Salih Tokmak
@DrSalihTokmak
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of G.I. / Diagnostic and interventional HBP / ERCP and EUS enthusiast / Difficult situations require different solutions / Tweets are my own
Duzce University
Joined February 2022
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@sahajrathi
@JovaniManol
I would definitely prefer our novel technique PA-EMR, especially for these types of papillae. I presented the data vs NKF in
@ESGEDays2023
and the vibes were strong
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@BegumOztan
Çünkü hizmet üretiyorum, emek harcıyorum. Oturduğum yerden al - sat yaparak ya da başka insanların emeklerini, babadan kalma zenginlik ile sömürerek asalaklık yapmıyorum. Vergimi eksiksiz ödüyorum. Devlet biliyor benim ne olduğumu, güveniyor. Sen kimsin? Sana neden güvensin?
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3
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⁉️ What's going on here? ⁉️
💡 49 y/o, M, hospitalized for alcohol-related severe acute pancreatitis
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I was reading this book 10 years ago while I was an internal medicine resident. At last, I met the legend
@KMonkemuller
at
#ESGEDays2024
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Introducing : EUS-FNA Phytobezoar Dissolvement
💉 19G EUS-FNA (
@bostonsci
Expect)
📍Penetrate deep inside the phytobezoar
🥤Inject Coke (citric acid) to the amount of your discresion.
🏪 Call the patient a week later, you'll see no such thing as a bezoar.
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Soooo, I said something like RELOADING OTSC last week. Here is how to do it:
@Stentingwoman
@helpatologist
@EHolzwanger
@DouglasAdlerMD
@neilRsharmaMD
@DrBloodandGuts
@Taalamri
@SahajRathi
@AgnihotriGI
@MendozaLadd
@AntonioFaccior6
@stevenbollipo
@drkeithsiau
@b
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89 y/o female
🚨 Perforated GB
🚨 Biliary sepsis
🚨 Intubated and on full pressors
➡️ 10F 10cm DPS to GB, transpapillary
Makes wonders 🎊🎊
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How is your saturday afternoon going? 🥩🫕 anyone?
We had an interesting visitor
🚨 That's a 20mm sphincteroplasty
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@drkeithsiau
That's explotation of the cheap workforce. I don't support and don't get involved in health tourism at all. But I can say this to some of the comments here : we can do everything you do and than some more. We could do even more if we had the infrastructure.
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Band EMR for Type-I NET in duodenal bulb gone wrong. OTSC for the rescue. What would be your approach?
#GITwitter
#MedTwitter
#ASGEendoscopy
@neilRsharmaMD
@DrSaeeeed
@DrBloodandGuts
@MendozaLadd
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3
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@ESGEDays2023
was a faboulous organization, including state of the art presentations and brilliant studies but these were the most important moments which are price less
@drkeithsiau
@stevenbollipo
@NEndoscopy
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⁉️⁉️ What's going on here ⁉️⁉️
🔥Tip : performed all - at-once
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🔥🔥That's what you see after sphincteroplasty with a 22mm diameter 🎈 for DASE.
➡️ For the optics : the diameter of the stone extraction balloon here is 15mm.
#GITwitter
#MedTwitter
#ERCP
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As of today, I'm 39 years old 🎂🎊
This year I think I gave myself the best present. I have been appointed as of GI last week 🎓
@DuzceUni
But still a way to go 🛣️ 5 more years for a full Professor position.
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🔥80 y/o male with acute RUQ pain
❌History of ERCP but no CCY (unfit for 🔪, b/c of 🫀failure)
🚨 Perforated GB!!! and on 🩸thinners
✅ ERCP to the rescue: Transpapillary GB drainage (7F 10cm DPS)
🔄 Only stent, no 🔪, no 🎈dilation
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So, what's with this papillae and the direction of sphincterotomy?
@DouglasAdlerMD
@Taalamri
@DrBloodandGuts
@MendozaLadd
@DrSaeeeed
@PadiWind
@ASGEendoscopy
@ESGE_news
#GITwitter
#MedTwitter
@AmerGastroAssn
@AmCollegeGastro
@japariciot2
@stevenbollipo
@NeilBhogalMD
@tberzin
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Bismuth Type IIIa cholangio carcinoma. Using 10Fr Cystotome facilitates access to right hepatic duct and performing stenting with ease. Does anyone use it?
