Thank you to all the speakers. We'll move into the Q&A session. Please use the app or text your questions in. We do have some questions, so go ahead and get started. So the first question is to Dr. Yadlapathy. The question is, if there is concomitant Barrett's esophagus with low-grade dysplasia and a 5-centimeter hernia, what do you treat first in the setting of GERD? Oh, well, that's complex. There's multiple layers there. So first of all, for low-grade dysplasia, the recommendation is to really have a shared decision process with your patient. So you can offer either surveillance or endoscopic eradication therapy. So first of all, making sure that we're addressing the Barrett's, making sure that they're on a good PPI or acid suppressive therapy. Now, a patient with a large hiatal hernia and Barrett's with dysplasia, likely volume reflux. And so we will discuss escalation of their management, make sure they have preoperative evaluation for something like surgical fund duplication or magnetic sphincter augmentation. It all depends on if their dysplasia can get controlled and their symptoms are controlled. Thank you. And the next question is for Dr. Crystal. So the question is, are all patients with EOE going to find one trigger or do some have no food triggers? Yeah, so I typically, when we do the six food elimination diet, studies have found that the most common triggers are dairy and wheat in that order, which is why the two food elimination diet eliminates those two. So trying to eliminate the most common food triggers. However, statistically speaking, patients will have one or two food groups, but I have seen patients with three. So that's why we do continue that entire reintroduction process. Thank you. And the next is for Dr. Andy. What are the tricks or techniques to get the sponge into the defect? Yeah, that's actually the most annoying part of the procedure. One of the tricks is to preload the NG tube and sponge with a guide wire inside of the venting tube. You know, NG tube has two tubes. It's got the one that suctions and has that weird funny blue one that's for venting. You can preload a guide wire into that. And then while you're trying to get it in there and it doesn't want to go and you can't drive the scope in, you can try to shoot the guide wire in. And if you can get it into the cavity, then you push the scope and the sponge all at the same time. And whoop, it'll kind of slide in. That's one technique. If you have a very, very harsh turn, this is very MacGyver-y, but you can take a 1-0 silk suture and tie it to the tip of the NG tube and then tie the other end to the most proximal port and then heighten that up. And you can make like a sphincter-tone bend in the NG tube and then you can put the sponge on top of that and the sponge will have a kind of a bent shape like that. And that can sometimes help you make that turn as well. This is really the art of the process. Thank you. There's another question for you, Andy. What are the complications of EVT endovac therapy? Yeah, they're rare, but there's major vessels in the area. So I have experienced where there's significant bleeding due to fistulization to a major blood vessel. And I've also had one situation where there was a broncho-esophageal fistula that developed. And so these are legitimate concerns, but they're very rare. I think they are very, very rare. And then you have to consider the alternative in these patients, which is, you know, devastatingly morbid, which is esophageal diversion with spit fistula and so on. So I do tell them about these complications, but they're often in such bad shape that they're willing to absolutely proceed. Perfect. Thank you. The next question is for Crystal. So this is about patients with EOE presenting with food impaction. And the question is, at the time of food impaction, after you disimpact, do you dilate and or biopsy during that same endoscopy session? How do you manage those cases? Yeah, so we know that over 50% of patients now in the United States who present to the ER with a food impaction will have EOE. So we absolutely do recommend biopsying. I think dilation is on a case-by-case basis, depending on how long the food has been there, what the appearance is, how that mucosa is looking, and what sort of ulcerated appearance you have there. I think that that can be at a higher risk for perforation, especially if you've ulcerated mucosa. So I would say always biopsy, and you certainly don't have to biopsy right at that food impaction site. We'll take at least six biopsies on at least two levels of the esophagus to adequately rule out EOE. And dilation, that would be plus or minus on depending on the case. Thank you. Then this is a question for Raina. What is the role of pain modulators in a refractory GERD? Great. Pain modulators. So we're thinking about neuromodulators, such as a low-dose TCA or SSRI. This is really for patients that you suspect may have hypersensitivity, such as esophageal reflux hypersensitivity. So oftentimes we'll talk with the patient. If they do indicate that, for instance, their symptoms are worse during times of stress or anxiety, or we've done the reflux monitoring and they have normal levels of acid, but every time they have a physiologic reflux episode, they're pressing that button for their symptom, we do consider starting. My choice is usually amitriptyline, starting at a low dose and escalating, but there are many different options. Some of our patients are really open also to hypnotherapy or cognitive biofeedback therapy, and they're a little bit averse to starting an antidepressant. So we offer all those options. Thank you. So this is a question for Crystal. Is pre-screening or monitoring needed for patients on dupilumab? Can you repeat the question? Oh, sorry. Is pre-screening or monitoring needed for patients on dupilumab? Yeah, certainly. So that's a great question. Dupilumab is regarding the trials, we saw the data at 24 weeks. And so typically we're assessing for remission at a longer interval than we typically have for diet, as well as topical steroids, which we typically will look at at 12 weeks. And so when we're looking at the time intervals, they're unique for dupilumab. As for when we use dupilumab, if you look at the studies on adults, 89% of those patients actually had another allergic disease. And so when you're looking at that patient's chart, trying to assess who's appropriate for dupilumab, it's largely patients with other Th2 type allergic diseases. We aren't doing any specific, there's no guidelines right now for any specific pre-dupilumab administration