Dr. Wani, join us and I want to introduce him Sachin Wani from the University of Colorado and he'll be the first one to take up on the debate for Barrett's esophagus cut or a blade. All right, good morning everyone. I want to start off by thanking the ASGE, Uzma, Jonathan and Vinay for this opportunity. It's so fantastic to see you guys here in presence. So my task in these next seven minutes is to convince you that ablation is the primary treatment modality for patients with Barrett's related neoplasia. All right. So let's set the stage for this debate between Dr. Dragunov and myself. I'm going to give you some background information. I think we can all acknowledge that endoscopic eradication therapy really has revolutionized the way we manage patients with Barrett's related neoplasia. This really offers a minimally invasive treatment approach, avoids the morbidity and mortality associated with esophagectomy. And I will show you that we have randomized controlled trials, observational data, population based data suggesting the efficacy, effectiveness and safety of endoscopic eradication therapy. And remember, this practice is actually endorsed by our GI guidelines. What are the principles of endoscopic eradication therapy? First and foremost, you need to perform resection of any visible lesion that you may see within the Barrett segment. That's the lesion most likely to harbor the highest grade of dysplasia. The next step is ablation of the remaining Barrett segment to reduce the risk of metacronus neoplasia. You need to be facile in the management of all complications related to endoscopic eradication therapy. And at least in 2023, all these patients need to be enrolled in surveillance programs after you achieve the endpoint of complete eradication of intestinal metaplasia. I want you to take a pause for a second here, and I'm going to challenge you to think about what the endpoints need to be or our goals need to be for endoscopic eradication therapy. Think of it in these three categories. Our immediate effectiveness goal, of course, is to achieve complete eradication of intestinal metaplasia. That's not where it ends. The next step is our goal to reduce future neoplastic recurrences and manage these recurrences when you see them when patients come back for their surveillance endoscopy. The third and the most important goal, our long-term goal, is to actually reduce esophageal cancer mortality. That's what we need to keep at the forefront of when you're managing your patients with Barrett-related neoplasia. I propose a few ground rules as Peter and I debate between ablation and resection. For one, we're not debating whether you should be resecting any visible lesion that you see within the Barrett segment. We're also not going to talk about ablation for non-displastic Barrett's esophagus. We can spend an entire morning debating whether you should be ablating non-displastic Barrett's. When you're making this decision of ablation versus resection, I think it's important to take into account all the risks and benefits. The risks that cross our minds include what are the periprocedural complications? Are you likely to achieve complete eradication of intestinal metaplasia? What's the risk of progression to esophageal adenocarcinoma? What's the recurrence rate? What's the cost? What is the feasibility and scalability of your approach to achieve complete eradication? I'm going to take a really pragmatic and an evidence-based approach to answer these questions. The first question that we should be answering is, does our current paradigm actually work? We have data from randomized control trials, the AIM-Dysplasia and the SURF trial that actually demonstrated that ablation reduces the risk of progression to a composite endpoint of high-grade dysplasia and cancer. If you're a purist, all you care about is progression to cancer. I'll tell you that ablation actually reduces the risk of progression to esophageal cancer as well. Now, Peter may argue that well-performing ablation may result in patients actually presenting with esophageal cancer. Let's try and answer this important question. How effective and durable is our current approach to managing patients with Barrett's related neoplasia outside of these randomized control trials? This slide is just a snapshot of all the data we have, data from population-based studies and data from large registries suggesting that ablation actually reduces the incidence of esophageal adenocarcinoma. Peter may argue that when you perform ablation and not resection, you're likely to see a lot of recurrences when you manage these patients with Barrett's related neoplasia. Not true. If you look at all the contemporary studies, you can see that the risk of recurrence of high-grade dysplasia or cancer is actually less than 1%. There's one important caveat in this slide and an important message that you need to take home, which is you're only going to find these results as long as patients are actually managed at tertiary care centers. So an important point to take away is that you need to consider centralization of care for our patients with Barrett's related neoplasia. The next important question is how safe is our current approach to managing patients with Barrett's related neoplasia? I'll tell you that from all the randomized control trials, all the observational data, we have zero deaths in terms of managing patients in the fashion that I've just described. The stricture rate is about 6%, easily managed with endoscopic dilation. The risk of bleeding and perforation, less than 1%. So ladies and gentlemen, what we're doing at the present time is safe and effective. Now the next important question is, do we have comparative data? That is comparing endoscopic resection of the entire Barrett segment compared to resection of any visible lesions followed by ablation of the remaining Barrett segment. And this was an important question that we recently addressed in our ASGE guidelines for Barrett's related neoplasia patients. This was a really elegant systematic review and meta-analysis that really showed no difference in our eradication rates, no difference in recurrence rates of cancers or dysplasia. But when you actually perform resection of the entire Barrett segment, you're going to have higher number of patients with strictures, perforations, and bleeding. So to support our current practice, the ASGE guidelines actually recommend doing what I've said for the past five minutes, which is resection of any visible lesion followed by ablation of the remaining Barrett segment. We gave this a strong recommendation. Now that we've addressed that our current practices work, I encourage you in the audience, all the members in the