So, next, I will listen to Simran Kochhar from Pittsburgh, who will present a few cases in IBD patients, interventional cases. Thank you, everyone. I think it's time to have some fun now, finally, you know, interventional cases. I would like to thank ASCE and Dr. Monica Fisher and Dr. Ruggiero for giving me this opportunity. So, I have a couple of cases here that we're going to discuss. These are my financial disclosures. So, case one is a 76-year-old female with more than 20 years of history of ulcerative colitis. She's referred to you for a non-lifting flat polyp and descending colon. The polyp is approximately 25 millimeter in size for the outside hospital report. And she had undergone an ESD with me previously for a flat fractal polyp. The path was consistent with tubular adenoma and the margins were negative. In regards to her current medication history, she's on a 5-ASA therapy. In the past, she was on Imuran and anti-TNF therapy, which was held by her gastroenterologist as she developed squamous cell skin cancer. Her most recent disease activity was described as Mayo Endoscopy Score 1, which, again, goes to the point that Dr. Ruggiero was making these little things help us to prepare as to how bad the inflammation is, so importance of reporting correctly. So that was helpful. And this is how the polyp looks in the middle. It's the scope cap right in the center right here. This is the polypoid lesion that they picked up. So my question here to the panelists is, and we can start with this, the first question is that it's a non-lifting polyp, so should the patient undergo surgery? It's an ulcerative colitis patient. And if the surgery is the answer, do you guys think she should get a J-pouch versus endileostomy? Any takers in the panel? So since we're in an endoscopic session, of course surgery's not the right answer. And the patient's gonna be referred for endoscopic resection. But all joking aside, I think based on showing the colon and essentially in what we would consider an endoscopic remission with this single segment, I do think it's appropriate to refer to somebody like you, an advanced endoscopist, to see if this could be removed. And I think the point was made earlier by Frank, I think as gastroenterologists, and I'm a wimp when it comes to scoping, we need to be careful not to biopsy this too much because then it's gonna make your job very difficult to resect. It does, it does, yes. So also the fact that it's non-lifting is because A, the person has ulcerative colitis and may have had inflammatory changes there and then there was a previous attempt at it. So although a non-lifting sign may be worrisome in a non-intervention colon, in this particular case, it's likely a consequence of the UC in the previous attempt. Right, so then if we are to consider the endoscopic modalities, I've listed three options here, EMR, ESD, full thickness resection. Because it's a non-lifting lesion, the EMR and ESD both are not gonna be possible or it's gonna be technically very challenging because you need some lift to grab the tissue. Simran. Yes. Sorry. So I have to interrupt here. So that's, as an endoscopist, what you can do is not necessary you should do. This patient, besides the total proctocolectomy with ileal pouch, 76 years old, right, as a disease limited in the descending colon or ascending colon? Descending colon. Descending colon, right? You can do the segmental colectomy or ileal rectal anastomosis subtotal colectomy and the surveillance of the rest of the rectum. It's not bad option. But you have to realize she had an ESD done in the rectum before already. She already threw a tubular adenoma before and segmental resections are not widely done for ulcerative colitis patient as yet. So you have to keep. Then even more case, you need a total colectomy. So you wanna give a 76 year old and ileostomy? Yes, colectomy needs to consult with a surgeon. Say, yes, it's like an unlifted lesions and then the long-term outcome of the ESD EMR on this impact oncology outcome. Technically, you can do. But oncology, are we doing right things? We don't know this is cancer yet, so hold on. Yeah, that's good discussion though. But here we go. So we brought her in. We had the discussion. She did see the surgeon, as Dr. Shen was mentioning. We see the lesion. So we decided to do a full thickness resection on this patient. The full thickness resection, you advance the scope. You find your lesion that you have to resect out. And I think there was a case shown earlier this morning in live session as well. So we found the lesion. The step one in this is that we mark our borders because that's very important. And you have to mark the borders clearly. You can use snare tip. You can use the device that comes in the kit. This is how the full thickness resection system looks like. It is fitted over your scope. That's how it is a clip. And the forceps has been shown. That's what you use to pull. You can use forceps or even a tissue helix device. So then we fit this device over our scope. We advance the scope to the lesion. The markings helps us. And then we try to grab the lesion. In this case, we are a little lucky because the