who was awake while we cleared out the gallbladder. And these patients are amongst my happiest patients, I mean, to learn that you don't have to live with this drain in your side for the rest of your life, and that you don't have to go in every 6 weeks for a drain change by IR. These folks are immensely happy and their quality of life goes up a lot. My IR folks are also pretty happy as well, because again, these people, when you have a large quantity of them coming in for drain changes as straightforward as a drain change is, it takes up time from other procedures that maybe are a little more urgent. And so we can save patients time and effort and energy and also save a lot of energy on the medical system; it's probably worth doing more often.
Ameer Farooq 22:06
That's fantastic. And one note I'll just make is I've seen your pictures that you draw up; you talk about taking a little time out and drawing a picture of people's anatomy. And I'll post that in our show notes. It's really quite superb the way you have the whole anatomy drawn out, and then you just pick the tool that's meant for it. The one big question I have with regards to your practice and all the amazing things that you do is, you know, there is an element of training that always is a question when people talk to you about your practice and there's discussions between you and other folks on Twitter. I was thinking recently of the discussion about lap CBD explorations, for example, sort of not surgical endoscopy, but along the same lines. How many of these procedures were you doing when you were a fellow? How many of these procedures did you have to kind of figure out once you became a staff and how does that training aspect and case numbers and things like that, how does that play into all this - especially when you were trained by a surgical endoscopist not necessarily endoscopist or GI folks. And so, you know, how does that whole interplay of training and especially training with surgeons, as opposed to the GI folks, how does that all kind of work out?
Eric Pauli 23:32
It's a great question. I was fortunate enough a lot of my early flexible endoscopy training was in the lab, when I was a research resident with my GI colleagues, because we were working on - as many folks were at the time - natural orifice surgical projects, right. And what really made me fall in love with concepts within flexible endoscopy was that we were in the lab doing cholecystectomies on pigs, transgastrically, right. And many times, I was the most qualified surgeon in the room because it was me as a third-year lab resident working with GI folks who have no formal surgical training beyond medical school. And so I got to do some of the endoscopy with them. I got to watch the maneuvers, the thought process, the techniques, but at the same time, I was also on the other side, kind of doing the surgical stuff, oftentimes with a laparoscope in place, and the ability to kind of see the tip of the endoscope, and at the same time, see what the person is doing with their hands to make the tip do that. It really solidified a lot of my understanding of how endoscopes move in space. A lot of the problems of laparoscopic and endoscopic surgery, you know, these are image-guided procedures; there are things happening that are not on the field of view, right? You can see your instrument tips open and move and rotate, but how your hands are moving and what they're doing is behind the field of view. And so people are creating and constantly remodeling mental roadmaps of how things work. I'm good at doing that. I think primarily, I tell the story, I teach a lot of radiology too. And I learned all of my anatomy when I was in high school and in college, because I worked as an x-ray file clerk. And the guys who were in the radiology group that I worked for knew that I wanted to go to medical school. And so they thought, "Hey, like, let's teach him anatomy." And so I would hang up the films because they were actual films back then. And then they would show me "Like, this is a liver, this is a, this is a kidney, and this is how they relate to one another." And by the time I was ready to graduate, I could do some basic diagnostic stuff by reading films. It was kind of like the organ grinders monkey, you know, like, he's not really playing music, but like sort of playing music. But what that forced me to do though, was my understanding of how organs relate in space was all based off of two-dimensional pictures that I was kind of putting back together three dimensionally when I got to the anatomy lab. And so I kind of learned it the wrong way around. And so my ability to create mental roadmaps I think, is maybe a little higher, or maybe a little more advanced in some other people. So what that meant for me was, as I was learning endoscopy, it felt very second nature to me. I understood that things were happening behind me that I needed to be aware of. And if I understood those things, I could kind of do it. Now, the surgeons that I trained with had a very good understanding of the surgical anatomy and the surgical principles and