#GITwitter
#MedTwitter
#ASGEendoscopy
@DouglasAdlerMD
@tberzin
@KMonkemuller
@DrSaeeeed
@neilRsharmaMD
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🚨EUS-CGS🚨
📍 We prefer biliary FC-SEMS with co-axial DPS to prevent migration
📍 1/3 the price of LAMS, way more chepaer than Hot-LAMSs.
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@drkeithsiau
That's not a public hospital. One of the very few. The infrastructure we need is increased workforce so that I didn't have to see 80 patients in clinic every day or at least 20 endoscopic procedures every day. And better equipment.
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🚨🚨
Excellent review from a magnificant crew
🔥🔥
🩸 Review on Endoscopic Therapy for Non-Variceal Upper GI Bleeding
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@DouglasAdlerMD
I prefer an EUS-FNA needle. Stick it all the way to the middle and inject Coke. You'll see the bubbles come out and fragmantation afterwards.
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Our study just published in
@endoscopyjrnl
about the use of RFA in patients with MBO.
📈 overall survival with RFA+stenting vs stenting only 🔥🔥
Thank you
@DarylRamai
for including me in this excellent study. Looking forward to the next one.
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Do you lock the R/L wheel of the duodenoscope while performing ERCP?
@drkeithsiau
@GWebster_endo
@DouglasAdlerMD
@sahajrathi
@stevenbollipo
@KMonkemuller
@helpatologist
@Taalamri
@DrBloodandGuts
@DrSaeeeed
#GITwitter
#MedTwitter
Of course 👍👍
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Hell no 😤😤
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87 y/o 🧓
🚨Acute cholangitis
🎈💠DASE - 22mm sphincteroplasty and en-bloc extraction of the stone
🏁 Total procedure time : 9 minutes
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🔪 edge technology of 4K scopes by
@PENTAXMedicalUK
with the brand 🆕 INSPIRA series.
🚨 After 5 months from it's World premiere in
@ESGEDays2023
, we have it here in
@duzceuniversite
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If you get over ambitious, perform a 22mm sphincteroplasty and a Stapfer Type II perforation occurs for en-bloc extraction of a 3cm CBD stone, you can use a 22mm DUODENAL FC-SEMS to close the defect.
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97 y/o 🧓, acute cholecystitis with multiple comorbidities 🫁🫀, unfit for surgery.
🪜Step-by-step transpapillary GB stenting 🛣️
🚨 Notice the long position of duodenoscope, searching for cystic duct.
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EUS-LB
➡️One pass
➡️Three actuations
➡️Wet suction (heparin primed)
Maximum patient comfort and much more easier to perform compared to percutaneous approach.
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The bile comes up and the bile goes down 🎢
📍 EUS-CDS (biliary FC-SEMS) plus duodenal U-SEMS in a patient with pancreatic cancer causing obstruction in both lumens after failed ERCP.
📍Cost-effectivity at it's highest.
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Had a great course this weekend in İzmir. The best part was meeting with the legendary Marc Barthet the first endoscopist to perform EUS-GJ and getting the top tips.
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❓What's the problem here❓
🥇Clue: The stent is in the pancreatic duct
@DouglasAdlerMD
@KMonkemuller
@docdhir
@NEndoscopy
@drkeithsiau
@neilRsharmaMD
@helpatologist
@DharJahnvi
@japariciot2
@DarylRamai
@sahajrathi
#GITwitter
#MedTwitter
#ERCP
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✅EUS-HG✅
📍82 y/o male, h/o Billroth-II for gastric ulcer 30 years ago
📍New onset metastatic colon cancer, duodenum infiltration
🚨Attention to the level of stent insertion ➡️ Just below the EG junction
💉 Bilirubin pre-procedure 21.9mg/dl, 12 hours later 13.4mg/dl
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🚨 EO-CBD (Ectopic opening of common bile duct)
➡️Forward-viewing therapeutic endoscope
➡️ Opening in the anterior wall of duodenal bulb
➡️ Note the hook-shaped distal CBD
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📢📢📢
And it's on... Starting with guideline guru
@AntonioFaccior6
and stellar Chairs, talking about an old nemesis: diagnostic workup of biliary strictures 🔥🔥
#ESGEDays2024
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EUS-LB for elevated liver enzymes of unknown etiology
📍 19G FNB needle
📍 Heparin flushed needle w/o stylet
📍 Single pass, three actuations
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@drkeithsiau
So many of my collegues is working like that, even worse. I bet it's the same in all the developing countries.
