My, my charge really is to talk about. Now this is a 30 minute lecture as opposed to the 20 minutes yesterday that we had. But still, it's a big topic, and I'll try to cover good, which is gastroesophageal reflux disease, as well as Barrett's esophagus and Barrett's endotherapy. So, just move this along here. So here are my disclosures. The objectives of this presentation are to review the presentation of good diagnostic parameters and some insight into management and reflect on some of the potential complications of good as such. Then discuss which patients should be screened for Barrett's esophagus and or are eligible candidates for endoscopic evaluation. And then of course, Barrett's patients who are candidates for endoscopic therapy, and the various modalities of endoscopic treatment that are available currently, and are well established, and then review some of the challenges along the way, and finish up with practice pearls so a lot to cover and I'll try to do it as lucidly as I can. So the good paradigm is, you know, and the outpatient setting probably one of the more common GI diagnosis that any and all of us will be will be seeing now I despite the fact that my practice is quite specialized in the pancreatic biliary and esophageal or GI oncology realm. I still every month will see new referrals for good or a typical good or some form thrust of reflux disease and a typical chest pain that are referred on after they've had multiple evaluations. And so this is not an uncommon diagnosis to be evaluating even in highly specialized clinics. The typical symptoms of good include heartburn and the so called water brash that's something you'll find in in textbooks, and occasionally patients may even have it would I know Asia which is painful swallowing from severe esophagitis, they may have a typical and difficulty swallowing which is dysphagia. A note about a typical chest pain is that when you see typically a male patient who's middle aged and is coming as a referral as a new referral for a typical chest pain, it behooves us to make sure that these patients have been evaluated, at least to some degree for cardiac disease, because, in general, a typical or typical chest pain or any degree of chest pain is not one of the first or typical findings of good so it's more of a rule out situation and it would be almost disastrous if we had an angel situation, presenting and being referred to us as reflux, and this is a common question on the GI boards for our fellows, and the answer almost always is initiate cardiac evaluation, or at least make sure that a cardiac evaluation was done so that's an important point I wanted to make. But of course many of these patients will always almost always will have had a cardiac evaluation and our charge at that point is to rule out reflux. It increases equal prevalence and males and females but increases suffragettes and males, particularly those who smoke, or have other lifestyle aggravators. Be aware of a typical symptoms such as horse voice and cough and so forth, we'll get into a little bit of that but occasionally it will present with symptoms like asthma and such as well. So let's see if this. So the pathology of good in a simplified way. Basically boils down to an increased into a relatively increased internal pressure presence of a higher to learn here which is usually in most of these patients and a defective esophageal clearance or motility and delayed emptying. Of course there's impairment of the lower esophageal sphincter, which is at the heart of the problem. And this graph shows very nicely, how content or acid refluxes back through the hiatus, and the lower esophageal sphincter which is more patent than it should be. And, and compared to a healthy stomach, where the sphincter is closed or pinched appropriately. When we are not eating and drinking. So, the symptomatology of good I reflected a little bit on that the typical patient will have heartburn, we're all very familiar with the heartburn presentation, sometimes older patients will have some more regurgitation especially at night when they are recumbent or supine, but a host of different symptoms will come especially in some of the younger patients, where they may have especially in females, a global sensation, some degree of chronic cough. As I mentioned, undiagnosed or asthma of unclear etiology. So all of these are symptoms to be considered when you're evaluating a case of suspected heartburn or reflux. There's a fair amount of data on on the good paradigm. These are some of the more recent guidelines, the American College, as well as the AGA has put out position statements and expert reviews and guidelines on the evaluation and management of patients with good so that they are mentioned here and are available to you on this deck through the enduring material component, which will be in the post conference setting. So these are important guidelines to at least look at once when you're starting a clinic or or establishing a practice, but also refer back to from time to time because they do get updated every several every so far so often, you know, based on new data that's available so good reference point to keep in your clinic. So according to the diagnosis of good which is based off of one of these guidelines, you have a patient with this is as simplified an algorithm I think that we can generate so patient comes in with heartburn regurgitation, and there are no alarm symptoms which basically means there's no dysphagia, there's no weight loss there's no upper GI bleeding, and so forth. And these symptoms are occurring with a sufficient frequency to to impair quality of life and this has become a problem so this is the kind of example you will get. And this so the initial recommendation is start the PPI, you know, for eight week once before meal. So daily PPI it's a relatively low dose. And