lesion is on a fold. You try to grab the lesion till you don't see the white margins on the side. That means you got the entire tissue in. Once you have got the entire tissue in, try not to suction, especially in the left colon because you might grab the ureter on the outside. You grab the entire lesion in. And then once you are confident that a lesion has fully come in, you will see the white clip on the side going forward. Then you cut the lesion. This is how it looks post-resection. As you can see, we got the entire four layers here. You know, this is how the sample looks like. The entire area was resected. You could see the white margins in the resected specimen. So the patient was discharged the same day. She had an uncomplicated post-procedure course. Their final path was tubular adenoma, no dysplasia, negative margins. So, you know, in this patient, had we sent her to endileostomy for a non-cancerous, non-lifting polyp, I think that's not good for the patient. So this is the concept that Dr. Frey was referring, that we should manage these patients in a very multidisciplinary fashion, have a discussion with the patients. Our endoscopy tools are improving. And this is what the six-month follow-up scar looks like. I almost fell in love with this scar. Like, everything is perfect. No polyp residual. You know, we did biopsy the scar, and it was normal tissue. And as the disease activity has not progressed, you know, we were able to, I think, for now, you know, save a colectomy for a tubular adenoma in a patient with ulcerative colitis. So I think these are some of the modalities that you can discuss with your advanced endoscopist if you have patients like this that might benefit. So spoken like a true endoscopist, I have not heard anybody describe falling in love with a scar. But there you go. One point I do want to make, and I think, you brought this up, this is very important. And I think to Bo's point, if this colon had much more disease activity or had multifocal dysplasia, true dysplasia, and Bo, then I would agree. I think a total colectomy and ileostomy. But you could argue in a 76-year-old, even a segmental resection, which is generally well-tolerated if you preserve the rectum, is gonna alter their quality of life. So it is an individualized approach. I think you've done this patient a great service because they actually probably just had a tubular, or an adenoma. But I think the point's well taken in terms of if it's single, if it's visible, if it's resectable, versus diffuse inflammation and multiple sites of dysplasia. Yes, I think that also goes with the SANIC guidelines that Dr. Frey was referencing. If you see the margins clearly, you know you can get the entire lesion. Only I think then these should be attempted because if we leave a tissue behind or we can't reset completely, then yes, it's a high-risk procedure for the patient. What will be your approach in terms of surveillance in the future? You will do dichromendoscopy, you will do virtual chromendoscopy, or a definition in this case? So I brought this patient back for a six-month follow-up. I did this procedure complete. This was a white light endoscopy. And now she's going to have a one-year surveillance, which will be a chromendoscopy. Yeah, yeah. Okay, in the interest of time, I'm going to quickly move to my case two. This one I think Dr. Shen and I have a common consensus on. A 19-year-old male who has been having GI symptoms for one and a half years, saw one of my partners and was having abdominal pain, cramping, bloating, and occasional blood in the stool. He underwent a workup and was found to have anemia. No history of NSAID use. He then underwent a CT entorhography. There was mild wall thickening of TI and cecum, increased mesenteric attenuation, increased lymph nodes in the region, but no fistula was seen. He underwent a chromendoscopy with my partner, and that's the picture of his ascending colon. You see those two small holes in there, pinholes. This is a non... This is... It's not a surgically altered anatomy. It's a native colon. So how would you like to manage this patient? There is data that primary structures don't respond very well to endoscopic therapy, so should this patient end up going to surgery? Should we perform endoscopic balloon dilatation, or should we perform something like endoscopic strictureotomy? Any takers in the panel? I would look at your picture, last picture. I need to make sure there's no fistula near that. Yes. I would guide wire through that. There's a slight dent there. I suspect that maybe there is a fistula nearby. The CT entrography didn't show the fistula. The two openings you see, the one one is the TI opening. This is the colon opening. I'll show the next video. But in this patient, assuming there is no fistula, and there is no fistula, I assure you, what would you like to do? Surgery, balloon, or strictureotomy? How long is the stricture, the length? This is in the ascending colon. We haven't seen the cecum, so it's proximal ascending colon. But CT scan showed your length of the stricture, right? On the CT entrography, it was distal TI thickening and the proximal cecal thickening. So