testing, though. Thank you. Then the next question is for Andy. What do you do in chronic small esophageal fistula that's sterile? Can you consider closing those? A chronic small esophageal fistula that is sterile? Yes, I'm presuming it probably leads to a chronic pleural cavity, like a small cavity there. In those situations, depending if the defect is very, very small, which in this case it is, I try first to leave a double pigtail stent in those. Okay. And if I leave a double pigtail stent, the natural history of that is sometimes the cavity, not the defect, but the cavity will get smaller. Okay. Sometimes. And if it gets smaller, then the next thing that I do is I beat that fistula tract up. I use a brush or APC, and I really, really try to de-epithelialize that tract. And then I will go ahead and go with a primary closure, like an over-the-scope clip, if it's small, or even try to suture it closed. I would probably do a two-stage attempt, minimize that cavity. Because remember, you close that thing up, you say it's clean, is it clean? You'd really try to make that as small as possible, and then try to change the histology before you go for the big, big win. And then Crystal, the next question, once in remission, this is for EOE, how often do you perform surveillance endoscopy in stable patients? And then the second part to that is, is 16 millimeter dilation safe? So surveillance endoscopy is a great question, and we don't have a great answer for that. Personally, I think when patients have more fibrosomatic-type disease, I have a lower threshold to do an endoscopy if they have any sort of change in symptoms, as opposed to a patient who largely seems like more of an inflammatory phenotype, though we know that those patients can transition towards a fibrosomatic phenotype. So typically, after they're in remission, as per symptoms, as well as histology, we'll consider taking a look anywhere from one, three to five years, depending on the patient, and depending on which center, our favor is favoring looking more every three to five years. And the second question was, is dilation safe? So I think that the prior studies, probably at least in the past like eight to 15 years, were concerning that patients with EOE had a higher perforation rate with dilation. But when you're looking at more recent studies on high volume EOE centers, the perforation rates reported are largely less than 1%. And so I think that as long as you're doing controlled dilations to a nice controlled tear, not going up too much at a time, and patients understand that a need for serial dilations is there, it's pretty safe to do. But remember that you need to be administering your anti-inflammatory therapy simultaneously as well to have histologic control of the disease. I just want to add on to that. If you do a dilation in an EOE patient, and you see a big mucosal rent, well, that's good. Right? That's good. That's what you came to do. Don't clip that close. You just undid what you just did. So leave that be. Now, if you're obviously concerned that there's a legitimate perforation, then you need to get a fluoroscopic examination. And then if there's a leak, then don't call the surgeon, clip it. You got to fix that right then. Don't wait. Otherwise, you get into a more delayed situation. Right? Thank you. The next question is for you, Andy. What material do you use for the sponge? I use the brand new foam kit from the KCI WoundVac system. It's just what almost every hospital carries for their WoundVac systems for external closure of post-surgical operative defects. So it's readily, readily available. Thank you. Back to you, Crystal. The question is, how long after starting PPI therapy, initially you're changing to steroids, do you wait to rescope EOE patients? Typically, I'll do the PPI trial for at least 8 to 12 weeks and then do the endoscopy. As for steroids, I'll typically wait the full 12 weeks, but there is data, especially on different formulations of budesonide showing a response rate that can be much earlier. But the problem with doing that early, of course, is that if it's positive, then you have to go ahead and rescope the patient and you have the endoscopy burden. And sometimes you can have a higher endoscopy burden just because they have strictures. And so typically I'll wait the full 12 weeks before I do the repeat endoscopy when the patient is on topical steroids. And then, Reina, is there a role for longer pH study like 96-hour Bravo or 48-hour pH impedance? Yeah, that's a great question. So when Bravo or wireless pH first came out, battery life was from 24 hours to 48 hours and then more recently now 96 hours. So we can monitor acid exposure across four days. And we all know, you know, if you're exercising or you're eating a big meal at DDW, your acid exposure levels will differ based on your activities. So getting that four-day snapshot is very, very useful. And we've shown in clinical trials that data from one day or two days does not predict how that patient's going to respond to medical management. So monitoring for over 72 hours is ideal. And the modern definition, Leon 2.0 definition for GERD was recently released, which also recommends 96-hour monitoring. And then you determine how many days are positive and determine your diagnosis based on that. Thank you. And we'll just take one last question. There's a lot of questions here, but we're running out of time. So this last question goes to you, Andy, and this is about nutrition after closure. When you leave a pigtail in the cavity and the patient is kept NPO until closure, when do you start feeding them? And when you feed them, do you start feeding via PEG-J? How do you feed the patient with PEG-J? I am very aggressive because I just cannot stomach a recurrence. And so I use a PEG-J tube until I'm fully confident that the fistula site is closed. And some people may differ in that. If you put a double pigtail, some people will at some point begin to feed them. I think it's reasonable. Here's a middle ground that I'm willing to compromise. If you get a CT scan in the interval and you show that the cavity is shrinking with the double pigtail stent and you're making progress, I think it's reasonable at that time to know that the inertia is that it's going to close. You might be able to introduce oral feeding at that time. But for the most part, I don't like them to eat, if possible, until the deed is done. Thank you. I'd like to thank all the speakers for their presentations today.

gastrointestinal conditions

Barrett's esophagus

EOE patients

endovac therapy

refractory GERD