Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have three Northwestern Medicine physicians for you today in a complex patient case at Northwestern Medicine. Joining me is Dr. Aziz Aadam, he's an Associate Professor of Medicine and the Director of Interventional Endoscopy; Dr. Daniel Borja-Cacho, he's an Associate Professor of Transplantation Surgery; and Dr. Ahsun Riaz, he's an Associate Professor of Vascular and Interventional Radiology.

Doctors, thank you so much for joining us today. And Dr. Borja, I'd like to start with you. How did this patient present to Northwestern Medicine?

Dr. Daniel Borja-Cacho: Yes, thank you. This is a patient that presented to our clinic after undergoing surgery. The patient developed initially a stage IV colon cancer with metastasis to the liver. He had surgery at a different institution and was referred to our clinic with two problems. The first one was a fistula, a biliary fistula. There was bile coming out of the drain for several weeks that was difficult to control. The second problem was an obstruction through the main right hepatic duct, so his liver was not working properly. And because of this obstruction, we knew that the fistula was not going to heal easily.

So, we have several thoughts. The first one, of course, we wanted to avoid any major intervention and any major surgery. The reason is this patient needs to receive chemotherapy. If we do a large surgery to fix his biliary fistula and the bile duct injury, we would have to have the patient for at least six to eight hours recovering, assuming that he did not have any complication during this time. He would not receive chemotherapy, his tumor was going to progress, so that was the first challenge.

The second, this is a patient that had multiple interventions before, multiple surgeries. And doing a surgery like this to fix his right hepatic duct is a surgery that can be associated with other complications, like bleeding, like injury to other structures like the bowel, fistulas, abscesses. So for us, it was very important to try to control this as soon as possible, and trying to avoid any major intervention. That's the reason why I decided to consult Dr. Aadam and Dr. Riaz and discussed the care of this patient.

Dr. Abdul Aziz Aadam: Yeah, I mean, I think that there was concern that there was a potential hepatic duct transection and discontinuity with the rest of the bile duct when we reviewed all the imaging together. So, you know, very complex situation, of course. I think the patient, you know, his quality of life was impacted quite a bit. He had two drains that were percutaneous, that were draining bile continuously. And I think that was really problematic for him. So, I think that this patient presenting, you know, a big challenge for us and really trying to see how is there a method that we can eliminate those drains and restore continuity to his bile duct.

Dr. Ahsun Riaz: Yeah. And I think one of the things that we have kind of worked on at Northwestern is to improve the patient's quality of life. Interventional radiologists have been using techniques to drain and decompress the biliary system for a very long time. But the problem with the way they've approached it is that there's something coming out of the skin. There's a drain coming out of the skin. There's leakage, there's pain, there's a lot of problems associated with drains. We actually published a paper recently showing that around 40% of patients with biliary drains have leakage around the drain that saturates their skin, that causes abscesses around the tract. So, we are very careful with these patients. And when we put these drains in, we're actually figuring out how to get these drains out. This patient presented from an outside hospital with two drains in and we wanted to get both of these drains out, but we did not really have a way to do this without this multidisciplinary approach that we have.

Melanie Cole, MS: Which leads me into my next question very well. Dr. Aadam, how did Northwestern address this challenging case? You all represent three surgical specialties that contribute to the patient's treatment plan. Tell us how you all work together for this multidisciplinary approach.

Dr. Abdul Aziz Aadam: That's a great question. And I think we've really developed this collaborative approach. And I think any hospital, obviously, you know, doctors collaborate together. But I think the difference at Northwestern Medicine is the way that we do that. And we do that seamlessly. We do that in each other's clinical spaces. We scrub in together during a case. And Dr. Borja might call me into the operating room, you know, "Can you scrub in? Can you tell me what you can offer for this patient?" while he's operating. For Dr. Riaz, he might have a complex case and say, you know, "Can you come over and can you simultaneously do an ERCP while I'm doing a percutaneous approach? And we can do a rendezvous procedure like we did in this situation."

And I think you only learn each other's true strengths and weaknesses when you're working together in the same session. So, in this patient's particular situation, he was worked on and had attempted surgeries to fix this problem at that original hospital on several occasions and several different experts.

But I think the difference is what we did, is doing it all at the same time. You know, we went to the Interventional Radiology suite, we brought all of our endoscopy equipment. We were alongside Dr. Riaz while he's working from the skin side. We have a scope in position, ready to do that ERCP portion. You know, grab that guide wire and allow him to pull us up. And when you work together like that, you learn so much about what each other can do, and it really opens a lot more doors than if you were working alone in your own respective clinical space.