the techniques, but in my fellowship training I did have the chance to work with several of the medical GI folks as well in Cleveland. And, they're just watching how they move and how they think about what's going on with the scope. It's just a little bit different. But at the same time, it's obviously the same tool that you're using. And so you can pick up little differences here and there, from how people are doing it. The words they use are slightly different. What I think surgeons need to get out of the training and endoscopy is 2 things: There's this big debate, obviously, about volume-based competency versus skills-based competency. Those 2 things - the Venn diagram of those two things - overlap. Nobody is proficient after 25 upper scopes, right? But do you need 200 upper scopes to be proficient in safety? No, probably not. But if you're going to move on, and you're going to be sort of a therapeutic endoscopist, you've got to bang out diagnostic scope after diagnostic scope after diagnostic scope. And I was fortunate enough that after I left the lab, and had this cool understanding of what an endoscopist can do, I went to our VA Medical Center, which did a lot of smaller surgeries, but also the surgeons there ran the endoscopy unit. And I basically just told my chief resident, "I have no desire to do any surgeries for the next 2 months while we're here. If that's cool with you, I'm going to go to the endo unit." She was like, "Yeah, I'll do the operations and you go do the scopes, you're an idiot." And I with the surgeons there just did diagnostic scope after diagnostic scope, upper and lowers. And that's really where that skill set kind of solidified. In fellowship, I did a lot of therapeutic stuff. I am trained in ERCP. We were doing a lot of POEMs back then. But many of the things that I currently do, especially all of this endoscopic management of leaks, we did very small amounts of. Endoscopic suturing devices were still in a first-generation mode. We were actually trying them in colons in a prospective clinical trial to make sure we wouldn't perforate the colon while we were suturing with them. Over-the-scope clips existed, but we didn't have them. And so a lot of the things that I do on a very regular basis have been worked out in the meantime. It'd be no different than if I told you that we had a new way to do a laparoscopic colon surgery, right? Instead of medial to lateral, lateral to medial, I'm going to teach you the bottoms-up technique, okay. If you understand laparoscopic surgery and you understand the colon, you can put those things together and build it up. And in my career as an endoscopist, I'm going to learn something new the next week and the next week in the next week because we have new tools and new devices available for things on a regular basis. So that's the other part that I really do love is that there's going to be a lifelong learning process of new things. I'm personally looking forward to flexible endoscopic robots, which is really the next thing that's gonna kind of hit the market here. You know, endoscopy is hard, because of all of those mental modeling things that you have to do, you know, your eyes and your hands are connected. Instruments only work in and out of the plane of the field of view. So the ability of a device to go in and triangulate with eyes above the hands, hands that can articulate in roticulate with some ability to oppose tissue and work 90 degrees to the field of view, is going to revolutionize how we do a lot of the surgeries that we think of as purgeries. If we can save the organ, but remove the cancer, I think people are going to like that concept. And, it's going to be surgical endoscopists who are uniquely situated to do it. We do the surgeries now, we already do robotics, so many of us, and we have access to flexible gastroscopes; we just kind of need the robot to help us with that minimal access portion of the procedure.
Ameer Farooq 31:13
I think that sounds fantastic. The last question on this topic is, you know, you're definitely a surgeon's best friend; I could totally see how your colleagues in the surgery world would just absolutely love having you because you're saving someone potentially a laparotomy, for example, within an enterocutaneous fistula, and a big surgery. You could potentially save them that huge operation with all the associated morbidity. But how do your GI colleagues feel about you sort of operating within their space? I like your phrase, all politics are local. Certainly, I've noticed here in Canada, there is a lot of trepidation sometimes from our GI colleagues about even training surgical residents. You know, we spend our rotations training with our GI colleagues to learn how to do scopes and most of the GI folks are happy to train us and love to train us and love having surgical residents around. But sometimes they're like, "Well, we don't want to train general surgery residents." So how does that kind of interplay happen at your institution? And what advice do you have for people who are interested in developing a surgical endoscopy practice?
