So it's time for questions and answers, and there's your QR code. So please go ahead. I've definitely gotten a handful of questions already, so we'll try to get through as much of these as possible. I'm going to start with Marvin. Question came in Marvin about thoughts on injection of feeder vessels and EUS coiling of gastric varices. Yeah. Great question. There is a focus right now on the optimal methodology for EUS coiling of gastric varices and feeder vessel targeting is definitely one question. My personal feeling on this is that the afferent and the efferent vessels feeding these gastric varices are not as simple as we would like to think or believe based on what we see on EUS appearance. So it's unclear if it's afferent, efferent, if they're multiples. So I think the jury is still out about targeting the efferent vessel. The other thing is that if you're doing this under for secondary prophylaxis and you have stigmata of the vessel and you inject the efferent vessel and create a pressure head in the gastric varices, you may actually be promoting bleeding by doing it that way. So I think it's a complex question and I think the jury is still out about optimal methodology for feeder vessels. So this is a follow-up question, a similar question came in about this. If you have lesser curve varices and you're doing that because the patient bled, you're not clear where the bleeding came from. Can you just talk about the approach? Do we target the gastric varices as part of that lesser curve chain? Do we also ban the esophageal varices in the same setting? What's your approach there? I think if you're dealing with what used to be called GOV1, so esophageal varices extending into the lesser curve and you don't quite know exactly where the bleeding source is and the gastric variceal component could be on the table as a source, then I would start with the gastric varices and work my way backwards in terms of banding. Thank you. Okay. This is for Allison. We have a handful of questions here about endoscopic sleeve gastroplasty and training. You had mentioned at the very end of your talk about a multidisciplinary center. As the overstitch device in particular is being utilized more and more for other things besides endobariatrics, just say closure of resection sites, what do we need to watch out for? What do we need to be, if people are looking to step into that arena, where do you draw the line? Where do you need to be part of University of Michigan, very complex center versus private practicing gastroenterologist who wants to offer this for his or her patients? Yeah. Thank you so much. This is a really good question and certainly one that comes up with almost every talk on this topic. I think that the answer is somewhat complex. We have developed several courses, including a star course that will occur in October, dedicated specifically to having people train on both TOR, which is revision of gastric bypass and endoscopic sleeve gastroplasty. People come from all different levels and it's interesting to see how people's skills changed throughout the course of the weekend. What I think has become very clear that it is challenging to learn a new device and a new procedure as complex as an endoscopic sleeve with just a few days. What we would like to do is to be able to develop new and several training programs and different places where people can go to get ongoing exposure and experience with the device. In addition to recognizing that obesity and obesity management is really not just focused on a single procedure, but that you very much need the cognitive training that goes into how to manage these patients over the course of time. We know that it's a chronic disease. The societies have put a lot of effort into trying to understand and trying to help training with procedures like this. I think as much exposure as you can get to the procedures themselves and then to kind of the cognitive components of the management of obesity and the multidisciplinary and synergistic components to endoscopic sleeve is helpful. Learning the device to begin with can be very helpful at then ultimately using what you have learned to learn endoscopic sleeve, but we are trying to also understand how many procedures it takes to make you somewhat proficient and to be able to do these independently. We clearly know that proctoring is a major component of being able to do this independently. Both the company that makes the device and many of the faculty that you've seen throughout DDW oftentimes can fly and proctor your first few cases. There's many studies looking at learning curve for a device like this. They range from one study showing nine procedures, which I think is very ambitious, but most of us feel that it's probably somewhere around 50, 35 to 50. This is not necessarily a procedure that you can really dabble in. I think the multidisciplinary component to it is extremely important. I think as much exposure as you can get to the device and to the cognitive components are very important. I would say that probably the hardest part about the device, once you even have the mechanics down, which does not take that long, is troubleshooting. That is where a lot of the experience and apprenticeships and societal courses and industry courses can be very helpful because they can walk you through common things that can happen while you're doing these procedures. I certainly think that