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💫🇩🇪💫
Enjoying the beautiful Berlin before the marvelous
#ESGEDays2024
(Please note the Marx and Engels subtweet 😏)
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Final lap for
#ESGEDays2024
!!! in Berlin 🇩🇪
I would like to remind everyone that as a member of the QIC ERCP Working Group, we welcome you for your questions about guidelines and our precious app during breaks.
See you soon!!!
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@DouglasAdlerMD
We perform ERCP in the ICU with the aid of abdominal US without x-ray for patients with biliary sepsis and on pressors. You can see guidewire moving in the common bile duct.
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@helpatologist
@DrLakhtakia
@GWebster_endo
@Srisha_Hebbar
@docdhir
@AnandSahaiEUS
@SahajRathi
@Endo_OC
@tberzin
@japariciot2
@TheBileDoc
@drkeithsiau
@KMonkemuller
@DouglasAdlerMD
@AdvaniRashmiMD
@kmalik2009
@Samir_Grover
@LumirKunovsky
@CarlKayMD
@pinoygastro
@shaimaa_elkholy
We also have a blue water trick :
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➡️ 67 y/o, M
➡️ h/o pancreatitis
➡️ early satiation, occasional vomiting, weight loss, constipation
➡️ 1/3 the price of LAMS. Nice alternative for resource limited settings.
Do you prefer that?
#GITwitter
#MedTwitter
#ASGEendoscopy
@DouglasAdlerMD
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@drkeithsiau
That's textbook divisum. Yes, the CBD is dilated but I think it's secondary to pancreatitis.
a-Gallbladder
b-CBD
c-Santorini
d-Wirsung
e-Renal calix
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⁉️⁉️ What's going on here ⁉️⁉️
🚨 Tip: watch out for the 🛣️
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Proud to be part of a brand new and ambitious editorial board.
🚨 Open access but no APC
🚨 5 year IF: 1.81
We are aiming for higher grounds and awaiting your contributions
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Three in a row or should I say three peat? (Sad Knicks fan here 🗽🏀😞)
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@drkeithsiau
@tberzin
Another tip : The width of vertebrae is approximately 3cm. Helps estimating the length of CBD and appropriate choice of stent, if need be.
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That's a Bristol Scale Type 2 😁
#MedTwitter
#GITwitter
@ASGEendoscopy
@AmerGastroAssn
@ESGE_news
@AmCollegeGastro
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Not even a single word about EUS-HGS for the management of hilar malignant obstruction? 🤯🤯🤯
In the 📕
#RedJournal
:
Diagnosis and Management of Biliary Strictures: A Clinical Practice Guideline Dissemination Tool
Anna Tavakkoli, MD, MSc & Jennifer L. Maranki, MD, MSc
👉
@MLongMD
@JasmohanBajaj
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@sahajrathi
@docdhir
@amolbapaye
@DouglasAdlerMD
@EHolzwanger
@NEndoscopy
@pbendoscopist
@helpatologist
@sachdevmd
@neilRsharmaMD
@AgnihotriGI
@ChahalPrabhleen
@BilalMohammadMD
@krishnanendo
@Taalamri
@drkeithsiau
@stevenbollipo
@DannyIssaMD
@CaptCholangio
@DrAshokGastro
I think you can guess that I'm a "Never take-off your feet from the pedal" kind of guy 😁 💨🏎️🏁
Joking aside, "tap-tap" is the same as pure cut and an independent risk factor for sphincterotomy related bleeding.
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Proud to be a part of
@ESGE_news
QIC ERCP Working Group. I'm looking forward to meet the members.
