Lot of interesting ideas, but Jonathan DeLong, MD took it w his frame-by-frame analysis!! Cystic duct is very short + inserts directly into R posterior sectoral duct. Contrast goes into liver preferentially (creating the 'blush', not a vascular fistula). It's an air bubble CBD, not a stone..

What is going on in this intraop cholangiogram?? (Hint: will be easy to get distracted by the less interesting abnormality...)
Eric Knauer Amber Shada Maggie Bosley, MD Shiva Jayaraman Jonathan DeLong, MD Michael J. Pucci David Gomez

Common during lap chole: after ductomy for IOC, you milk a stone out of cystic duct. Cystic then feels soft, but when you place IOC cath there is complete resistance/back pressure to flushing. WWYD next??!?

Eric Knauer Maggie Bosley, MD Michael J. Pucci Hope T. Jackson, MD Ron Barbosa MD FACS Kevin El-Hayek, MD, MBA, FACS

Very important for all trainees + surgeons who do chole to watch. I've been called in on 2 similar injuries. Two things jump to mind: 1) realizing how contracted GB can be w chronic itis 2) continuous reorientation to 'landmarks' (duo, falci, Rouviere) to avoid medial dissection

As Eric Knauer mentioned, cystic insertion was too acute/medial to flex scope into CHD. So did balloon sphincteroplasty w hope that fragments would flush antegrade. Interestingly, initial post-plasty IOC w complete obstruction (?stone, spasm), but after more flush final was 👍

Awesome job Cassie Valukas, MD (@purplesurg resident) presenting a complex case of endoscopic treatment for leak after sleeve gastrectomy at SAGES is in Long Beach in 2025! #SAGES2024 . On that screen, the leak defect was about 10 feet in diameter!!

Blind Spots of EGD

1️⃣ Esophageal Inlet
2️⃣ Esophagogastric junction
3️⃣ Diffusely narrowed esophagus

🧵How to mitigate each blind spot 👇

#GITwitter

Great discussion! Here's what I did: needed wire to get scope in. Stones too large to extract, so crushed + flushed into duo. CBD looked clear, but on completion IOC possible stones in hepatic ducts. WWYD now??

Eric Knauer Maggie Bosley, MD Michael J. Pucci Eric Pauli Matthew Martin, MD, FACS, McRIB

Interested in GI perspective. What would you recommend/do if you got called by surgeon intraoperatively during this case??
RKeswaniMD Jasmine Sinha Joseph Triggs, MD, PhD Douglas G. Adler MD, FASGE, FACG, AGAF Sri Komanduri Aziz Aadam Allison Schulman MD, MPH A. Samad Soudagar

Lap cholecystectomy in pt w h/o Roux-en-Y gastric bypass. Unfortunately cystic ductotomy avulsed when trying to milk out stones. IOC then shows CBD stones, but no obstruction. WWYD now??!?

Eric Knauer Michael J. Pucci Maggie Bosley, MD Shiva Jayaraman Alberto Isla Kevin El-Hayek, MD, MBA, FACS

Patient w prior lapatotomy has recurrent small bowel obstructions, on CT have the same transition point. SBOs resolve w non op mgmt. At what point (if ever) would you recommend elective adhesiolysis to prevent future SBO??

Eric Knauer Amber Shada Ron Barbosa MD FACS Michael J. Pucci

How many hernia sacs does a paraesophageal hernia have?

Amber Shada Abhishek Parmar Eric Pauli Vahagn C. Nikolian, MD Paul Colavita Andrew Wright MD Eric Knauer

Interesting path of the thoracic aorta, as seen through the hiatus during lap paraesophageal hernia repair... (**for bonus points, can you find another vascular anatomic variant here??)

Excited to share our early results with this new technique!

Love this slide from Prakash Gyawali on using adjunctive tests to build confidence for EGJ outlet obstruction disorders

ANMS Clinical Virtual Symposium on Oesophageal Motility Testing happening now

Diana Snyder, MD Bianca Chang

#GITwitter

📣EXCITING OPPORTUNITY to join a top ranked division by U.S. News & World Report for Gastroenterology and GI Surgery
Details here: tinyurl.com/2p9ve43t

🧵regarding 1-handed knot tying:

We'll go over basic concepts about knots and how to tie the '1-handed' knot.

We will also explore why one of the 'throws' is harder than the other, and a different way to do it that may be new to many who trained in surgery in the U.S.
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