you can say 5 centimeter total combined TI and cecum. Personally, I would send this to surgery. But I'm sitting with an advanced endoscopist, so I'm sure you're going to say something else. But quite honestly, I would send this to surgery. The other thing is sometimes you can hide cancers. This is a young patient. I think it's unlikely. But we have picked up lymphomas and adenocarcinomas sometimes in these strictures. But tell us what you did. He first went balloon dilatation with my partners. And as you can see, they can see the cecum through the stricture now. And the left upper opening right here is the TI opening. So that was a small hole you were seeing. So then they couldn't intubate the TI after the balloon dilatation. His biopsies from the stricture revealed granulomas. He started on outpatient infliximab. His initial symptoms did improve, but then the symptoms gradually came back and were progressive. Same complaints of abdominal pain and cramping. And then his repeat colonoscopy six months later showed this. And this opening right here is the TI opening. And this is the cecal opening back. So based on this, now that he has failed EBD, I think, Dr. Rogero, now, would you still be inclined to send him to surgery? Or you will repeat balloon dilatation, maybe inject steroids at this time? I would never inject steroids myself. But I would still send to surgery. I can see the appeal to possibly doing an endoscopic stricturotomy. But I'm worried based on the, when I see something that distorted, especially in Crohn's with that much fibrosis, I worry that that's never gonna correct. So personally, I would send to surgery. Okay. Well, that's the fact that there are some fistula from the terminal ileum to cecum. There's no fistula, I assure you. But you can see the opening, right? Beau's gonna push you until there's a fistula. No, there's no fistula. I know you like fistula, there's no fistula. Okay. Can we go one slide back, sorry? So again, the patient's 19 years old. Again, the question's going to be how many endoscopic stricturotomies you're going to do. Right now, there doesn't seem to be any active disease, though again, we haven't intubated the terminal ileum to see. So again, someone who's 76 with comorbidities, that's one patient, this particular patient. I think maybe restarting the clock by removing this and putting him on postoperative therapy would be another option. So I think the answer everybody wants is can we go to the TI? So we did go to the TI. So we start doing the stricturotomy. We start from the TI side, because it's easier to cut towards the lumen. So we start cutting from the TI side into the sacral lumen first. That opens up our TI, and you see the stricture starts opening up even the sacral side, because the tension from the scar tissue is released. So now we start cutting the stricture on the sacral side. I use an adult colonoscope usually in my practice, so that's at least 13 millimeter or higher size, so we know that. So you need to at least have a stricture diameter of 15 millimeter to pass the scope. So we do that, we intubate the cecum, this is the appendix orifice, everything is fine. Now we're gonna go back into the TI. So we try to go to TI, there's still some resistance in scar tissue. We do more cutting on the TI side to get that scar tissue out. I like to get the scar tissue visibly out if possible, and IC valve is a nice area to do the cutting actually, because you have more room. And then we intubate the TI, and as you will see here, after we are in the TI, except for maybe the initial one centimeter, which was probably from the fecal stasis, the rest of the TI looks beautiful. I mean, there's no inflammation. You know, this is something, you know, it's not inflamed at all, there was no fistula. So we obviously clip our lesions after stricture artemies, so I clip the TI side first, and the colonic side first. Patient is asymptomatic, as he's approaching his six months mark. We're going to bring him back for either repeat imaging or scope soon. But I think in this case, the main question was, should we get into a TI, rule out a fistula, we did that. There is not much endoscopic disease activity, because maybe infliximab is helping him. So it was more of a mechanical complication. I do respect that primary stricture should go for surgery, but I also respect the role of IC valve that plays in a person's life, especially when you're 19. And because there was not much inflammation, proximal or distal, we decided to treat this endoscopically versus surgery. Basically, you did a valvectomy. Yeah, actually, a valvectomy in that case can cure the disease on top of the biologic agent. Yes, although there's going to be a lot of bile salt issues. Yeah, so if you ever want to look really good in one of these panels, just invite me along, and I'll always say surgery, and you can always show up. Yes. I'm not sure. So the patient was discharged the same day and there were no post-procedural complication. And as I said, he's symptomatically doing great, and we're going to beat an MRE and see how he does. With that, I would like to thank him once again. If there are any questions, I'm