audience, to think about the questions that we should be asking at the present time to improve how we manage our patients with Barrett's related neoplasia. How can we actually improve our risk stratification tools? Are there patients who may benefit from actually performing resection of the Barrett segment as opposed to resection followed by ablation? What can we do to make our therapies even safer and more effective? Can we use a personalized approach to therapy and surveillance after endoscopic eradication therapy? And I will encourage you to really commit to the quality metrics that have been established for endoscopic eradication therapy as endorsed by the ASGE. Thank you so much for your attention. Thank you, Saachin. My slides are loading up. I like if you have the opportunity, if you speak first, to set the ground rules. But I will follow those ground rules. And when I first read the title Cut to a Blade, I could not restrain myself to think of a book that I ran into many years ago. And the title of the book was A Chance to Cut is a Chance to Cure. And this is the actual book. You may still find it. It's kind of probably never be published again because a lot of the statements there will be politically incorrect nowadays with very cynical approach to patient care, kind of similar to the house of God. Nevertheless, there is a lot of pearls. One of my favorite ones is a good surgical judgment comes from experience and experience comes from poor surgical judgment. So going back to Barrett's, as Saachin correctly pointed out, currently we are removing all irregularities with endoscopic resection, usually MR. And I want to emphasize irregularities, not just nodules. If something looks different than the rest of the Barrett's, you still should resect. And then we ablate the remaining Barrett's usually with RFA. And Saachin certainly is a very eloquent speaker, as you just experienced, but let me tell you what's really going on here. Ablation has a significant downside. First of all, is burden to the patient. It requires multiple sessions, which brings the issue of compliance. Post-procedure pain is a common occurrence. Complications are indeed relatively uncommon, but they do occur. Saachin pointed to that, but the quality of RFA is still an issue in our days with expert centers having better outcomes than other centers. And to add to that, now we have multiple ablation modalities, but the patient's triage to a specific modality is not well delineated. Saachin said recurrence of 1% or so, but actual recent publications, I'm quoting four papers, show a different story. The recurrence of Barrett's esophagus is roughly 40% in five years, with about 15% of those being the bad guys of high-grade dysplasia or cancer. So those are real-life data. This is not ivory tower of academics where everything is perfect, but when you do it in real practice, you can expect about 15% recurrence of high-level lesions. We are coming now to what in my mind is one of the biggest downsides of ablation. Here, I have listed the tests available to us that we use to evaluate patients with Barrett's esophagus to decide what to do. You can count how many tests we have, and the very fact that we have that many tests tells us that we have a problem. And the problem is that frequently we don't know exactly what we are doing, and we don't have a high degree of certainty of the disease that we are dealing with up front. So to that, now we add the issue with ablation, that you don't have a final pathology. So we're not sure what disease state we started with, and at the end, after ablation, we still do not have, we don't know exactly what we're dealing with. That's a problem. And to quote Yogi Berra, if you don't know where you're going, you might wind up somewhere else, and that's exactly what is happening with ablation. And of course, EMR is now a well-established procedure. It has some clear advantages. First of all, and foremost, provides post-procedure tissue diagnosis, even if non-curative, it can provide staging relatively easy. But the issue is actually that histology by EMR is less than ideal, and I'm not just talking about the lateral margin in piecemeal EMR, the deep margin evaluation can also be compromised because of curling of the specimen and orientation. So EMR is okay, but in a way, it's okay in the sense of the AT&T commercial. Sometimes just okay is not okay. And that's where ESD comes, and it has some advantages. It's oncologically sound procedure, provides unblocked resection, lower recurrence compared with EMR, allows resection when EMR is suboptimal, and it can provide cure in early cancer. Furthermore, and most importantly, it provides accurate histopathologic assessment of curative treatment. Yes, it is technically complex, and it does carry somewhat higher complication rate than EMR. So how you decide one versus the other? We put together this expert review published in Clinical Gastroenterology and Hepatology about three years ago, and we suggested that ESD should be considered in high-grade dysplasia greater than 15 millimeters. So the larger the lesion, the more likely the patient will benefit from ESD over EMR. Depressed lesions, bulky lesions, suspected superficial intermucosal cancer, or equivocal histology on biopsy. How many times you get these readings from the pathology where they say, at least intermucosal adenocarcinoma, right? And the reason they are iffing about it, because they have no submucosa in their specimen, so that's what they will say. So you don't know exactly what you're dealing up front. Certainly, if you have EMR with positive margin or recurrent lesions after RFA or EMR. I think those are very reasonable recommendations, but obviously, if you look at the authors' lists, they're all basically ESD experts. So could this be a self-serving thing? I mean, after all, if you go to a barber, you end up with a haircut. If you go to an ESD expert, you end up with ESD. Well, it was actually very reassuring that the most recent ACG guidelines published last year basically reaffirmed the following direct quotation. ESD may have a role in resection of larger lesions, which are unsuitable for unblocked resection by EMR. Lesions with potential submucosal invasion or lesions arising post-ablation, rendering EMR challenging due to scarring. So to summarize, our current approach has continued to evolve. We still need to remove all visible mucosal irregularities with endoscopic resection, traditionally EMR, but now expanding role of ESD, and ablate the remaining Barrett's epithelium, usually RFA, but now we have expanding options with cryo and hybrid APC. Thank you.

Barrett's esophagus

neoplasia

ablation

endoscopic eradication therapy

esophagectomy