Eric Pauli 32:33
It is a challenge. There are territorial issues and patient-management issues everywhere you go. I think at the end of the day, what most people have in their heart of hearts is the desire that people get high-quality endoscopy. This is, I hope, not about them versus us, but about what is best for the patient. Okay, and we might disagree on that. But at the end of the day, I hope that we're keeping the patient as the forefront. Why do we have arguments over who should do endoscopy? I have carved out a niche that nobody really wants; nobody wants to manage leaks and fistulous. This was advice that I got from Mike Rosen, which was advice that he got from his mentors, which was "find an area of surgery that nobody really wants to deal with and you'll have patients all day long, and you can become an expert in something pretty quickly." This is this is a field of surgery where there are no elegant surgical solutions. And that's something that I tell patients, right? You open up a book of surgery, you get some antibiotics, and you get a drain and you get some TPN. And then we wait a whole bunch of time, and then we come back and if we need to do a surgery we do. And so there's this huge space in the middle there where we're just waiting around and what can we do in that timeframe? What I do in terms of leak management is not something that I think most gastroenterologists - at least in my place as well - want to deal with on a regular basis. There's a variety of reasons for that; these patients are extremely time consuming. Many of them are not stable or fit to be scoped in an endoscopy unit. So they need to be managed in an operating room. Sometimes the tools and the devices and the things that you need to do these procedures are endoscopic tools, but also some surgical tools - endoscopic vacuum therapy, if you're going to do that, your endo unit has to stock the vacuums, you've got to get them over, you've got to have needle drivers and sutures to construct the device because there's no currently commercially available version. So if you're going to do that, you've got to have access to some surgical tools and equipment and for me the best place to do that as the operating room. These are a highly litigious group of patients. And I mean, not just my group of patients who leak but in general, patients who leak and have post-surgical complications are more likely to be involved in lawsuits. There's good literature from the bariatric literature, from the colorectal literature to support that. If you asked me, "By the way, would you be interested in doing something that's really complex, that's going to occupy a lot of your time - in a patient who's extremely likely to sue us and the institution?" I think most reasonable people would say, I'm not super interested in doing that. But as I've done more and more and more of these, I think the main things that are helpful, yeah, I can't close every week, all right, but we can make almost everybody better in some fashion. Sometimes that better is just an understanding of what the process is. Sometimes that better is just me coming along and reinforcing to the patient that they have a problem, that their surgeon is managing that problem completely appropriately, and that I have nothing to offer from a scope perspective, but that they're being well cared for. It's just that reassurance, it's a second free surgical opinion about the problem that really helps the patients understand that, like, "I'm not happy that this happened, but I am glad that you know, Dr. so-and-so is taking good care of me and I've got a second opinion that says that." But as you said, Ameer, for the people who we endoscopically close, these people are exceptionally happy. You know, many of them were referred to us being told "You need a surgery." There's a patient who I remember very distinctly who was referred to me by one of my former coresidents, who's a bariatric surgeon, and he had done a sleeve on her and 2 years or so after the sleeve, she was getting a thyroid operation. And after her thyroid surgery, she started having these really weird fevers and wasn't feeling well. And they were trying to figure out "How is this endocrine-related at all?" And they eventually imaged her because she was complaining about some abdominal pain and they found a big fluid collection around the sleeve staple line. And they sent her to me as a potential chronic sleeve leak. Interestingly enough, we actually published this in the Bariatric Times a couple years ago. They had put an NG tube in her during the thyroid surgery, because she said I have a lot of reflux, and they were concerned about her aspirating. And they actually perforated the sleeve with the NG tube. I mean, the hole was straight past the EG junction straight into the sleeve right above the staple line. And it was a straight up NG tube-related perforation. But she came to me having been told, "You have a chronic leak; you're gonna need antibiotics, you've got to drain in and it's going to be there for a while; you might need TPN for a while." And it was close to the holiday season in December. And she was just absolutely dejected that she thought her surgery was going to be done, she'd be recuperating for the holidays, and here she was with a drain and a PICC line and a bunch of other stuff. I remember scoping her and going, "This isn't a chronic sleeve leak; this is an NG tube perforation, like look at this. And we closed it. We took her drain out and we pulled her PICC line before she left and she was just like, "I don't understand, this is totally the opposite