Dr. Ahsun Riaz: Yeah. I have to mention that as well. So, interventional radiologists are trained to use imaging. They know how to use x-ray, read an MRI. But in this case, we were using endoscopy from the skin as well. So, that's something that is very unique to our program where we've learned so much from our GI colleagues that we can actually put a scope through a subcentimeter hole incision in the skin and get into areas where we were not able to get into. We were able to see a three-dimensional structure in a three-dimensional fashion and then use that information to do what we need to. In this case, we were able to put a camera down through that area where the drain was already placed, making no new incisions. And we were able to do the rest of the procedure through that, which is amazing. And the credit goes to Gastric/GI because they were able to help us and they were able to teach us to do that. It's a very unique situation where we're doing this to benefit the patient, improve their quality of life. I think Dr. Aadam and his colleagues have done a great job at nurturing and teaching me, and I've become a better interventional radiologist because of that.

Dr. Abdul Aziz Aadam: Well, it's very kind of you to give us credit. But he was the wizard, you know, really working the endoscope, percutaneously, the guide wires. It was truly remarkable to see this live, because when we reviewed this case I think that the chance of success, I think we had put at 50/50. And I think by working together again in that same capacity, that's what really opened a lot of opportunities here.

Dr. Daniel Borja-Cacho: And I think that most of the people that are familiar with cases like this outside Northwestern are going to understand that these cases always, or almost always, go to surgery. The type of therapy that was offered at Northwestern was unique. It's not something that is offered at every single institution. And these both super specialties are great for us. It helps a lot in the management of complex biliary cases.

Dr. Ahsun Riaz: And one other thing that I have to really mention, I think this is something that makes me very comfortable is that I'm going into these cases having outside-the-box approaches, but I'm able to do that because I have colleagues like Aziz and Dr. Borja. If something goes wrong, I know Dr. Borja can do something to repair the injury that I may cause in trying to do these outside-the-box cases. If I didn't have that backup, I would not do these really complex cases. And that is a very, very important thing for me. The confidence that it brings that having surgeons like Dr. Borja around, where I can just give him a call and say, "Oh, I think there is something that happened that might not be something that we can take care of," and then surgery is the next option.

Dr. Abdul Aziz Aadam: Yeah, it's really remarkable that we're doing a case together. And we'll say, "Wow, well, you know, this is kind of far apart. I don't know that I would normally attempt to go this sort of distance." And I'll look over at Dr. Riaz, like, "That's okay, just go for it." Because he knows that he could rescue me and he's in position. And I think that that trust in each other, and we can rely on each other's expertise, that's what really, I think, makes the difference in a situation as complex as this.

Melanie Cole, MS: It really is amazing and such a comprehensive approach how you all work together. Dr. Riaz, what postoperative care was required to ensure the patient's recovery? How was this part coordinated among you three specialties? Speak a little bit about followup and postoperative care.

Dr. Ahsun Riaz: So, I think there were a few components that we are going to talk about. The immediate postop care is really important in these patients. We've done complex cases, sometimes created tracts that are not anatomical, not natural. And we want to make sure that there's no leakage in those tracts. And the patient does not have major problems with the drain or the stents that we placed. So, immediately post-procedure, the patient goes to our post-anesthesia care unit. They make sure that the patient's doing well, is recovering from anesthesia. And then, we admit them to our hospitalist service or the transplant service, they get admitted overnight. We make sure they are doing okay.

In this case, the patient did perfectly fine. IR and GI closely followed them while they were inpatients. And then, in the morning after the procedure, because the patient was doing well, we were able to discharge them. So, the immediate postop care was very, very uneventful. The long-term care, I think, is the more important part in this case. We've placed the drain that we needed to. We've crossed the stricture. And we are able to now have access across the narrowing and do things about it.

So, the next things were guided by two principles. To try to get the drain out as quickly as possible so that the patient's quality of life got better, and to address the narrowing at the same time, which increases the ability of us to take the drain out and make a viable solution for this patient where he does not require a drain again.