if you have complete relief of symptoms and good is the likely diagnosis, and at that point you can discontinue the proton pump therapy. And if the symptoms recur the patient goes to endoscopy. Now on the other side, if you try the PPI trial, and the patient has incomplete relief or no relief or symptoms worsen, then definitely I think endoscopy is indicated pretty much at any age. And there are a few outcomes from endoscopy that you can have that, especially if the patient is off of PPI, is that you can have what we call esophagitis defined by LA grades, Los Angeles classification BC and D which is more significant esophagitis, or, or if you have an esophagus which I will describe later on in the talk so if you have one of these findings, then good is confirmed. On the other hand, if you have a normal upper endoscopy, or very minimal esophagitis, then at that point, you are basically looking at some type of pH monitoring whether it's a 24 hour pH or a Bravo test and so forth. And if that pH testing is normal, then the patient doesn't have classic acid reflux, then you need to consider other causes for the symptoms, and those other causes can range from dysmotility to non acid reflux or a variety of other situations but at least a an objective test that reveals lack of acid exposure would be an important data point to have. But on the other hand, if acid measurement reveals significant acid exposure, then good is confirmed and then you can go ahead and treat the patient with PPI. The reality of clinical practice is such that the vast majority of patients who will present with classic acid reflux early on, particularly at the primary care level, or at the general GI clinic referral for the first time, they will likely have reflux they'll have some inciting lifestyle factors, and they will respond to PPI, and the vast majority of them will continue to be dependent on PPI in one form or the other, some will undergo endoscopy, and some will have more difficult disease to treat some will have easier disease to treat some will be compliant or adherent with their lifestyle modifications, others will not. So that's kind of sort of how this table or algorithm really pans out in life and we can talk a little bit about in the discussion, but I thought this was a very simplistic way of presenting how we approach this. Now the next slide is really very important and I should say that it also represents a very important board question on the GI board so when the third year GI fellow graduates, then they have to write the ABIM GI boards, and this is an almost a question every year. And the question is the is the emphasis on the importance of dietary and lifestyle modifications so the message here is that unless the patient is making a concerted effort to, to, to, to, to address these lifestyle modifications. PPI alone may only take you so far. So you have the patient is smoking they have to stop smoking, you know, they have to elevate the head of the bed to a degree that is, you know, adequate for the symptom control and really try to avoid trigger foods that are here and that we are very well aware of. I think one of the important things we talked about is not eating within three, three hours of going to bed or laying down, because that's, that's something that can incite reflux very easily. And this can be even several more hours depending on if you have gastric dysmotility so gastric dysmotility is an important cause of persistent reflux despite doing all the things right, and should be something that's kept in mind so somebody comes in and they're doing the dietary and lifestyle modifications they're on PPI they're being good citizens, but they're still not feeling well, I would think in terms of whether their stomach is too slow and not clearing the food in the typical amount of time that's normal. Increased BMI has been reflected upon as something that has, you know, an adverse effect so weight loss is important and it has several other beneficial effects, but it also helps with management of reflux. So when to perform an upper endoscopy for for for good. Certainly, a patient present at any age with alarm symptoms which is dysphagia upper GI bleeding or melanoma. And, you know, and weight loss and older patients, anytime, or anytime you have an abnormal upper GI imaging such as a barium swallow or chest CT which is done for whatever reasons, and shows a problem. So anytime you have any alarm symptom or sign or diagnostic test upper endoscopy should be performed with a low threshold. Anytime the patient has an inadequate response to PPI, such as we talked about earlier, endoscopy should be invoked and then of course there are other benefits of symptoms. After discontinuation of proton pump therapy. I mentioned about the typical chest pain, this is a recurring theme both in clinical practice and on exams. As you can see here, there is an increased emphasis on making sure that these patients don't have an underlying cardiac etiology and of course when the patient presents with a history of long standing reflux typically more than five years, and on top of that, IBMI is Caucasian male possibly has a family history of Barrett's or esophageal cancer. I wouldn't waste much time and bring that patient to endoscopy because that is a poster child for Barrett's and for development of esophageal cancer. So these are listed here in an easy format to read and will be available to you on the enduring material. Now the esophagitis is based on the LA classification system as you can see here minimal esophagitis or a few mucosal breaks, grade A, and then it goes through BC and to D where D is confluential breaks in the mucosa pretty much circumferential disease. This is, this is bad news. This needs to be treated aggressively and optimally, and has a combination of patient lifestyle modification, as well as