So I'm going to ask, Dennis, if you don't mind, tell us, what's your approach for carcinoids as far as resection strategy? The issue is, if you do EMR and TSD, you very commonly end up with positive departure, just because of a significant desmoplastic reaction. Is there any role for EFTR? Yeah, that's a great question. I think there's definitely a role for that. More than once, particularly for duodenal carcinoids, a lot of times you see these lesions in the bulb. They're not very large. And multiple times I've tried to ban the EMR, and the deep end comes back positive. So a lot of times, if it's a smaller lesion, generally one and a half or one, it can come out easily with EFTR. I may be biased. A lot of times I still do ESD. In the stomach, I've had better experience with regards to deep margins. But in the bulb, I tend to favor EFTR. Thank you. Sachin? Peter, I wanted to ask you a question. There are many trainees in the audience. You talked about the role of ESD. Can you provide some guidance for trainees interested in learning third space endoscopy? What's the pathway for ESD here in the United States? Absolutely. Please come tomorrow at the dedicated session. I'm going to give a 15-minute talk on that. But the 30-second version is that at this point, we have evolved to a significant degree. There is a multitude of courses, entry type of courses, mid-level courses, and advanced courses, some sponsored by the ASG, some sponsored by industry. A lot of self-learning can be done through video and textbooks. But ultimately, if you have the commitment, that's the key component, you will be successful. But it is clearly not a procedure where you take one weekend course and off you go. There is now expansion of programs that offer training within the advanced endoscopy fellowship program. But it's a journey rather than a specific destination. And the journey continues. Thank you. Sawani, do you have any comments on using EFTR in early gastric cancer? Have you had any, again, same thoughts as Dennis? Yes. So because when we resect the lesion, we also consider risk of metastasis. So if the lesion is deep invasion, like T1B or T2, even you remove it by FTRD, we still cannot address lymph node status. So if the patient is a surgical candidate, I still recommend that they stand out of care still surgery if the lesion involves muscle layer. But if it's superficial, then we should be able to get negative margins with the ESD. I just want to make a comment on the gastric cancer talks, perhaps because this is a little bit different than when we do colorectal EMR. For gastric cancers, if the lesion is more than 10 millimeters, it's probably not a good idea to do EMR. So generally, we think about in-block resection. We think, OK, well, if it's smaller than 2 centimeters, I should be able to get it in-block. And that may be applicable in the colon. But when we're talking about gastric cancer, data shows fairly high incomplete resection rates. So anything more than 1 centimeter should probably go for ESD. I want to add that oftentimes, when we do a biopsy, you can just get low-grade dysplasia or high-grade dysplasia. But we know that after we resect those lesions, many of those are prestige to cancer. So this should also apply to non-cancerous dysplasia that you saw on the biopsy. But because like the case that we show has the depressed morphology, that's also the high-risk feature for high-grade or cancer. So if the biopsy only show high-grade dysplasia and have morphology concerning, you still should attempt on-block resection with ESD. A question to Dr. Condit came through online. Can you discuss the rule of three for dilation? Is it from the first dilation or the first time you see bleeding and mucosal disruption? Sure. In terms of the rule of three, that's based on large experience that's just been going on and taught from over the years of generations of gastroenterologists. And basically it is from the point in time where you encounter moderate resistance. So then you can consider going three more. Having said that, I think every stricture is different and every endoscopist is different. And sometimes you may want to stop if it's a more fragile stricture in the setting of like lymphocytic esophagitis or sometimes the lichen planus esophagus strictures that we saw in the video earlier, or a post-ESD stricture, I might not want to go rule of three. I'm going to stop a lot earlier. And maybe when I first see mucosal disruption or heme on the dilator rod, or I'll do frequent re-look endoscopies. And then other times, if I really know a stricture and it's a sort of Soctin radiation stricture, and I've been repeating this person every couple of weeks, and I know their esophagus, I might want to go a little bit more. So I think that there is a lot of variability and a lot of it has to do with your own experience, the type of stricture and how much you know what's going on with that patient. Thank you. Sachin. Yeah, I just have a question for Ara and for Dennis, if you guys can speak to the basic tenets of a high quality exam in the stomach so that we can reduce these rates of misleasure and how can we do a better job in detection of gastric dysplasia and intestinal metaplasia and what's your sampling protocol? Yeah, that's a good question, Sachin. I think Sawani gave some nice pointers there in terms of make sure that first of all, the stomach is really clean and often I'll use some methicone to really, you know, nicely lavage the stomach and get a good view, distend the stomach properly, and I always look at the stomach both with white light and with NBI. Chromoendoscopy can be used if you have experience in that just to kind of broadly spray methylene blue or indigo carmine, which can help detect very subtle lesions. In terms of sampling protocol, I mean, I think if you're doing mapping biopsies for intestinal metaplasia, then I'm kind of doing a standard protocol sampling lesser curvature, greater curvature, both in the antrum body and the fundus. But really, I think, you know, when you're sampling randomly, we always prefer to target if we can. So I think that's when our imaging modalities are really important, looking carefully with NBI and if you see anything really subtle, kind of trying to target that. And do you submit these in separate jars or do you put all of those biopsies in one jar? No, I do them all in separate jars. And if I see something that I think is questionable in terms of a lesion, then I'll even do separate jars in terms of that lesion. So I'll biopsy in a certain spot, I'll take a picture of that, and I'll even then biopsy around it to try to sort of see if I can sort out what the margins of that are and even put that in a separate file. So really trying to map even on an individual lesion if possible. And Dennis, what do you do for a high quality Barrett's exam? I mean, similar, I think a lot of the same principles, right? So we pay a lot of attention regarding quality metrics to a good colonoscopy example. We don't do that much attention when it comes to the upper GI. For Barrett's esophagus, same thing, one of the most important concepts is take your time, right? So you want to inspect carefully. A lot of times it's extremely difficult to examine the G junction when it's not insufflating adequately. So you may have to wait a little bit longer. Using a distal attachment cap can be extremely helpful to kind of plead out some of those folds in order to identify subtle nodularities, subtle irregularities that may have escaped. And that's particularly true also when you have a hiatal hernia. If you have a lot of bubbles, Symethicone can help a lot both in the stomach as well as in the esophagus. I want to stress using the cap for Barrett's esophagus. I think the most important thing, really, you know, looking at the G junction carefully and examining the segment and can really stabilize the mucosa to help you find really subtle lesions. My favorite tool. I agree. Thank you, guys. We need to go into a break. There are still a few questions. I would ask the faculty to hang around for a couple of minutes for people to approach them. But enjoy the break and we'll see you in 15 minutes.

endoscopic resection strategies

carcinoids

gastrointestinal lesions

endoscopic mucosal resection

transanal submucosal dissection