So, in this case, we had, as Daniel Borja mentioned, we had a leak where the bile was leaking into an area above the liver. The drain output, even after our drain placement, the complex procedure was still high. So, we actually went in from the drain that was going into this biloma into the duct that was leaking and embolized it. And that significantly decreased the leakage that was happening from that duct. And after that, once that duct was embolized by particles and coils, we were able to do a procedure with GI again. So, a second rendezvous procedure, where we took the drain out, and then GI placed a stent. So, there are two systems, the anterior system and the posterior system. The anterior system is where the drain was, the posterior system was where GI was able to get a stent in in the beginning. And through the anterior system, we were able to place a stent. And then, the patient was drain-free. So, there was nothing exiting the skin. The output, there was no more leakage. The patient's doing great as far as their liver function is concerned. So, this is a great outcome.

Dr. Abdul Aziz Aadam: Yeah, I think that it's important to highlight that this minimally invasive approach, you know, as opposed to an operation where the patient would be admitted for several days and recovering, that this was a 23-hour observation. And, you know, the patient did really well and was able to go home. And then, we brought him back a week later for the second procedure and effectively remove the drain, that external drain at that time. And this patient, I think he really felt defeated. He is dealing with a very difficult diagnosis to begin with an advanced stage cancer. And on top of that, has these morbid drains, which are leaking and are causing a lot of problems for him and had several attempts to fix this and it didn't happen. So, he felt defeated. And I think that day when we told him that it was successful and that we were going to do this followup procedure a week later to take this drain out and internalize it with a stent, you know, the smile on his face and his family's face. You know, it was really remarkable that we were able to come together and really give the patient not only a good outcome, but a positive outlook on his situation itself.

Dr. Ahsun Riaz: So, I think there were a few things that happened, right? So, there are a few images that are there. So, figure one is kind of what the patient came to us with. It's a T2-weighted coronal MRI, which is showing a biloma, which is on top of the liver, where bile is just leaking into the space above the liver, and then very dilated ducts. So, the biloma is where the green arrow is pointing to. And then, the dilated ducts, because there's a narrowing downstream, this is the white arrow. So, the patient presented to us with a drain in the biloma and an external biliary drain in the duct, and the previous attempts at outside hospitals have failed. So, that's why we coordinated this amazing case.

And I think one of the major credits goes to our hepatobiliary team where Allison Reiland, one of my nurses, and Kristine Stiff, one of my nurses, was able to coordinate this really great case where Anesthesia, our room, Gastroenterology, everyone had to be. And I think it's a well-conducted orchestra when everything happens well. And that was the case in this case, GI was able to get access to where they needed to be. I had the ability to get to where I needed to be.

So on the day of the procedure, as you can see in figure two, we were able to put a camera through the skin, and one of the arrows is pointing over there. And then, figure three is where I think the game-changing aspect of this case happened. We're looking at a flush occlusion of the actual duct, and we were looking at it, and we saw this little green dot at the two o'clock position inside this image. And we started focusing our wire. It's not even a millimeter, the size of that little dot. And our wire is 0.035 inches. So, we started pushing our wire in that specific spot, and we're able to cross into the main duct from that little stricture. And that, I think, was the main reason this procedure went the way it did. Because we were able to see a 3D structure in a 3D fashion from the inside.

And then, figure four shows the very common, very tiny common bile duct that we were able to cross. And once we were able to cross it and get into the bowel, that's where the beauty of this multidisciplinary approach comes in. We had a wire down, gastroenterology was able to use that wire to get up into the posterior duct. In an instance, if we did have this multidisciplinary approach, the patient would require another right-sided posterior drain, and we were able to do this procedure with the minimal number of drains possible. And then, Dr. Aadam expertly placed a stent into the posterior system, I placed the drain into the right anterior system, which we were later able to convert into a stent a week later. And the patient did not have anything exiting the skin.

I think one of the things that's really important was that the patient, as Aziz said, was ecstatic after the procedure. We gave him hope when we started, the process of doing this case, and we were able to do what we intended to, which is amazing, because I think that multidisciplinary approach was able to do that.

 I think one of the things that I wanted to mention was because of this multidisciplinary approach, we're able to do innovative procedures. We have backup, we have backup ideas in our mind in case our first line approach doesn't work. And I think that's what makes us great.

Dr. Abdul Aziz Aadam: Yeah, I think the key differentiator here really is the use of endoscopy percutaneously by Dr. Riaz. And I think, you know, that's where our expertise kind of crosses lines, it crosses specialties. So normally, you would expect the endoscopist to be performing the endoscopy. But here, Dr. Riaz, you know, who's nationally and internationally renowned for his cholangioscopy from a percutaneous approach, because I don't think that this case would have been successful without the use of a cholangioscope inside that duct. Don't you think? I mean, it's an acute angle. It's a tiny, tiny opening. I think if you just use the traditional fluoroscopic methods, I don't think you ever would have crossed it. What do you think?