of what I was just told." What I said was, "What you were told was 100% correct. These are all of the right maneuvers that you need for a sleeve leak, except it's not a chronic sleeve leak; this is an acute process. We just managed it endoscopically and you're good to go. And she left; she was with us for 18 hours overnight, we transferred her, did the procedure and sent her home the next day. So for some of these patients in whom we do these kind of "one and done" procedures, it's remarkable the difference in their perception of what they were expecting, which is kind of the standard stuff versus what we can offer. Oh, that story's amazing. Eric, I think you need to come to Western Canada and work with us up here. We'd love it. I was wondering for some of our listeners, and I don't just mean trainees, I mean all of us. Could you give us sort of a verbal framework of your approach to anastomotic leaks in general? How do you initially look at those patients and what sort of pathways might they go down? Yeah, I mean, the first part of the pathway is one that I think we as surgeons all know very well, which is patients with hard surgical signs, go to the operating room and get an operation. What I would say is, I think fortunately, with modern practice of surgery, many leaks are identified very early. These are people who have a low-grade fever or mild leukocytosis, who get appropriate imaging and are diagnosed with a small, early leak. So once we're sure that they don't have a hard surgical sign, we take them to the endoscopy unit. Now the basic principles are that the leak has to be within reach of an endoscope. So that's roughly ligament of Treitz, depending on what part of the colon was resected, we can obviously reach ileocolic anastomosis. Small bowel and anastomosis, kind of remain an area where it has to be a chronic issue, because we can't really reach that. So a JJ leak after a bariatric operation is not one where we are capable of managing endoscopically with our currently available tools, unfortunately. But that being said, most anastomosis that are leaking are within reach of what we can do with a scope. Basic principles are to start with diagnostic endoscopy. So we start with a small diagnostic scope, the smallest shortest scope that will reach the distance is what we try to use; we want something that's super maneuverable, that can look around corners. We do these generally in the operating room and always with carbon dioxide insufflation. You know, our anaesthesia colleagues at this point are pretty used to us doing these kind of ridiculous things. But we always have a discussion with them in our safety timeout, that this patient has a hole in some organ, and we are going to be insufflating with carbon dioxide. And that if they have any issues with respiratory pressures, peak or plateau pressures going up, hypoxia, they gotta let me know because there are things that obviously we can do to fix that; we can simply decompress. If I need to stick a needle in the abdomen to decompress the abdomen, we can do that; these are all things that we learn from POEMs procedures, right. Patients are always positioned for us to use fluoroscopy; it's really in the marriage of surgical knowledge, flexible endoscopy skill, but radiographic interpretation that we're really successful. So, before I scope anybody, I take a look at that CAT scan, I read the op notes that I know what surgery did this person do - exactly how does this person make their anastomosis? And if I don't have the op note, or they're being transferred to me, I talk to the surgeon directly. I mean, we always try to talk directly to the person who did it. Tell me - not just like this is a ileocolic anastomosis, how do you make your anastomosis? Which way are the limbs? Where do you put sutures, tell me what you did. And then we use the CAT scan to build kind of a preprocedure roadmap, and then we scope and we've got our endoscopic view, and then we inject contrast. And that contrast injection comes in the form of sinus tract injection, direct injection via the endoscope, we'll inject drains to try and figure out where stuff is going. And we'll use small ERCP catheters to investigate little nooks and crannies and staple lines to see what may be leaking. Then we're going to outline what is the exact problem. This is where Ameer said we'd put a picture up; this is where we stop and draw the picture. This is the anatomy. This is the leak. This is what's going on. Our group has a sort of a groupthink or a policy I guess of: if the leak can be closed, let us try and close it today. In order to do that, I think the main principle that we look at is how much infection and contamination are we going to orphan on the other side if we close this? If there's a drain, the answer is, it doesn't matter, right? As long as we don't catch the drain with a stitch or with the clip. We'll just leave the drain there to kind of manage whatever is leftover. If there's no drain, sometimes we go out and we wash out the cavity, decontaminate, suction out all the air and carbon dioxide and then we'll close again, in some of those patients. The worst case scenario is they get an abscess in the area where the leak used to be and need a percutaneous drain put in. In some people with that can't be reached with a percutaneous method. You know, I tell them if I had to go back and take off the clip and go into the abscess and leave an internal drain, I guess I could do that. I worry about it a lot, but I've actually never had to do that. If we're going to close it, we think about what's the best closure tool. And