this is a procedure that can and should be scalable. We're seeing more and more people doing these with interest, and clearly it has become a very exciting avenue for patients to have some procedural option that doesn't require overnight stays and doesn't come with high risks of complications. People feel very well after these procedures. It's not like some of the other procedures that we either offer or surgeons offer. This is one that's very well tolerated. I think with time, we'll learn more about how to effectively and safely train, but I will say it does take active participation and certainly as much exposure as you can get. Thank you. Great. Okay, Praveen, question about duodenal adenomas, large adenomas. When is endoscopy not called for? When do you say that should go to surgery instead? Can you describe that? Then a follow-up question is when you do endoscopic removal in a lesion, what's your approach to surveillance? Yeah. Thank you so much. So I think when do we stop? What are the criteria for not embarking on a polypectomy? I think first and foremost, one, you would want to look at the person who is going to be doing the polypectomy. What is your own skill set? And if you are equipped, the setting, obviously, you know, it is a tertiary care center. You have a backup if the complications were to happen and then the competent team. So that is the setup that you would require, especially with a large. So when would you not want to, especially if you think that you may not be able to clear it, they have obviously high-risk features possibly concerning for endocarcinoma if there is an involvement for the ampulla straddling across multiple folds, although that is not really a contraindication for not removing the polyp. If the patient has severe underlying comorbidities, especially if they are coagulopathic, they are cirrhotic, they have cardiac or pulmonary comorbidities, you may want to really think about polypectomy in that setting. So the second question was surveillance, yes. So I think when you look at the guidelines and that is our practice as well, we bring the patient back within three months. So the first follow-up interval is at that three month and we are talking about the sporadic non-ampullary duodenal adenomas. Thank you. Okay, Marvin, back to you. One of the, I would say I'm speaking for many gastroenterologists and one of the biggest fears about endoscopic gastric varices treatment endoscopically is the dreaded concern over embolization. And in many ways, glue is the simplest thing for us to do. Not everybody does EUS, so not everyone's going to be able to do coils and relatively straightforward in terms of the technique. So what can we do if you are doing that and you have a center, you're capable to do that at your center and your endoscopy unit, what can you do technically to do as much as you can do to prevent an embolization adverse event? Great question. Embolic complications from glue are actually more common than we think, I believe. And that statement is based on randomized controlled trials where a CT scan of the chest was performed per protocol on every patient. And the patients who received glue injection, the rate of actually pulmonary embolism from the glue was north of 50%, even though the vast majority were asymptomatic. So I think when we inject glue into a shunt indiscriminately, we are actually causing more embolic complications than we realize. In terms of endoscopic maneuvers that you can do to minimize that risk, I think it's important to inject small aliquots of glue and then pretty much rapidly flush with a certain amount of distilled water. You want to make sure that you understand what the dead space is in your scleroneedle and then inject just a little bit more so that you're not over flushing also. So there is a balance to be struck there in terms of the injection of the distilled water to clear your scleroneedle. And then after you inject, you want to gauge your hemostasis response. And then the conventional teaching is to probe with the blunt end of the catheter and make sure that it's indurated to kind of see when you should finish your procedure. Now theoretically, US coil-based therapies minimize that risk of embolization because you're injecting these discrete metal coils. And so you can account for each one of these discrete prosthetics that you're eventually injecting into the vascular space. And then theoretically, the glue that you chased after it is actually latching onto the coiled scaffolding, thereby minimizing the embolic complications. That's a theory. I don't think that's been really proven yet. Are you doing fluoro for the glue-only cases? I think for glue-only, no. But I think when you're doing... I think fluoro can be a helpful adjunct, especially if you're injecting coils, especially if it's early on in your learning curve. I think it can be a helpful secondary kind of modality to complement the EUS image. But for when you're glue alone, and you're not doing EUS, and you're just injecting glue, is there any role still to inject a little bit under fluoro and to make sure that it's staying contained within your... If you're going to do that, it would have to be mixed with liplapyrol, which is a radiopig contrast agent, and that will delay polymerization, and that is not recommended with the Dermabond that is usually available in this country. Last thing, something came up in one of