JEFFREY W. MILSON Novel Multidisciplinary approach: Small Bowel Obtruction

Nice. I was hoping. So how many different countries are...

A lot. A lot. And also you have to think about that yesterday more than 50,000 people were connected.

connected wow wow really a lot that is that is that's crazy yes it is say that again you said

50 50 000 people were connected wow that is amazing and how many different countries

I can tell you

I can tell you how many

but I can tell you

the number of the

countries I can tell you

in a couple of minutes

ok so

do you want me to start my presentation

yes you can it's 1 o'clock

ok everybody

I want to thank

the organizers

of this conference and especially

my friends longtime friends Marco Vitellaro from Milano and Giorgio

Palazzini Giorgio thank you and to all the organizers of the many many people

they're working and I want to also say thank you to the many contributors to

this meeting and I hope that we can have a good exchange of ideas I want to tell

you something about some of the new ideas that we're bringing up in treating intestinal conditions.

And with my colleagues listed here, Anuj Malhotra is an interventional radiologist

who's among the people working very hard in the operating theaters, along with Tejero Hirashta

and Shinya Urakawa, who are two research fellows working with me. Tejero is from

from Oita University in the southern part of Japan. Shinya is from Osaka University

in Osaka, Japan. And I want to thank all my other colleagues from Weill Cornell, New York

Presbyterian Hospital, the many nurses, technicians, and other people. My conflict of interest,

I'm on the advisory board of one of the products that we use in this procedure.

Lumendi is the name of the company.

And so I want to take a pause and to say also that I hope all of you out there who are working today are staying safe.

And we know there's a crisis in many countries.

I'm just showing you as of this morning what the case numbers, et cetera, in the United States are.

This is from just a little after midnight this morning, and we know that all of you face crises in the pandemic,

and I think there's cause for optimism even amongst us as surgeons that this is a time of stimulation.

and we'll talk about that later. So our mission, and it's not just my mission, but I believe it's

all of our missions here, is to create new approaches to the treatment of GI diseases,

new therapies, and in my opinion, they have to be less invasive. They should be less costly

and safer of course and so with that today's patient is someone who has a small bowel

obstruction all of you know and are very familiar with this disease it's so common

and about probably one-third of patients who develop a small bowel obstruction are going to

to need surgery. And in our country, this is a disease that's twice as common as colorectal

cancer as far as the need for surgery. Surgery is associated with huge complications and a certain

mortality. And the cost in our country of treating small bowel obstruction is huge. And so we've

tried to develop a strategy for acute obstruction, everybody knows that someone who might have

dead bowel or strangulation, et cetera, has to be operated on. But there are others, quite

a few others, where we could consider other approaches. And in our case, those approaches

are going to be potentially use of endoscopy and advanced imaging. And I want to emphasize

that this is a surgical mentality that we have to take, and likewise, I want to talk to you a

little bit about percutaneously approaching the intestine. Now, if the patient has something that

we're also very familiar with, intermittent obstructions, meaning comes and goes, we again,

those patients get imaging studies and may or may not have surgical treatment, and this could be

either open or laparoscopic. But when it's in the distal part of the intestine, what we've learned

here over the last year or so is that we can potentially approach these patients like the

patient we have today using some novel approaches. So I'm going to just speak for a second about

using endoscopy and advanced imaging. What do I mean by that? So we're using, and this is one of

of our actual operating rooms that you see on the right side, where we have a type of machine. This

is a cone beam CT made by General Electric, but we have this or the Zego Artist. And this actually

is an operating room in our interventional radiology suite in one of our new buildings.

And with this, we're borrowing, for the time being, catheters, guide wires, and balloon dilating type

of instruments from the vascular surgery and cardiology worlds, and we're combining this

with endoscopic tools that most of you may be familiar with, along with guide wires and balloon

dilation catheters common to endoscopy. We also have this sleeve that we'll show you an example

of that we slide over the endoscope that provides improvements in navigation stability, and it also

allows us to exchange instruments through the intestine through this, if you want to

call it an overtube, that's one of the things that we call it, or we are now calling it

an interventional platform.

So one of the first patients we treated for an adhesive band, you can see over here on

the left side of the screen, we were able to approach, you can see this patient had

an adhesive band.

It looks like a stenosis, but it's actually a band.

And what happened was we got a guide wire through there, and all of a sudden the adhesion was released.

And this angulation of the scope suddenly straightened out, and we got upstream.

So this is where we got some of the inspiration that this could potentially be a treatment for adhesive small bowel obstruction.

structure. Now, percutaneous access to the bowel is another idea that we're pursuing

because it's a direct path, and it allows us to gain entry into the small intestine,

and it also permits tool exchange of things like guide wires, balloons, and other things,

so that we felt taking this direct path, if it was safe, was something to consider. In

And in our lab, we worked on some models you're seeing here on the left side.

