We do have a question in the Q&A. Please explain again the difference in selection for EMR versus ESD for early gastric cancer. On the slides, both say for less than two centimeters, not following the differentiated. Yeah, I think the slides represent current practice as well. So just to simplify it here, since the question has been asked, anything that you can unblock or reset with one band EMR should go to band EMR or SNARE EMR, if you will, but typically more like a band EMR or a CAP EMR. But anything that's typically outside of the borders of a single unblock resection in this day and age will more likely go to ESD. And whereas there are occasionally some gastric neoplastic lesions that are referred to all of us that are relatively smaller, think of it like the size of a quarter, the reality is that the majority of these gastric cancers are actually three, four, or five centimeters in their diameter, and they warrant ESD at this time. Thank you, Dr. Kaul. Let's see, we have one in the chat, and then we'll come back to the Q&A. In your experience with POEM and gPOEMs, I think this is directed to Caitlin, what is the efficacy of these procedures and can they be repeated? So overall efficacy, as we had talked about in the during the chats, range close to 80%, depending on how you're measuring it for both procedures. Generally speaking, these procedures are not repeated. I can cover that completely, and I think at this point, the POEM data and the POEM outcomes are a little bit more robust. The gPOEM is making its way, but it's also a more difficult and nebulous patient population that needs to be parsed out, so completely. For sure, thank you. This is a question regarding celiac plexus neuralysis. What are the most common adverse effects you have seen with CPN? Can you discuss the reason for those adverse effects? Let's see, it's Dr. Martin or Dr. Call. Yeah, I'm happy to. The most common is hypotension from the parasympathetic nerve pathway. The pain really shouldn't be there because you're fixing pain, but these patients come in, we need to hydrate them well, we need to monitor them for a little bit after the procedure. And one of the fearsome side effects is actually irreversible paralysis. It's been reported. I haven't seen it, fortunately, but celiac plexus really works very well in the cancer patient. And short of that, I think best avoided in the benign disease patient for those reasons. Yes, agreed. For EMR, if a lesion does not lift, do you continue to resect it or is the risk of perforation too high? Yeah, so this is an excellent question. I think if you look at the textbook, if the lesion doesn't lift, it's called the non-lifting sign. And the non-lifting sign means that instead of the whole lesion lifting like a balloon, the sides of the lesion will lift and you have a central depression because that's where it's hunkered down. Now, as time goes on and you see a lot of patients and you gain experience with this disease state, you also start wondering and realizing that there is a bunch of patients who actually have this central scarring, not from cancer. They actually have fixity from inflammation, multiple biopsies, tattoo injections, or some other reason. And so therefore, it is an in the moment decision based on the patient's situation, the lesion size, cross-sectional imaging, biopsy results, the overall behavior of the tissue, but most importantly, your expertise level and your confidence in managing a focal perforation should wanna occur. So all of this is going through your mind when you're making a decision about the non-lifting sign. How I use it in my mind the best is if I go in and take a look at a lesion and without even touching it, it is smelling like cancer to me, I just use the non-lifting sign to confirm my impression. And when I go in and I see a lesion that looks imminently resectable and it's non-lifting sign positive, then I do take the risk of attempting the resection. And most of the times in that case, I will go ahead and be able to completely remove it one way or the other. So that's kind of sort of how I use it. Thank you, Dr. Kaul. Your experience with that obviously puts you ahead of some of us who may not have taken that risk. No, and again, taking risk foolishly is not advisable, but in all of endoscopic practice, if you have a reasonable certainty of managing a problem that you create, then I think a calculated risk is reasonable because you avoid unnecessary surgery in a patient who has relatively benign disease. But if you're turning around a corner or if you are in a location where you can't even reliably place an endoclip or the patient is so surgically unfit that has no medical reserve in the moment for an emergency surgery, then I think it's foolhardy to go beyond a certain point. So a lot of this is clinical judgment and experience and it builds up over time. There's really no shortcut to it. So other questions? It's all about anticipating and being mentally prepared for that possibility. Good, thank you. Yep. I think we have one more question. Would you schedule gastric emptying to make diagnosis on someone with gastric sleeve or bypass surgery? So you certainly can utilize gastric emptying scans in patients that have altered anatomy. If you're worried about gastroparesis, I think in the setting of a gastric sleeve and if you're thinking about should this patient eventually qualify for a G-POM, they would still have an intact pylorus, but oftentimes with bypass surgery that ruin my gastric bypass, they don't have necessarily that pylorus to perform that G-POM on. So it wouldn't necessarily be an evaluation for further interventions in regards to POM or G-POM, but could still provide you with valuable information for diagnoses. Thank you, Caitlin. That was the last question we have. I know we're, oh, one more popped up. Just before we address that question, I do wanna give people the opportunity, I guess, to take a quick break. I know it's only a couple of minutes, but we'd like to keep going to try to keep people on time. There's only one hour left and this is an exciting portion of the meeting coming up. So I wanna give everybody a second here if you need to. We'll take a minute to answer this last question and then proceed. So the last question I have is, how long does patients need PPI after POM? Will this be lifetime therapy considering new questionable risk factor in patients with renal disorders and osteoporosis? Yeah, so we usually recommend PPI therapy for at least three months and they need to be counseled on that. This could be lifetime. There is a higher risk that we see with GERD after POM compared to most other treatment options. So it is something that could become a lifetime therapy. They saw up to that one, the study from New England Journal saw about 40%, I believe it was, of ongoing GERD at that two-year mark. So it's a real possibility that they are gonna require lifetime PPI therapy. So that needs to be discussed before the procedure as a risk as well. Definitely an important consideration. Thank you to all of our panelists so far.

Endoscopic Mucosal Resection

Endoscopic Submucosal Dissection

early gastric cancer

POEM procedures

Proton Pump Inhibitor therapy