optimal dosing of PPI, and there is a recommendation to confirm healing of esophagitis particularly for grade C and D, where you really cannot tell in the index endoscopy, whether this patient really has a degree of Barrett's or intestinal metaplasia or not. And that can only be discovered properly. Once you, you know, achieve healing, and the patient comes back, typically in a two to three month timeframe. Another thing that's important to note is that when your endoscopies are performing biopsies in the setting of severe inflammation, the pathologists actually are not able to distinguish sometimes whether there is inflammation, or this severe inflammation could be indefinite dysplasia, or low grade dysplasia. So there's a lot of confusion that is created when you biopsy severe esophagitis, and that's another reason that patients need to come back to check the healing, and then, and then biopsy if an abnormality is found such as Barrett's. A word about pH testing here, the Bravo pH study is very familiar with this is an endoscopically placed device, and the study goes on for several hours, and it really is mainly for acid reflux does has no impact on non acid reflux, such as it doesn't measure impedance, and typically we perform this off of PPI, some patients will have some chest pain, whether it's psychological or real, we can never really parse it out, because it does get pinched onto the esophageal mucosa, and the esophagus lining is quite sensitive to any intervention compared to some of the other organs, but it's a very commonly done test, and can be done very easily on an outpatient setting and provides presents very minimal discomfort to the patient because there's nothing hanging off of their nose. The pH plus impedance study now pH is for acid and impedance is for non acid reflux is typically done for 24 hours is can be placed without sedation. But some patients will need endoscopy for placement, and it can be uncomfortable with something hanging off your nose, but it's also done to rule out acid reflux and non acid reflux, both of these entities so just to note on that. The management of persistent good is basically failed medical management. The traditional therapies have been laparoscopic fundoplication, and for obese patients even gastric bypass has been invoked and sphincter augmentation type of procedures have been done, but more recently there is a lot of excitement about the endoscopic procedure the trans oral incision less fundoplication, which is being done in many centers right now in the United States and other parts of the world. So there's more to come on this I think as data evolves the selection criteria for the patients are very strict and the long term outcomes are still awaited but it's looking in the last three decades many endoscopic reflux anti reflux procedures have been developed, but this seems to be the TIFF procedure seems to be the one that that seems to be here to stay for now. Complications of GERD, I refer to a few of them peptic strictures develop when severe esophagitis is not managed well. Schatzky's ring develops a peptic stricture, peptic ring develops there. Early these patients can bleed and over time develop iron deficiency. And then of course we are very familiar with the potential for development of Barrett's esophagus and esophageal adenocarcinoma with long standing untreated uncontrolled reflux. The practice pearls for GERD are listed on this slide we've covered most of them, but an eight week empiric PPI trial is important as the initial therapeutic trial and and the algorithm I've already discussed for that chest pain without classic heartburn cardiac evaluation warrants an EGD with pH testing or even impedance testing depending on the presentation endoscopy for all patients with alarm symptoms, the very high significance of dietary and lifestyle modifications and gastric emptying studies for those who are not responding with stomach dysmotility is suspected. And of course I refer to the endoscopic and surgical options for patients who have diagnosed diagnosed GERD, but have not responded to medical therapy. Now moving on to Barrett's esophagus. It's definitely a pre cancerous condition in the United States defined as at least one centimeter of what we call columnar lined epithelium, which is typically found in endoscopy, and when we biopsy the segment, you need to be specialized intestinal metaplasia with goblet cell metaplasia so this is the US definition in Europe and other parts of the world. They accept the definition of just one centimeter or more of endoscopically visualized columnar lined epithelium they don't require the biopsies, and that is the way it stands right now. Short segment Barrett's is less than three centimeters and long segment Barrett's is more than three centimeters. And as I mentioned it's a pre cancerous condition, and the annual risk of progression to adenocarcinoma 0.3% in patients who have been diagnosed The importance of short and long segment has recently become important because in the recent guidelines, the recommendation for short segment Barrett's is to come back for surveillance in five years, but for long segment Barrett's, the recommendation is now changed to three years, so that's important. Risk factors for Barrett's have alluded to some of them but Caucasian race, obesity, male gender, older age and family history are some of the big ones. And these do keep popping up on exams and in clinical practice of course it's very relevant. Alcohol consumption does not increase the risk of developing Barrett's and that's a frequently asked question, and comes up in clinical context as well. The natural history of Barrett's esophagus is described on this slide I use this actually a hand right or hand right it almost every time I see a patient with with new Barrett's nondisplastic be or Barrett's is what