This is actually the abdominal wall of a pig, pig intestine,

and that using some techniques you can say that were borrowed from percutaneous gastrostomy

where T-fasteners that you see at the bottom of the screen,

you'll see in our patient that we use this, can be used,

And then in the middle of a triangle that you form on the abdominal wall, you can begin to introduce small sheaths like what you're seeing here.

These are vascular sheaths that are nothing more than like a small trocar, although they have several different functions.

And that we showed some things, this is one of our experiments, just so that we could close the holes made with endoscopic clips.

And so, this inspired us to consider that maybe this could be done in patients.

So, the case that I'm presenting today is a woman in her late 60s who has had chronic, intermittent, but severe small bowel obstruction.

Many years ago, underwent rectal cancer treatment with radiation post-operatively.

and as a result developed narrowing in the intestine

and is on TPN now for the last several months

because of the severity of her obstruction.

She also has developed strictures in other body parts

as a result of her radiation.

She has a permanent colostomy

and she was just taken to the operating room.

Dr. Palazzini wanted a live case

so this was a little easier for us so three days ago the patient was taken to

our special theater okay so I'm going to begin to start showing you and I will

pause this is about a five minute but we're in the operating room now and what

What we're doing is loading up this overtube called the dilumen.

And we're first lubricating and getting it set to be put in the body through the patient's colostomy.

You can see in the operating room, it's very crowded.

We have the endoscopic towers.

We have a lot of different screens in the room.

And you'll see as we go through, the patient's over here on the right side.

Okay.

So you are approaching from the stoma.

What's that, Marco?

You are approaching from the stoma.

Yeah, so we're approaching this.

She has a permanent colostomy.

Hold on a second.

I'm trying to see how I can go forward.

Now I'm advancing the platform, see?

We have this stable platform, see?

and now through this diluent sheath we're passing a catheter so that we can then inject contrast so

we pulled the endoscope back okay and we're passing this through the sheath over into the

right part of the colon oh sorry sorry about that hit the wrong button so now you see we're into the

small intestine and we've passed this catheter with a balloon on it which

we're now blowing up and then we're going to inject contrast through this.

Can you hear me Marco? Yes, yes we can and also we can see everything.

So now what we're going to do you this if you see my screen this is the

cone beam CT okay and we're now positioning this so that we can start to see the stricture so we

have the endoscope in place and we are going to now inject contrast through this catheter you

see this is a digital subtraction image here's the colonoscope up here and the stricture is going to

to be located down in this area and we're doing it what's called a digital subtraction image

and so it's a contrast if you look right here this is where what the stricture is going

okay so contrast going retrograde down into this loop of intestine and then you're going to see

the contrast and here's a very dilated loop up here that is upstream of this obstruction

You'll see a little bit of the dye now start to trickle upstream into this very dilated

loop.

Again, the strictures here.

Can you see it?

Yes.

This is, again, a digital subtraction type image.

Most of you familiar with this in vascular surgery, they use this all the time.

The other thing you can notice, the patient's severity of radiation.

The reason we wanted to avoid surgery is she has a ureteral stent here.

She has an iliac artery stent, and these are some of the consequences of her severe radiation.

So now we're going to do what we call a spin.

We're going to do the cone beam CT.

That's going to give us the idea of where we can approach the intestine percutaneously.

continuously. So what you get with that type of image is a series of still images, just

like in regular CT. You get a series of two-dimensional pictures that are pieced together to give

you a three-dimensional image. Again, by taking this in around the patient, and then we could

could see, here's the endoscope, we could see that the colon itself, and again, we were

focusing, I'm just giving you one still shot of this, but we could see that we could approach

the intestine straight through here to pursue a pathway that would allow us to get out the

stricture. Again, rather than going entirely through the whole colon, why not, if it seems

safe and feasible go right through the skin so at this point we then marked a

place on the patient's abdomen and then this is Dr. Malhotra who's my colleague

in interventional radiology he's passing a needle through the skin he's injecting

some contrast we see what that we're in the in the lumen of the bowel and I'm

I'm confirming this endoscopically, so in other words, at the same time, I'm watching

and we're confirming that this is in the proper place.

So you understand then that we've now stabilized the wall of the intestine so that we can get

entry.

And so we're making a plan then, how can we safely get in?

And so you see here in the operating room, we have our radiographic images to the left.

This is actually a 3D image that we used as part of the cone beam CT.