that's based off of what scope are we using, where are we located? Can we take the scope out and put a closure device on? Or are we kind of stuck here and we need to use through-the-endoscope methods of closure. And so that'll tell us of our 4 or 5 closure tools which one's the right one for this patient. If it can't be closed, and sometimes they can't be closed because of contamination or chronicity, we talk about: "Is this a person who we should internally drain, who we should send over with a self-expanding metal stent, or we should do endoscopic vacuum therapy? You know the beauty of all of these things is if we can reach it there once we can reach it again, generally. And that means that none of the things that we do are necessarily permanent. If I put a clip on and it fails and the patient needs a surgery, we go back and we take the clip off so that when surgeons are firing staplers, the anastomosis can safely be created. We ward every patient that we can make them worse by doing this. Theoretically, I could make a leak worse, or I could take them from a situation of a stable controlled abscess to something that's uncontained. But we've done several 100 of these now and it's just simply not the case. You know, nobody in our series of these procedures has gone from stable, contained leak situation, okay, for endoscopy to this warrants urgent surgical exploration because of something that we did. We have found some patients who when we scoped them, we kind of looked and said, "Holy cow, this person has gross peritonitis, and this is not manageable endoscopically." These are folks who are immunosuppressed and it's not obvious how sick they are when you're there doing it. But good news, we're in an operating room. And we have surgeons here not only doing the procedure, but who own this patient. And we simply say, "Hey, we're doing a scope on this person, and they have you know, peritonitis." I show a video that I have with a patient who had a total gastrectomy and who had a leak from the EJ anastomosis, low-grade white count, low-grade tachycardia, low-grade fever, not overtly sick. And when we scoped, the anastomosis on the left hand side was mostly missing. And I found a little pocket and I kind of went into the pocket and I kind of navigated. And then I realized I was kind of along a paracolic gutter. I went down the paracolic gutter and then suddenly, I was free intraperitoneal. And there was just gross contamination everywhere. And I called up the surg-onc team who owned that patient and said, "Guys, listen, I'm sorry, but I can't fix this. I want you to come and take a look." And they said, "Yeah, alright, so let's get some stuff." And they were calling for tools to do a laparotomy. And I said, "We don't need to do a laparotomy. And they said, "This guy had an open total gastrectomy 14 days ago, there's going to be adhesions everywhere. We can't do this laparoscopically." And I said, you can because I'm already intraperitoneal. And I can actually show you where to put ports in. And so we've got videos of endoscopic-guided laparoscopic port placement for a lap washout. And then we placed drains and then we sent over the patient. And so while I couldn't manage the infection, we were still able to make it a less invasive procedure to manage that problem. So even when we fail, you know, just the anatomic understanding of what the problem is, and sometimes these endoscopic laparoscopic procedures still have some patient benefit. But you got to know when to say when. Nope, we don't got 'em. I mean, they just they weren't widely available.
Ameer Farooq 47:59
We definitely have over-the-scope clips, but again, it's one of those things where, as a general surgery resident or a general surgeon, it's not something you're necessarily seeing every day. So I don't know that all of our listeners will know what you're talking about.
Eric Pauli 48:10
We have several different closure devices that we use endoscopically. Through the scope clips are small, individual clips that provide some mechanical compression. They're very commonly used for GI bleeding. They're useful as radiographic markers; you can clip and I use them a lot when I'm putting a nasaogastric tube or a Jejunal feeding extension in place; I put a little suture loop on the end and I clip that suture loop right to the mucosa. They're nice because they go through the scope. So if the scope is there, you can leave the scope there and just pass them right down the instrument channel, which is means you don't have to move the scope. They're widely available. Every endoscopy unit has these; the downside is many of them are not approved for full thickness closure because they just don't get very big bites. But they also come off very easily. And this both good and bad. If you put it in the wrong spot, you take it off, but they don't have a lot of mechanical closing force. Over-the-scope clips are much larger compressive devices that are mounted on the end of the scope with a cap attachment that looks like a kind of rigid plastic hood. And these devices are nitinol and they're kind of sprung open. And when you work a deployment mechanism, it pushes the clip off of the cap and then the nitinol makes it spring-closed. There's 2 versions on the US market, one closes in kind of a stellate pattern, right to the center circle. And the other one closes looks like a bear trap essentially; it kind of springs open and close just like a bear trap. Those are nice because they are approved for full seconds closure. They get very deep bites of tissue. But that also makes them extremely hard to remove and