typically most patients will have and they will die with that disease without any further progression. But a certain number of patients will progress, as shown here, some will go to indefinite and stay there and bounce around between indefinite and low grade. Some will progress from low grade to high grade and intramucosal carcinoma very fast. And then, if untreated intramucosal carcinoma does not take too long to become invasive. It goes on to a much more ominous pathway so this is very educational for patients to know most of the patients that are referred to us for endoscopic therapy lie in this middle stage which is low high grade displays here or intramucosal cancer. Some are referred for this stage but actually have more invasive disease. And so it's a spectrum of patients but this is very educational for patients to know the rates of progression for nondisplastic Barrett's are point two to point 5% per year, this is pretty consistent in literature. And when you have low grade displays here, of course the rates go up, and when you have high grade displays here, then it really goes tenfold so high grade displays here is an entity you really have to treat endoscopically low grade displays you can monitor or offer treatment as part of the current guidelines. So the development of neoplasia listed here. I do believe I think the advancing age and longer segment of Barrett's and central obesity are big ones, tobacco smoking doesn't help. So who should be treated for Barrett's esophagus. This slide is interesting because we have on the one hand, folks who have the option of surveillance, so to speak, so definitely most patients with nondisplastic Barrett's should be monitored. The current guidelines do not strongly recommend treatment at all. Most patients for indefinite for displays here should be under monitoring. But once you get into high grade displays here and bona fide persistent multifocal low grade displays here. In some cases, endoscopic eradication therapy is is the standard. Some patients who will have invasive disease will then move on to the surgical realm, and certainly most patients with submucosal disease or more advanced stages of disease will or need to be offered surgery and we can discuss that a little bit in the, in the after q amp a management of low grade dysplasia, as I mentioned, could be ablation or surveillance. The controversies here are that low grade displays here progresses relatively slowly, and there's a lot of inter observer variation among pathologists in this realm. So that's why the guidelines still hang on to the surveillance paradigm. However, and this is what I teach to the fellows and whoever is listening, and definitely explain to the patient is that low grade displays here is not all alike. Low grade dysplasia that is confirmed by an expert pathologist comes with a family history, you know, older patient low grade displays is persistent that's multifocal that means multiple sites in the esophagus nodular disease, and where there is a significant concern for progression. These are absolutely perfect candidates for treatment, and with shared decision making many of such candidates will go on to treatment and they should. So how do you determine the appropriate therapy this question does come up a lot in the Barrett's clinic. So first step is confirm what you're treating. And I think this study here from a few years ago, basically had 293 low grade displays your patients, out of which a third of them only had confirmed low grade dysplasia, and 14% were downstage to indefinite for dysplasia, and the majority were downstage to non dysplastic Barrett's esophagus so just want to say that much about the study. And you can see that if you have, you know, a set of patients are under the study and they actually go formal assessment, only a third of them with low grade dysplasia will have will have the actual disease so confirm what you're treating and patients again as I mentioned, those who have a confirmed low grade displays your diagnosis by an expert pathologist have a significantly higher risk of progression to high grade dysplasia and cancer, and they represent a different population. So my recommendations to the patients who come in, and before even they come to clinic, we want to make sure that they've had a second opinion. And if they have not had a second opinion, we'll get them that at our institution. The second step, of course, is understanding that you know if you see nodular mucosa or irregularities that are focal, they need to be removed. And this is another board question that comes up in the GI boards, is that when you see a nodule in a Barrett what is the next step. The next step is endoscopic resection. And if it is a T1A, which is a pathology that's limited to the mucosa, then you can continue with endoscopic therapy. If it's T1B, which means the tumor is now in the submucosa, then you need to bring that patient every time to a tumor board, even today. So these are the options for endoscopic eradication therapy. Nodular Barretts receives endoscopic resection, which is typically done by two modalities, and nowadays, the concept of endoscopic submucosal dissection has also been invoked, which is fine. It takes longer and has a slightly higher perforation rate. Flat Barretts, of course, without nodules can be and should be treated with radiofrequency ablation, cryotherapy, or a variety of thermal therapies. So many patients require multimodal therapy, that means endoscopic resection, RFA, cryo, and we had a paper on our 10 year experience in that. Patients must commit to every six to eight week treatment sessions. And of course, they need to manage their acid reflux as well as the treatment induced injury with very strict So here's an example of an endoscopic resection using a band EMR technique. This band EMR apparatus is very similar to the