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Preparing a lecture about how to organize an endoscopy suit. Besides the guidelines, I want to make it more colorfull. Any suggestions or slides? 😁
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@ThomasBalanis
1️⃣ That's a fantastic MRCP image and I see pancreas divisium.🪢
2️⃣ Oncocytic type is a rare subtype of IPMN and unfortunately the prognosis is poor.
💡The diameter of PD seems at the border, so it's not main duct IPMN.
📍Suggestion: distal pancreatectomy +splenectomy
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@docdhir
@SahajRathi
@NEndoscopy
@DouglasAdlerMD
@MBronswijkMD
Whooaa!! Dr Huibregtse is the first endoscopist to use needle knife!! No wonder this is a textbook papillotomy 👏👏👏
I'm still not a fan tough. Back than I would go directly to fistulotomy but now, I prefer this:
@sahajrathi
@JovaniManol
I would definitely prefer our novel technique PA-EMR, especially for these types of papillae. I presented the data vs NKF in
@ESGEDays2023
and the vibes were strong
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61 y/o female, LDLT, NASH related cirrhosis. Post LT strictures (Type-IVa) caused intrahepatic lithiasis in all ducts.
Cleared them all, stent them all...
🚨 Notice the broken peace of GW from a previous ERCP in another center
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@drkeithsiau
I'm also an anti-lock endoscopist, especially in ERCP. I believe locking prevents getting to more favorable angle.
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💡Has anyone seen a pancreatic lipoma?
🔎 Definetly hard to see with EUS. Elastography for the rescue
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@DouglasAdlerMD
I always put two stents in. I think if even both get obstructed, bile still can flow between them. Is it wishfull thinking? WDYT?
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@Dr_mike08
@puentesfabi
@drkeithsiau
@RodriguezParra_
@mauriciorincons
@edgmarparra
@Angel_Rojas_E
@Calvo_Gastro_sv
@KMonkemuller
@EricKnauerMD
@neilRsharmaMD
@jeanvemer
@mdjuanalcivar
@jgarciacano1
@ViryOregel
@DrJBerrueta
I have an idea :
Sphincteroplasty with 20mm balloon can be safe and very effective in selected cases. It would be much better to extract the stone en-bloc, rather than fragmentation. High probability of residual small stones.
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Back-to-back EUS-BD procedures
➡️ 67 y/o M, EO-CBD, cannulation failure, choledochobulbostomy
➡️ 74 y/o M, Whipple (Roux-en-Y) for pancreatic malignancy. Anastomotic relapse and liver metastasis, hepaticogastrostomy
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Fascinating image of cannulation using PA-EMR technique:
➡️ A very bulky Haraldson Type 3 papilla
➡️ Orifice is down there in the right corner (red arrow)
🚨 Any ideas about the orifice in the upper right? (orange frame)
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Late bloomers, you're missing a state of the art presentation about pancreatic cyst sampling by
@AntonioFaccior6
with a killer faculty
@ESGEDays2023
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@sahajrathi
@omukkkk
@stevenbollipo
@drkeithsiau
@KMonkemuller
For the record, hemoclips are very effective in variceal bleeding especially in non-tumoral formation fundal varices as was on the video and the blebs in between post banding fibrotic tissue.
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@drkeithsiau
Need to see the path report but if it’s Marsh-IIIa or above, it can be seronegative celiac disease. It's more frequent than you can imagine :
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@Taalamri
@AkwiAsombangMD
@Dr_mike08
@DrWahab1
@alerepici
@alhaddad_mo
@KMonkemuller
@TarunRustaGI_MD
@EndoCollabcom
I just don't understand the need for grading biliary leaks. What difference does it make whether it's high grade or low grade? The SS rule doesn't change : Sphincterotomy + Stent
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Dear
@MendozaLadd
I would like you to know that I believe you'll be a great "Member Councilor" of
@ESGE_news
and that I voted for you.👏👏👏
Looking forward to meet you in person. 🙋
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@drkeithsiau
@DouglasAdlerMD
@tberzin
@KMonkemuller
@DrSaeeeed
@DrBloodandGuts
@GWebster_endo
@Taalamri
@MendozaLadd
@sahajrathi
@stevenbollipo
@EndoTx
@NeilBhogalMD
@MetabolicEndo
@CaptCholangio
@ChahalPrabhleen
The role of percutaneous intervention is almost non - existent in our approach to HBP pathologies. If it can be done, transpapillary route is the first line (mimics the physiology) and if not, EUS guided transluminary approach.