And then the endoscopic image here that we're using so that simultaneously we can see on the surface, inside the lumen, and radiographically.

and we're now attempting to thread the introducer first with a guide wire and we're right now at

the junction between the patient is already also because of the radiation had the cecum

and a portion of the terminal ileum removed and you can see an anastomosis here it's an old

anastomosis so a guide wire is being threaded downstream sorry upstream it's following the

the pathway. It's following a pathway upstream into the small intestine. And then using that,

we were able to thread first a guide wire and then an introducer sheath. And this is, again,

borrowing from what interventional radiologists, cardiologists, and vascular surgeons use all the

the time, which are tools that we're obviously going to have to modify as we move forward

in performing new therapeutic approaches to treating intestinal diseases.

So what we're now seeing is that we now are upstream of the stricture.

You can see this contrast is falling into a very dilated loop of intestine right here.

Can you see that, Marco?

Yes.

And so you can see we've threaded this guide wire way upstream so as it's allowed to be safely into that area.

And now we've passed a balloon catheter upstream.

So we now have the, I'm going to stop this for a second, we now have this catheter in the large dilated upstream portion of the intestine.

And back here, you should see the shoulder of the stricture, where the balloon is indented.

This is prior to putting a lot of pressure into the balloon dilator.

And this is now going backwards.

You can see, again, this is the stricture and possibly some other areas,

because we think this stricture was not just a simple, short diaphragmatic stricture,

but probably several centimeters long.

and we're gradually blowing up, and now we're pulling this back.

You can see how the balloon is indented here and thinned out

because I think the stricture is likely somewhat of a U-shaped segment of the intestine.

But you'll notice also that the intestine has taken on a much straighter pathway

since we've introduced the catheters, guide wires, and balloons into this.

so this is at a low pressure and that we got serially dilating this area so we've pulled back

this is the upstream part this is where the introducer sheath is so now we're in the middle

of the area that is narrowed and we're using again our combination of modalities

these, a sophisticated fluoroscopy, cone beam CT, several screens showing the radiographic

images, and then intermittently the endoscopic image, and using tools now that are largely

made for vascular interventions, including the balloon dilators, we're going backwards

through, or sorry, we're going pro-grade, but we're pulling backwards through the stricture

and making sure every part of it is dilated up so now we're like nestled right in the middle of

where we think the narrowed area is we're blowing it back up again and and there's a pressure range

that you follow uh that we're learning about what can be safe but uh the technique of doing this

is obviously still under development in the intestinal world and then bringing

it up and holding it there for one or two minutes we're now again in the

middle and you can see now with an imaging shot that contrast is flowing

freely through it's going to back that up for a second contrast is flowing

three freely through the intestine upstream into the very dilated part here

and that there's nothing like what you saw earlier about this convoluted.

And you see that the loop of the intestine has been straightened out quite a bit as well.

We then took out the introducer sheath, the balloon,

and we're now left with a single guide wire that's entering the lateral and anterior wall of the colon up here.

And what we're going to do is, after pulling that, close this area.

We decided in this case to use three clips.

but usually two or three clips are going to be adequate to close this. This is

just showing passage of the third clip. Again doing this under endoscopic and

this is Dr. Lowenfeld, one of my partners in colorectal surgery. So this is

and this is Dr. Malhotra, interventional radiologist working all of us in tandem.

them it's a good team a good team shot so this is placement of the third clip and then exit from the

bowel and finally just the appearance of we this is a radiographic shot to confirm that we we had

closure and then this is it this is the entirety of the wounds on the for the patient these little

T-tag holders. So the patient was allowed to awake from anesthesia. On her first day,

she was given a liquid diet. She was taking no pain meds or maybe Tylenol. Yesterday,

we kept her in the hospital because she had a high ostomy output. It was a little bit dehydrated,

but was eating a soft food diet. And I actually went to see her this morning

before this conference and she's ready to go home. She feels good. Her vitals are stable

and she's ready to go home. So in summary, for the treatment of distal small bowel obstructions

that could be approached through the colon or percutaneously, we think combination types of

treatment that we've discussed today appear to be feasible. We've treated about eight patients

thus far, with several more scheduled. The treatment appears to be durable. Some of the

patients have been treated as long as a year ago, and we also, up for discussion, believe that novel

approaches to treating various intestinal conditions are emerging. I know it's controversial

controversial in some countries when you would look at a procedure like this and just say well

well you know uh i don't do endoscopy as a surgeon that's gastroenterologist's job

but my my feeling is for us to make advances we should be looking on the talents of many people

from many different disciplines not just doctors but engineers nurses phds etc if we're going to

to move things forward we're we're considering other conditions uh that and we have treated

other conditions that you see listed here uh and reporting on these over the ensuing months

i want to remind all of you in the midst of all what all of what seems chaotic and uncontrollable

that pandemics should drive progress

and to remember that imagination,

that thinking of new ideas

is what will give birth to an evolution in our field.