if you put them on wrong, you can't really work around them, you've got to take them off and removing them is really quite challenging. There are devices that are made to remove them by breaking them into pieces. But even still, it takes about 45 minutes in some circumstances to dig them out and get them off. We have 2 endoscopic suturing devices on the market. These work very similar to the endo stitch device that many laparoscopic surgeons use; it's a needle with a suture kind of swedged on to it that kind of shuttles back and forth between 2 opposing portions of the tool. And what makes this nice is it is a needle and thread. And if every laparoscopic stapler in the world broke tomorrow, surgeons would still be able to do an anastomosis because we all know how to sew. And that's really what makes these unique is if you can sew it, you can do it right. The downside is they're very challenging to learn how to use because, you've got suture everywhere, you've got a field of view that's somewhat limited; it'd be like suturing if the laparoscope was essentially tangled in the suture the entire time. They also take a little bit of working space to be able to work; the swing arm has to open and close, and if you don't have room for it to open and close or the hole is in a very small nook or cranny, the you can't get the bites that you want to get. But the universality of suture is really what makes them I think excel. The newest device on the market is a device that is basically small helical tacks, and they screw into tissue just like a laparoscopic tack that you might use to secure mesh. But run between each of the tacks is a 3-O prolene suture. Essentially it passes down through the instrument channel. So without taking the scope out, you can essentially pass this device down and you can kind of rivet 4 little rivets with a string in between them and when you pull, it opposes tissue. It doesn't get very deep bites of tissue and it's primarily indicated for closing, let's say a colonic mucosal resection bed so that you're not leaving a massive ulcer, you can actually close those fresh tissue edges. But we've definitely been using it for more challenging locations; if I can't get the jaws of a clip to open, or it's so far in a corner pocket that my Ovesco cap can't actually even get in there. This device can get right down in and you can kind of spot rivet very small areas closed. So we're kind of learning where that fits in our armamentarium. So those are kind of the workhorses of our actual closure toolset. Alright, so this is the video that I was mentioning. When we're talking about managing leaks, I said you have to be comfortable getting out into the leak cavity. And so in the video that's playing, the blue is the actual sleeve lumen and the yellow there is the leak cavity. So this is us taking a an ultra slim 4.9 millimeter scope out into the leak cavity. And we're doing some drain management; we want to put the drain right next to the leak before we close it. And obviously that cavity is pretty heavily contaminated. So we will get out there and we'll kind of wash that cavity out. Now this is the other video - this is the patient who does not have a drain in their cavity yet. And so I mentioned earlier that if there's a large amount of contamination, I can't really close the leak without managing that leak cavity. So just like interventional radiology would place a percutaneous drain in with some guidance, this is what we do here. We've got endoscopic and we've got fluoroscopic guidance. So that's the endoscopic view of a percutaneous drain being placed into a cavity and this is, let's call it, a medium-sized, pretty-well-contained cavity. Obviously, some cavities are uncontained. So this is that patient I said who had gross peritonitis, day 14 from a total gastrectomy, EJ [Esophagojejunal] and anastomotic leak. I cannot fix this endoscopically, but this is the patient who my partner said, "Well, we'll just open up the midline again, and we'll do a laparotomy." And I said, "Look, just get a trocar in and if you get a trocar in and take a look with a scope and you can't find any place else to put ports in, fine; but, there's a laparoscopic port going in." Somewhere I've got this entire video. You can see the endoscope from the laparoscopic side and the laparoscope from the endoscopic side. It's kind of fun to see those views but we placed 3 or 4 trocars, this patient got washed out, got some drains put in and he's actually like 4 years out now from his cancer surgery and he's doing well, so [he] did not have to get another operation for the leak just needed that washed out, which was done successfully.
Ameer Farooq 55:02
And just for our listeners who might have missed that, there's literally a video of Dr. Pauli with a scope and all this small bowel that you could see in the video - just sitting there in front of you. So clearly, you've been able to push the boundaries a little bit because I think my heart would have stopped, I would have needed some of the metoprolol from my anesthetist's anesthesic machine. The last thing that we wanted to chat with you about, and it's been just such a wonderful conversation with you today, Dr. Pauli, so thank you so much for joining us. The last thing I just wanted to touch on briefly was fistula management. So obviously, I'm a clerical fellow, so I've got to bring this in somehow. You showed us some great examples. Again, if you wanted to pull up those videos, that'd be great, of you managing colovesicular fistulas, again, with some of the same techniques? Can you talk to us a little bit about that?