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Introducing CAST : cap asisted suction technique for clearence of bile duct stones.
#GITwitter
#MedTwitter
#ASGEendoscopy
@neilRsharmaMD
@DrSaeeeed
@DrBloodandGuts
@AmerGastroAssn
@AmCollegeGastro
@DouglasAdlerMD
@tberzin
@ESGE_news
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@sahajrathi
@DrLakhtakia
@drsridhars
@NEndoscopy
@helpatologist
@Taalamri
@ChahalPrabhleen
@stevenbollipo
@amolbapaye
Happened to me once : passed a GW, pulled off the LAMS, angulated the GW to proximal CBD with a sphincterotome and then deployed an 8cm biliary FC-SEMS with a co-axial 10F, 8.5cm DPS.
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@charlie_lees
You sounded like thiopurines are off-the list completely. They're not for induction of remission, we all know that. Nothing's new here. Still recommended for maintenence.
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Just found out that I'll be presenting in the same session in
@ESGEDays2023
with
@DarylRamai
. Looking forward to meet in person. Maybe even a handshake will increase the number of my publications 👏👏
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Nasty maljunction. Had to perform contrast guided cannulation. That's a first after more than 4000 ERCPs
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@helpatologist
@Srisha_Hebbar
@KM_Pawlak
@SunilAminMD
@drdalbir
@GI_Guy
@DouglasAdlerMD
@pbendoscopist
@HilarHolzy
@SahajRathi
@KMonkemuller
@manuknayar
@DannyIssaMD
@GWebster_endo
@TheBileDoc
@CaptCholangio
@GNTPak
@drkeithsiau
@DharJahnvi
@LumirKunovsky
@Taalamri
@NEndoscopy
@drnataliegastro
The GW could not be negotiated in to duodenum. I would try an ERCP cannula or sphincterotome to get it past through that acute angle and papilla instead of Cystotome.
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@Taalamri
@neilRsharmaMD
@DrLakhtakia
@TarunRustaGI_MD
@SyedGerdezi
@NEndoscopy
@MendozaLadd
@drkeithsiau
@AlmuhaidbAymen
@BilalMohammadMD
@JoanB_Gornals
@KMonkemuller
@KM_Pawlak
@EndoCollabcom
@Samir_Grover
@shifaumarMD
@doctorboletoh
Until it resolves but I always put a co-axial DPS to prevent adverse events or guidence for reintervention.
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@NickMcDonaldMD
@ChahalPrabhleen
@bsc_endoscopy
Great tips. Let me add three more :
1️⃣ Put GWs both sides first and than proceed to stenting
2️⃣ Always dilate hilum bilaterally before stenting
3️⃣ If you don't have Johlin (we don't) and afraid that you might not traverse the stricture, modify a NBD appropriately
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@dramrmaged
@Taalamri
@HilarHolzy
@amolbapaye
@AnandSahaiEUS
@DouglasAdlerMD
@neilRsharmaMD
@AgnihotriGI
@AntonioFaccior6
@Belenmm271
@ChahalPrabhleen
@MetabolicEndo
@CaptCholangio
@Stentingwoman
@SahajRathi
@NEndoscopy
@docdhir
@drkeithsiau
@DharJahnvi
Those are excellent questions.
First, it's temporary of course. Based on control imaging, we will approach this like a WON.
Second, the patient comfort is off-the charts and this is the most crucial thing about internal drainage procedures.
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@japariciot2
@EndoscopiaH
@Belenmm271
Perfect position of the scope, excellent technique 👏👏
Questions :
1️⃣ For tract dilation, did you use balloon, Cystotome or neither?
2️⃣ You pushed the 🎈 out of CBD to D2 but nothing else for the sphincter. What if the stone gets impacted? What about adding sphincteroplasty?
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📢 Packed with fantastic presentatitons,
#ESGEDays2024
ended but I must say that this session was the best.
Thanks to stellar Tomas Hucl, Jan-werner Poley, Ionnais Papanikolaou and Marianna Arvanitakis for the interaction 🔥🔥🔥🔥
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