banding device that we use for esophageal variceal banding, but it has a dedicated snare that you will see soon coming down the pike, and a couple of mock moves, and then you suck the tumor in, and then you place the snare, create a pseudopolyp, and you place the snare, and there comes a snare, and then you dissect the specimen, and then you collect it out. And this is a very safe technique, and the way this apparatus is designed, it typically will, that's the defect over there, sorry. You can see there, that's the muscle layer in the base, and two layers of the esophageal wall have been removed. Very safe and works very well, and the way this apparatus is designed, it typically will not suck up the muscle layer in the esophagus, but if you apply this in other parts of the body, such as stomach or colon or duodenum, it will suck up the muscle, and you will have a perforation. The CAP EMR technique is one of my favorite techniques. It's a CAP that is designed specifically for removing large tumors, and this is a large tumor in the esophagus, spanning the GE junction. This particular device has a dedicated snare that comes and seats itself, it's a crescent-shaped snare, comes and seats itself at the base of the CAP, and sits there until you suck up the tumor. So here goes. Take the first portion of the tumor, suck it up, and the snare is waiting down there, and as soon as you suck it up, the snare is deployed, and using standard electrocautery, you resect it. This resets much larger specimens, almost two to three times the size of the band EMR, is much more risky in terms of perforation and bleeding, and requires a certain degree of expertise to do it safely. And you can see here how big the tumor is, I have to literally shake the bed to get this out, and that's not all of it. There's a lot more tumor down here, as you will see now. And of course this type of lesion can be done with endoscopic submucosal dissection, and probably would take about two hours to do this, even in good hands, but this whole case was finished in eight minutes using the CAP EMR technique. So you can see here the snare is being seated, and there goes the snare, and then this is the tumor. And we do this contiguously, so there are no areas of tumor left, and by the time both the specimens, both the pieces are removed, it's one large defect about five to six centimeter wide. And most certainly, in the past these patients were going to surgery, and you can imagine doing a esophagectomy with partial gastrectomy for an older patient is not an easy endeavor. So these are the two pieces, and we collect them with a basket. And in about 10 minutes the tumor is out. And this is the size of the defect you can see it here. It's a surgical defect, all done endoscopically. So, CAP EMR is very effective. But now we have endoscopic submucosal dissection which is basically taking a knife and lifting the tumor up, and then carving out the lesion in one piece, you know, and making sure you have an oncologic specimen. Endoscopic ESD allows end block resection of larger lesions. It is more time consuming and higher risk of perforation, and this nice meta analysis actually speaks to all the aspects of pros and cons of ESD. So the estimated recurrence of Barrett's associated neoplasia after a curative resection was very low, and that's why it is such an attractive procedure, although it's still relatively early in its time in the United States for the esophagus. Now coming to endoscopic ablation which is of course the mainstay of therapy. Ablation means you're basically destroying tissue, radiofrequency ablation was amongst the early ones that was that came on the scene. And then of course cryotherapy has has been more recently available, and in Europe they are doing a lot of thermal therapies and we have adopted some of these as well because they're much cheaper, a little bit more direct treatment, and allows for very efficient multimodality care. The contraindications to ablation are listed here, obviously patients who had esophageal varices, or who have eosinophilic esophagitis or structures from radiation, although the radiation structure and EOE are not absolute contraindications, but one has to be very careful when introducing these devices into these type of esophagi. The ideal ablation technique, you know balances uniform mucosal injury has low recurrence states is safe is outpatient well tolerated and has long term efficacy and the current modalities of radiofrequency ablation and cryo ablation fulfill most all of these criteria. So this is an example of radiofrequency ablation, this is a catheter that goes down to the esophagus GE junction and then moves up proximally to whatever length you need to cover. So bipolar energy system, and very high rates of dysplasia eradication are seen, even in the New England Journal trial that was presented earlier, and these rates have been improved upon considerably, especially with the introduction of multimodality therapy, which means the liberal use of endoscopic dissection, the use of radiofrequency ablation to start the filling up of any residual areas with argon plasma coagulation or with cryotherapy, or with additional resection so multimodality therapies have shown that you can achieve very very high rates of eradication of both dysplasia and metaplasia, as shown here. So here's a technique of RFA ablation, the pedal is placed across the GE junction. And all you have to do is press the pedal once and then twice in succession and you have a coagulum that appears, and then you move around circumferentially and finish the treatment of that segment, extremely effective, very efficient and very safe. Cryotherapy based platforms are listed on the slide this is liquid nitrogen spray cryotherapy with liquid nitrogen at minus 192 degrees centigrade period centigrade, and then this is carbon dioxide