Dr. Ahsun Riaz: I totally agree with you. There was no passage of contrast from the main duct that we were in to the duct that we wanted to be in. And this was all just being able to see that little green dot where we thought the opening was and focusing our attention to that specific area. If we didn't have endoscopy, this would not have happened.

Dr. Abdul Aziz Aadam: Yeah. So, this non-conventional method, this newer technology that has really been innovated at Northwestern is the use of percutaneous cholangioscopy, the use of interventional radiology-guided endoscopy that I think really, you know, pun intended, opened up the case here and was really able to restore continuity of this bile duct and eliminate this drain. And, you know, now the patient has a stent, which is changed periodically. But the overall improvement in his treatment plan, his quality of life is just immense.

Melanie Cole, MS: Doctors, this is such an exciting patient case that you have all worked on together. It really is amazing technology. I'd like you each to give a final thought. And Dr. Riaz, since so much of this has been focused on quality of life, speak about that patient now and what their quality of life is like. And then I'd like the other two docs to speak about lessons learned from this case that you can really use because it is so remarkable how you all work together. Lessons learned that can be applied to future complex resections.

Dr. Ahsun Riaz: So, I'll start with the quality of life question. I think we as physicians are great at doing our procedures. And some of our medicines are great at improving survival. We are not really good at improving quality of life. And I think the focus of our procedures should be improving quality of life. And I speak for Interventional Radiology, that before we started doing all of these multidisciplinary cases, We were doing procedures where we were just putting drains in, and these drains would be inside patients for over 10 years without really a resolution for them in sight, because there was nothing we could offer. Now we can, because of these multidisciplinary approaches. The fact that we could convert a drain to a stent, where the patient doesn't need anything coming out of their skin, and then go to Aziz, or one of his amazing colleagues, where they can exchange the stents, and do what is intended to be done from the inside without having something coming outside their skin, is amazing.

And the patients extremely appreciate that. I think once they, once we put the drain in, we have the ability to discuss how to get that drain out. This patient's quality of life improved significantly. From two drains coming out the skin, there were zero. Whatever problems were associated with those two drains that he had, he came to me at one point with one of the drains completely dislodged. The drain just fell out. And we had to get back in because we needed that access. So, the having no drains coming out the skin, having everything internal is a huge improvement in quality of life. They can do what they intend to do as their normal day of life activities. They can swim, they can take a bath. With the drain coming out the skin, you can't do all of those things. They can sleep properly. Imagine having something sticking out of your skin and trying to go to sleep. I think those are all things we don't really think about. But we have started thinking about it and trying to minimize the impact of these drains in these patients.

Dr. Abdul Aziz Aadam: Yeah, I mean, I think we're guided by common principles and we have the saying, you know, no drain left behind. And it's important because at the onset, before the procedures even started, we're thinking of, "Okay, if this drain is placed, how is it going to come out? And when?" To avoid those patients who have indwelling drains for years or 10 years. And that coming up with a treatment plan in advance and leaning on each other's abilities and expertise is really what what makes the difference here. And I think, especially in this situation, that that definitely held true.

I think, you know, lessons learned otherwise is when we encounter these very complicated cases to anticipate where problems may arise and talk across specialties and collaborate with each other to say, "Okay, if this happens, you know, what would be my rescue? Is this something that I need to involve you? What can you offer?" And then, ultimately, you know, how can we solve any problems that they create as a result of what we're about to encounter?

Dr. Daniel Borja-Cacho: Yeah. The last thing that I want to emphasize is that cancer patients are very complicated. And every time that they have a complication like this, it delays the additional therapy that they need, right? Sometimes they need chemotherapy, sometimes they need radiation. So when they have a complication like this, the standard of care is delayed. So, having a team like we have at Northwestern that fixes this complication as soon as possible that allows the patient to finish or undergo the rest of the therapy is very important.

We're talking about one patient here, but we have a monthly meeting in which we discuss all our complicated patients, transplant patients, cancer patients, patients with bile duct injuries, and being humble and recognizing that sometimes other specialties can provide feedback that is going to help you.

The outcome of your patients is very important. I think that that's perhaps one of the most important lessons. Always be open to the opinion of your colleagues rather than opposing to the advice of someone else. Always listen to the advice and try to solve the problem as soon as you can.

Melanie Cole, MS: Very well said. Doctors, thank you so much for this absolutely fascinating discussion and for sharing your expertise for other providers. Thank you again for joining us. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.