the sessions yesterday afternoon on Therapeutic US about using hemostatic gel, like Puristat, for injecting into gastric varices. Have you had any experience with that? Obviously, that's much easier to use. It's not cumbersome. It's sort of everywhere now around endoscopy units these days. Yeah. I think Todd Barron's group actually reported on that. I don't have any personal experience on that. I wanted to speak with Todd about that, but my experience is more with gel foam, which is a similar idea where you don't... The embolic complications, I think, are much fewer, and there is not that feared complication of getting the substance onto your scope or your needle. Okay. Thank you. Okay, Allison, another difficult question, because it has to do with practice. So the question is, there's a couple here. I had it myself, and there's a couple of people who raised it here, and it has to do with the growing demand and use of the anti-obesity medicines, GLP-1, Receptra Agonis, and what is that going to do to endobariatrics, and what's it also going to do to payment reimbursement where we've struggled with endobariatrics? Is that going to make it even less likely to happen, or what are your thoughts on that? Yeah. Those are great questions, and certainly have come up in the setting of many forums over the last couple of days. I think that the current availability of GLP-1s and the second-generation anti-obesity meds is a great thing for many people. Many people are having significant weight loss, improvement in their diabetes, cardiovascular outcomes. I do not see these as a competitor, but more as an adjunct to some of the procedures that we can offer. The struggle with medications is that compliance is terrible, and so when you look at all the studies that have been done on these medications and their predecessors, the compliance rates at best are about 40% at one year, so 60% of people who start these stop these. Many times, it's just because people don't like to be on long-term medications. Sometimes they lose insurance coverage, and they can't pay for them. Sometimes they have side effects, gastrointestinal side effects or other issues, and they want to stop them. I think that this is a major problem. There's also some new data that I was seeing that kind of fluctuations in starting and stopping these meds may also kind of worsen some of your comorbidities in the long run. I see the medications as an amazing option for people who can get them and people who are willing to take them, but most people don't. The endoscopic interventions that I commented on and spoke about today are a really nice option for people who really want not necessarily a one-time fix or procedure because we know obesity is a chronic disease, and they may require repeat endoscopic sleeves and another or additional synergistic therapies, but they're a really nice option for more durable management. When you add endoscopic sleeve plus these medications, your weight loss almost mirrors surgical sleeve weight loss, so we're seeing about 25% total body weight loss. I think that the meds are amazing in many ways, and I think they'll target many people who may not have exposure to or have heard of the endoscopic therapies, but I really think that we need more options because people will not continue to take medications in the long term. Thank you. Time for one more, one or two more, probably a lot of questions about technique and duodenal EMR. For cold EMR, are you injecting and then doing your cold, or are you just going right to the cold snare without any kind of subucosal injection? So cold snare polypectomy, we usually reserve it only for the small, and it just varies based on the location of the polyp, the type of the polyp. We may not always inject a subucosal lifting agent, so it may just go straight with the polypectomy or may use, depending upon the location and what the morphology of the polyp. So when you remove a large four centimeter duodenal lesion, and you know that there's a very high rate of bleeding afterwards, I think you showed a slide that said somewhere around 40%, and it's certainly, if a patient's on antithrombotics, it may be higher if they have to go back on those within a couple of days or what have you. So you talked about admitting the patient. So what do you do? You admit them, you observe them. Do you sort of cross your fingers and hope they don't bleed? Do you check a CBC? What do you do? Yes. No, good question. I'm assuming these are the patients where we haven't done a closure on the defect. If we were not able to- Right. Yes. So if we are not able to close, they always get a topical hemostatic agent, like Puristat. And when we admit them, they are on PPI, they are on Carafate, and then obviously, yes, we cross our fingers. They have their type and screen before we embark on that. So in terms of resuming, if they're on anticoagulation, that is a conversation that we have before with the team as to what is the indication for them to be on an anticoagulation. And we try to hold this as long as possible, at least 48 to 72 hours. And for topical, you're talking about a gel, a matrix gel. You're not using a spray, right? Correct. Matrix gel. Okay. Great. Thank you, everybody. That's a great session. Thanks for everybody's attention. Thank you.

endoscopic procedures

feeder vessels injection

EUS coiling

duodenal adenomas management

endoscopic sleeve gastroplasty