Eric Pauli 55:52
Yeah, absolutely. Colovesicular and colovaginal fistulas, obviously, are a challenging problem. Many of these folks are older, they' may be ill, a lot of them have already had a surgical intervention; you caught the vaginal cuff in your staple line, and you need a brand new surgery there and the person's got a problem. So, again, if we can reach it with a scope, then we certainly will try and manage it endoscopically. This is a patient who has a colovaginal fistula and this is actually a flexible gastroscope that we've placed in the vagina, and the reason we go in the vagina is this is a patient who's had a hysterectomy, there should really be no outflow to the vagina, I guess inflow, and there's a hole and so we can place a wire through that defect. That means that when we do our flexible sigmoidoscopy, as you see us doing here, we can find that wire. I'm not looking for a minuscule hole near a staple line, or I'm not looking for, which diverticulum in this entire colon filled with [inaudible] caused the problem, because that's very challenging. Diverticular processes are amongst the hardest that we manage endoscopically because they're very hard to find. So once we have that wire, you can actually see in the center of the screen here is the defect that this is coming through; it is a pinpoint opening, you would never, ever have found that looking at just the colon. But by using the wire, and by advancing [inaudible], we're using an over-the-scope clip in this video, by advancing the over-the-scope-clip, essentially over the wire, we can find that area and we can get a clip on this with some ease. We typically ablate fistula tracts, because the chronic processes that are often epithelialized, and so we have the ability to do that from the vaginal side as well. And we're using some imaging here to show that the defect is closed. Now colovesicular fistulas - similar process. And this is where teamwork is important. I have a urologic colleague who just loves doing this stuff the same way that I do. He is a percutaneous master and his name is John Knoedler. And I like working with him because every time I work with him, I see a new tool or a new device or a new thing. You know, I'm very jealous of his lasers and all sorts of stuff. But he is kind enough to scope all of these patients with these colovesicular fistulous. For the same reason, the bladder should have 3 holes in it: 2 ureters and 1 urethra; he's occupying the urethra with a scope, he can find the 2 ureters and the third hole that doesn't belong there is the fistula. So here you see, they're using a cystoscope to intubate over a wire to intubate that fistula. And then essentially advanced the wire along the fistula track using fluoro to guide into the colon. So he's doing the same thing that I do for gastric sleeve leak only he's doing it from the bladder side. And then we'll do the same thing; we're taking an over-the-scope clip here with a cap attachment, we're going to find that wire from the colon side, we're going to grab it. Now the cool part here is oftentimes the configuration of where these fistula are located is very challenging. If you think about how the bladder and the colon relate to one another, especially when the bladder is full. These fistula are often on the inside of the sigmoid bend, very challenging to reach that with a scope in an end-on position to do therapy. But what he what can do is he can actually deflate the bladder, and he can actually use his rigid scope to kind of push the bladder one direction or the other. And I can use that guidewire to kind of pull the colon in one direction or another in between the two of us utilizing tools that are inside these organs, we can actually manipulate and make the angle of approach for closure a little more reasonable. In the inset you can see there's the clip - on the inside curve of the sigmoid colon right on top of the bladder there, and he's now going to use a neodymium laser. He's going to laser ablate the fistula tract. Again, this is stuff that's in their wheelhouse. They use those lasers to carve through the prostate and breakup stones and he wields it like a Jedi. So it's always good to have somebody who can work a scope. We do a lot of dual scope procedures. If we have somebody with a gastrocolic fistula, for example, from a PEG gastrostomy complication, oftentimes, we need a scope in the colon and the scope in the GI tract at the same time. The fact that I don't do flexible cystoscopy in my practice is sort of limiting, except I've got a great colleague who's interested in doing these procedures, and so we play very nicely in the sandbox. I have one, I think, coming up, gosh, maybe next week, we've got a guy with anastomotic fistula to the bladder. And he was already treated once at his local hospital; they put an Amplatzer plug in it - they got wire access, and they put an Amplatzer plug in. And I'd never seen that or read about anybody doing that before. We don't know where the plug is, except when I talked with the patient I said, "We don't know where the plug is; it may be there; it may not be there; we may need to remove it." And he's like, "I'm pretty sure I peed that out." I go, "Really?" He goes, "Yeah, about 3 weeks after the procedure; I thought I was passing a kidney stone, this thing came shooting out; I told them about it; they said 'Yeah, maybe it was maybe it wasn't'." So I think he actually urinated out his fistula plug.