modality which is no longer used I believe at this time, but the other modality that's available is the nitrous oxide balloon therapy, and so called C2 balloon, and these are available as well. This is a slide on liquid nitrogen therapy, this is the console, and this is how the spray comes out. And this is the indications for spray cryotherapy are for primary therapy for secondary therapy where you have radiofrequency already done, but you're not getting purchase. And of course for salvage therapy when you have treatment of cancer so here's a video that shows how spray cryotherapy works. So this is a catheter coming out of the endoscope, and you can see the spray coming on here, and we wait for a nice thick freeze to develop, and, and then we, we, we spray the catheter two or three times depending on what we are treating so it's a little bit more work compared to RFA in the moment, but it, it really goes down very deep into the esophageal wall and can treat cancer whereas RFA cannot treat cancer. So, all the parrots endotherapy are listed here, fortunately, after all is said and done, the complication profile is pretty good. Again, like any other endoscopic event sedation remains the most common event, but some chest discomfort throat discomfort is there, but there is a finite structure rate, more with the thermal therapies, less with the cryotherapies. And so overall pretty safe challenging scenarios for better center therapy, in my mind, are persistent esophagitis, despite aggressive anti reflux regimen and this occurs in referral practices where the patient is doing everything they can you are doing everything you can, but the esophagitis doesn't heal. And it's a particular problem in patients who are undergoing endoscopic therapy, because you need the esophagus before you can move on to the next step which is surveillance. I find difficult anatomy to be a very problematic situation, whether it's a post op situation or radiation structures osteophytes in the cervical esophagus, or any type of an impediment that that creates difficulty in our ability to, to, you know, apply therapy effectively. So, number one is patient adherence. I had a patient once who could not afford, you know, gas coming to see us you know he had a big truck, and he claimed that it took him about 50 60 bucks per session to come in, come in, you know, come in and get the gas, and he stopped coming and then several years later we found out that he had advanced esophageal cancer so elderly patients patients with cognitive challenges language barriers, it's a difficult population, if you if you if you are managing these patients and a lot of diligence and and what goes into making sure that these patients stick to the primrose path. In my paper I think Sarah was the first author on this better center therapy and elderly patients. This you can review in the enduring materials but increasingly a lot of the older patients are being referred with with with challenging esophageal neoplasia, this is a very special population that has very unique risks, and the risk benefit ratio of treating Barrett's in the elderly is a topic for another lecture, but it's something that we have recognized indications for surgical therapy are very important as you know, some people's own invention, especially in patients who have poorly differentiated tumor biology. One takeaway message from all of this is that if you have any cancer that has a poorly differentiated biology, they need to go to the tumor board. I sometimes will even take a key one, a patient to the tumor board, because I don't like the bad biology and that behaves very differently and very aggressively lymphovascular invasion always needs to be considered because these rates of lymph node metastases. up to 25 to 30% in the media Steinem nodular Barrett's is very difficult sometimes and lesions that are not amenable to endoscopic resection they're too large to scarred non compliant patients, and so forth so there are specific indications for surgery and whenever in doubt bring the patient to the tumor board. So I'll skip that in the interest of time here a little bit. When you're dealing with Barrett's and esophageal cancer you really need an experienced team with all the modalities of treatment available. You need a good high quality thoracic surgery team. Excellent pathologists who can achieve a degree of concordance in their diagnoses, and of course the role of the APP is very important, which I think will be the next slide. And this is a slide that is important because our APP is in the Barrett's clinic will will see the patient with us, learn and understand the, the guideline based therapy significantly support us in the very procedure management and facilitate the tumor board discussions and surgical and oncologic referrals when needed. presentations and manuscripts so that's that's another platform that lends itself nicely to academic and scholarly achievements for the APP. Final practice pills, a multi modality therapy for Barrett's and esophageal cancer is where the state of the science is. I think that even when you are done with endoscopic therapy ongoing diligent surveillance is really really important. Anti reflux therapy, whether it's medical or surgical is crucial for healing and best outcomes and patients with T1B, a submucosal invasion or worse pathology should be referred to a multidisciplinary tumor board and further recommendations can come from the consensus there. In my mind, as we have experienced and demonstrated APPs have a very pivotal role in a Barrett's practice from initial assessment to active management and including clinical research and academic productivity depending on where they're going and what they're doing. Thank you and sorry for going over.

GERD

Barrett's esophagus

endoscopy

dysplasia

management

complications

patient adherence