So with that, I want to thank Dr. Palazzini and his crew

for giving me a chance to share one of our approaches

to treating intestinal conditions and would

answer any questions if any of you have any. And I want to thank

all the members of my colleagues,

associates for their support, including

some of whom I'm seeing are on the call, some of the colorectal surgeons.

Marco, you know Dr. Pagazzi. He's our new chief here.

Absolutely. Dr. Yeo, Dr. Lowenfeld, Dr. Shukla.

Dr. Garrett, actually, Kelly Garrett, one of my colleagues, this was her patient, actually,

who she asked me to consider this kind of treatment on, Dr. Dan Hunt.

And obviously, I'm emphasizing multidisciplinary, but none of these things are possible without collective efforts from many people.

Congratulations. It's a great idea.

idea. Obviously, it's a great performance

and it's absolutely important

to perform this type of

procedure in a place with a

multidisciplinary team that can guarantee

a procedure like this

because it's

It's a very big organization in the back to have the chance to do this.

For sure.

And I think also some of us are so fortunate to work in a large institution like yours, Marco, as well.

Absolutely.

National Tumor Institute, this is our responsibility to find safer, more effective,

and in my opinion also less expensive means of treating patients with the diseases that are so common

and so deadly around the world.

Right now the patients that you have treated are patients all with bowel obstruction

obstruction or also bleeding? Yeah, this is probably one of the more

common indications that I think we're seeing bowel obstructions. The first patient that I

treated was an elderly woman who was in the hospital for three weeks after a colon surgery,

and Mike Lieberman, one of my colleagues, said to me, hey, Jeff, I don't want this lady to have

have another surgery. She's kind of stuck. Is there any thing you could do? And so I was lucky,

I think, that I was able to get and kind of break an adhesion. We're also using it to treat

fistulas. We've treated several fistulas successfully using endoscopic and advanced

advanced imaging, and enderocutaneous fistulas, and we're optimistic that it can be applied

to some of these other conditions. I think you can imagine also that once you,

once you, once, and I believe we will prove that percutaneous approaches to the intestine

are safe, that you can start thinking about a lot of things that could be treated, polyps,

probably early cancers. And it's not just catheters and guide wires. In our lab, we are

inserting tools. So you can even put graspers and other surgical instruments, and you can go from

one thing to the next, meaning endoscopy, well, then people will say, well, why can't I put

two introducers or three introducers? Why can't one of them have a camera on it? And so there'll

be a progression. And so then also, like you and I've said many years ago, Marco,

today, somebody might watch this presentation and say, well, that's for gastroenterologists,

just maybe but then wait a second well how about if i put start to put things that cut or things

that grasp or things that clip or close divide directly through the skin that when it takes on

a real uh if you want to call it a real flavor of surgery who should do that and so this is uh

This is much like other fields that I think new therapies are going to evolve

and that, in my opinion, although I'm biased,

surgeons should be among the main drivers of that change.

Absolutely. I agree with you.

I can see Alessio. Welcome.

Hi, Marco. Congratulations.

for the new job in New York

thank you very much

I know you

Dr. Morrissey

and the rest of the team told me a lot

about your time here

I'm sorry I missed you for a few years

but please come back and visit us

absolutely, thank you very much

thank you

and

obviously

congratulations for

for this type of new combined therapies

that could be done in a great place

like New York Presbyterian,

where you can do,

where you can project

and then you can study on the model

and then you can do on patients.

I saw all the track in your place when I was there, and I think it's a great opportunity for a place like yours to have the chance to think about new strategies like this.

We'll keep going.

Absolutely.

And Alessio, Marco, and Giorgio told me next year they want to invite you

to do a live surgery for the meeting.

Great.

Thank you so much.

And thank you, Jeff.

I think this is a great demonstration of what surgical innovation is about,

about imagination, multidisciplinary approach, and a lot of guts.

So, kudos.

We'll keep going.

Okay.

Thank you very much.

The imaging is perfect, the sound also, we have a great presentation from New York,

and so we really thank you for your time and for being here in the conference

that something like 50,000 people were on this conference

in the last two days.

And how many countries, Marco?

Okay, I will send you something, I think, like 25, 26.

Wow.

Thank you for letting us be a part of it.

It's a very great opportunity.

And for you, Giorgio, that's Guglielmo.

sitting next to you

we look forward to meeting and continuing

to exchange ideas

thank you very much, see you soon

let's go

ciao, have a great day

have a great conference and we thank you

thank you very much, ciao Alessio

see you soon

thanks to all my colleagues for joining

ciao