Chad Ball 1:01:38
Wow, that's a wild story. Dr. Pauli, we can't thank you enough for spending the time with our audience. For faculty and trainees alike you've, no doubt, expanded our horizons and given us some really great things to talk about. I think we could chat for hours, even moving beyond the medical side of things and talking about the culture of innovation and development and the economics of it, and maybe down the road, we can invite you back to explore some of those areas. It would be great to have you.
Eric Pauli 1:02:10
Be happy to. If you guys want to talk about cheese, let me know. That's my forte.
Chad Ball 1:02:15
Exactly; we were going to close with that. And one of the questions we try and ask all of our guests is if you look back in your career and think about coming up as a trainee, what sort of advice would you have given to yourself at the time - with the insight you have now? And I was hoping you would comment on your love of cheese somewhere in there.
Eric Pauli 1:02:38
I'm not sure how that specifically relates. I guess the main thing that I would tell younger me is to realize that the plans that you have are probably not the way it's gonna turn out. I was originally going to be a family practice doctor. And then I was going to be a private practice vascular surgeon. And then I was going to be a flexible endoscopist. But then I wound up learning hernia surgery from some people, and so a lot of folks know me as a hernia surgeon. So, I just kinda go where the road has taken me. I think the other piece of advice that I always tell folks, at least in terms of research is, if there's a project that you can do and there's nothing else going on, probably do it. I wrote this paper when I was a fourth-year resident, and it sometimes winds up on Twitter. It's this thing with liver anatomy, like the little liver fist thing, you know, how to do segmental liver anatomy. So, I learned that from my surg-onc guys, and I was like, "This is amazing; other people should know this; I can't find this anywhere; It's not in a book; It's not in a reference." And they said, "Well, it's just a thing that we teach each other." So they said, "Why don't you write it up?" So we wrote about it. About 2 years later, I got an invite to write a paper from a guy who is an anatomist. And he said, "Hey, I'm an editor at The Journal of Anatomy and I read this paper; I think it's really clever; would you be willing to write a paper on liver anatomy?" I was a first-year attending at the time, and I had a lab resident named Ryan Juza, who is now a flexible endoscopist and hernia surgeon in Wisconsin - at the University of Wisconsin. I said, "Ryan, look, I'm just starting as faculty, you're in the lab; I don't have any projects for you right now. Like, we're just getting going. Do you want to do this? I think it's kind of stupid and you and I are not liver people, but he's asking, it's an invited paper, let's just do it." And he was like, "Yeah, sure; let's do it." He did an awesome job. It's a really great paper; it reviews liver anatomy from cells all the way up to macroscopic, including that little liver fist thing. And he handed it in and we added it to our CV and we kind of moved on with life. Well, that same guy - the anatomist who invited us to do it has moved on in life and he is now one of the section editors at Grey's Anatomy. And about, I don't know, 6 years after we wrote that paper, he came back to me and he said, "Hey, you may not remember me, but I asked you to write this liver paper and I'm now at Grey's Anatomy and I looked you up, because I remember you wrote this thing, and I thought it was really good, and I see that you're a hernia surgeon; would you be willing to write the abdominal wall chapter for Grey's Anatomy?" Of course, I would. I mean, obviously, that's a yes. But, that opportunity came from something that amused me that I was interested in, followed by something that was maybe not so amusing, but I felt was at least something academic for us to do while we were getting our lab up and running into something - my mom is actually really proud that like my son wrote a Grey's Anatomy chapter, right. So opportunities sometimes come disguised as work. I'm not saying say yes to everything. You obviously have to have a pocket full of no's here and there for things you definitely don't want to do. But don't just say no because something isn't exactly how you want it to be; be open to new opportunities.
Ameer Farooq 1:06:23
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.