happy to take those. The last case you'll present almost look like the people describe like achalasia. So the achalasia cut the EG junction, right? This cut the valve. Sometimes it's curable for the disease. We actually have some case reports on that. Thank you, Simran. So if you allow us five more minutes, I would like Amiguel to present a few cases on post-operative care. Actually, we're going to keep this to three minutes. Okay. I know we're getting into the break and you have other speakers. I wanted to show one video case. I think this is probably pretty easy to score, but this will just give you an example of the Rutgers score. So 26-year-old, status post-second surgery for Crohn's on infliximab for five years. Prior to the first surgery, they had an abscess. And initially, she didn't want any medicines after her first surgery. So the second surgery is an end-to-end ileoclonic anastomosis for a fistula and intra-abdominal abscess. And within four weeks, started on adalibumab. She has good levels. But one year after the second surgery, fecal coprotectin is high. And this is what the colonoscopy shows. So I think you're all going to agree and you can shout it out in the audience. Rutgers score is zero, one, two, three, four. So this is in the colon. And you can see these deep ulcers as you go through the colon. And now this is on adalibumab. And the other question I'm going to ask, and I'll ask Frank this at the end after we get the score is, what would you do next? This is approaching the ileum. You can see deep ulcers in the ileocolonic anastomosis. Remember, this is an end-to-end. So it's easier to pass the scope through. And now you pop into what seems to be the normal ileum. So you have a patient, colonic size, very severe disease, anastomosis, severe disease, neoterminal ileum, and then the neoterminal ileum. So, Monica, how would you score this? I think you would say a Rutgers score of four. Okay, so Frank, this is a patient with a recurrence of a four. We agree with that. And now the question is, what do you do? I might actually use the SES score because we also have to grade the colonic disease on the distal side of the anastomosis. So basically, the first thing we do is do reactive drug monitoring. So we would check a baseline of trough adalibium level to determine whether we need to make a switch in her medicine. And her level, you may have missed it because I flipped through, is 22. Okay, so then. No antibodies. So if her level is 22, then that mechanism of action is not the mechanism of action you're going to use. You need to switch to a different mechanism of action. You can go to Eustachiniumab probably in this particular case. Pick one. Eustachiniumab. All right, so she was switched over to Eustachiniumab. We actually didn't plan this. I don't think Frank saw the case. Three months later, actually doing well. Her fecal calprotectin dropped. And now I'm going to ask you, what's the score on this? Her ileum is totally normal, and her colon is totally normal. Marietta, how would you score this? So this is just looking at the anastomosis. The ileum's normal, and the colon is normal. I think if we use the Modify root versus 2B, there is five, you know, I can count there five, more than five small ulcers. Bo? Yes, I would say the score is two. Now, regarding the anastomosis ulcer, the controversial, is this a Crohn's disease, ischemia? Actually, two different studies, one from New York, one from Chicago. Right. However, the ischemic, you know, I don't know, Bo, from your experience, but ischemic is normally one ulcer, rather than having multiple, several ulcers. So I think in this case, I agree. This is actually Crohn's. This is not ischemia. However, since it's just at the anastomosis, it's I2A. I'll leave the audience with some of this. You probably have seen these scoring, where we now modify I2A at the anastomosis. I2B includes the anastomosis and before. As Bo said, it's confusing, right? One study actually showed that the I2A and I2B doesn't matter. Both are actually progressed, or both don't progress, where one other study from Chicago shows progression. Then there was a more recent study showing that post-op endoscopic recurrence in the neo-terminal ileum did not progress if it was just at the anastomosis. And then our group out of Cleveland Clinic actually showed that just anastomosis only does not progress. So probably next year, we're gonna come back and tell you something totally different. But we go back and forth, and I think the point is that that's recurrence at the anastomosis. As Frank said, we needed to switch mechanism. And Bo, we'll get into this next time, she actually developed an anastomotic stricture, and the question is, how do you dilate it? These, to me, are probably the easiest to dilate with balloons. I don't think we need fancy stricturotomies in this case. But we really appreciate all of your attention. Thank you for hanging in there with us. I think, Monica, I'll turn it back to you to end out the session, but thank you very much. Thank you.

inflammatory bowel disease

ulcerative colitis

endoscopic submucosal dissection

J-pouch

Crohn's disease

stricturotomy