Okay, so I'll start, you know, as we are waiting, probably we'll go ahead with the next two lectures as well. So if I can have my slides, I'll start with the second presentation. And part of this goes directly into what we heard from Torsten Benja and the case that we were seeing about recognition of early neoplastic barrettes, because if you miss that cancer that he showed us, that would present as a cancer post-endoscopy. So what's post-endoscopy barrettes neoplasia? So this is any neoplastic lesion which is detected or found within a few months or years after the initial endoscopy had been done in which no high-grade dysplasia or cancer has been diagnosed. The relevance and concept of post-endoscopy barrettes neoplasia actually comes from post-colonoscopy colorectal cancer, and we have Michael Kaminsky sitting here who wrote the WEO paper on that as well as Doug Rex who've talked about this interval cancer. And the relevance and importance for upper GI endoscopy is equally there. It's increasing incidence of cancer that we know. Endoscopy barrettes is the precursor lesion, and if early cancer is treated, you can prevent invasive cancer. And studies have shown that a number of these cancers are missed on the initial endoscopy, and we'll show you some data on that. And then unlike PCCRC, we don't have standardized definitions for post-endoscopy barrettes neoplasia. So let's look at this timeline, and this again follows the WEO definition of PCCRC, which is you have an index endoscopy, and then within six months, if you have a neoplastic lesion detected, this is sort of a detected neoplasia within the first six months. And this could be due to a variety of reasons, including being missed. Even if you had it before the next surveillance interval is due, that is what really defines the interval neoplasia in barrettes esophagus, and then finally after three years, what you have are the actual incident neoplasia, and that's why we do the surveillance endoscopy after three years. So based on this, what are the numbers? This is a meta-analysis by one of our colleagues in Kansas City, Madhav Desai, in which he looked at most of the cancers and when are they detected. And you can see that based on those definitions, the highest category are the initial detected cancers or the prevalent neoplasias, which tells us that the first endoscopy that you do in patients with barrettes esophagus is probably your most critical endoscopy, and that's when you're going to diagnose most of these neoplastic lesions. So why is this important, and how can we turn this into a quality metric like adenoma detection rate so that we are doing a careful examination? So this is the percentage of patients who have neoplasia on the initial endoscopy. And why is it relevant? Because this is increasing. This is a multicenter study of close to 3,600 patients, and if you plot it over the last three decades, what you see are the visible lesions are increasing on the index endoscopy, and this could be a function of just better endoscopes, right? So we have much smarter endoscopes. You'll be going to 4K scopes very soon. Low-grade dysplasia has remained stable during this time period, but high-grade dysplasia and cancer on the index endoscopy has been increasing. So this is a clinically significant lesion for you to be recognizing in practice. So what should your neoplasia detection rate be when you do that index endoscopy? And this comes from this meta-analysis, which showed that the pooled prevalence of these lesions at the index endoscopy is about 7% with a range of 4% to 10%. So at least on an institution level, you can try looking at this and seeing whether you are diagnosing enough number of high-grade dysplasias and cancers on your index endoscopy. So how can you improve it? Performing a high-quality endoscopy, careful inspection, adequate sampling, and then appropriate recognition of lesions. So we saw from that live example, you know, it was very clean esophagus. You will see a very subtle lesion here at the 12 o'clock position if you pay attention to this. There's the early adenocarcinoma, which is there. You can see that this can easily be missed. And you can do your random biopsies and say that the patient has no dysplasia, but this is a missed adenocarcinoma. The inspection time, very similar to the colonoscopy withdrawal time, make sure you are inspecting the Barrett's mucosa. This is a very elegant study by Neil Gupta, who showed that as you go from the left to the right, the more time you spend in the esophagus examining the Barrett's segment, the more likely you are to find high-grade dysplasia and adenocarcinoma. So inspection becomes important as well. Adequate biopsy sampling, well, after you've done the inspection, then you can go to your Seattle protocol. What we always miss in the Seattle protocol is that the Seattle protocol includes first target biopsies, then the random biopsies. So the target biopsies are critical. And remember the dictum that look more, biopsy less. Because if you look more, you'll find the target lesion. That's your highest yield. Your lowest yield is in the random biopsies. And this will go in IBD as well, that Monica during that session will be discussing that in IBD it's the same concept. So always look for these lesions. And of course, we need appropriate recognition of neoplasias. Here are two endoscopic images, and if all of you can look at those and try to see if you see where the early mucosal adenocarcinoma are in both these images. They are very subtle, but you see this right here in the three o'clock position. And then on this one, it's up in the one o'clock position. These are early mucosal cancers. And I'm sure all of us at some point will miss these. So it's important to train yourself in your eyes. Similarly here, both these patients have early adenocarcinomas. And these are located here in the 12 o'clock position. In this area as well. So recognizing lesions is the key for you to improve your neoplasia detection rate. You can use techniques such as virtual chromoendoscopy, narrowband imaging, blue light imaging, eye scan, which will help you look at these lesions. But more importantly, this is flat high-grade dysplasia in here with this abnormal irregular pattern that you see on the mucosa. So recognizing is key to performing a high-quality endoscopy. How else can you improve this? By education. Coming to courses like this, doing other CME programs. And we showed this in a randomized controlled trial. We took eight sites from the GI-Quick registry, so community sites. And what we did is we gave them a structured education on the landmarks and on Barrett's esophagus on neoplasia detection rate. And you can see when you compare the control sites in which the education was not continued after six months to those in which it was continued, they had a significant improvement in their identification of landmarks as well as obtaining good biopsies. So education also is key and can help us in this situation. So here are two proposed quality metrics for Barrett's esophagus that hopefully you can take home today from this presentation. Inspection time. Make sure that you're not very, you know, feeling proud of doing a 60-second upper endoscopy, right? I mean, don't use that to get to your colonoscopy because the upper endoscopy is equally important as a colonoscopy. Neoplasia detection rate. Start measuring that in your practice, at least at an institution on a practice-based level, and see whether you are finding enough high-grade dysplasias and cancers on your index endoscopy. That will be a high-quality examination. So to conclude, knowledge of post-endoscopy Barrett's neoplasia and the detection rate is important. And we are learning it from our colonoscopy colleagues. We probably miss neoplasia at the index endoscopy, and the high-quality examination is critical if we are to impact post-endoscopy Barrett's neoplasia. And as you can see from the live case as well, if you recognize it early, you can actually do a minimally invasive endoscopic therapy to cure and treat our patients better. Thank you all very much for your attention.

post-endoscopy barrettes neoplasia

early detection

invasive cancer prevention

standardized definitions

barrettes esophagus