Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event titled Management of Barrett's Esophagus. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI Fellow Moderator, Sujan Dharuvangadam, an Advanced Endoscopy Fellow at UCLA Health in Los Angeles. I will hand over this presentation to Sujan. Hello, everyone. I would like to introduce our two content experts, Dr. Mathesami and Dr. Thakkar. Dr. Mathesami is an internationally recognized leader in advanced endoscopic procedures. His clinical research interests focus on the evaluation of existing and new endoscopic technologies for the diagnosis and treatment of digestive disorders. They include endoscopic ablative techniques for Barrett's esophagus with dysplasia and early esophageal adenocarcinoma, clinical applications of endoscopic ultrasound with a particular interest in phalangeoscopy, I'm sorry, with a particular focus on EOS guided tissue acquisition, ERCP with a particular interest in phalangeoscopy, stent placement and device reprocessing, and endoscopic mucosal resection. Dr. Mathesami also has participated in numerous studies involving the development of quality metrics in endoscopy and methods to improve the efficiency of and safety of endoscopic care, including the leading of a multi-center evaluation of the first single-use duodenoscope. In total, he has published more than 350 peer-reviewed manuscripts and abstracts and is an editor of clinical gastroenterology endoscopy textbooks. Dr. Mathesami is currently a professor of clinical medicine at the David Geffen School of Medicine at UCLA and is a medical director of endoscopy for UCLA Health. Prior to his recruitment to UCLA in 2011, he was a faculty member at the University of California Irvine Medical Center. In addition to his extensive clinical work in interventional endoscopy, he also served as the director of the GI fellowship program at UC Irvine. He has also previously served as director of endoscopic ultrasound at the University of California San Francisco. Dr. Mathesami completed his undergraduate work at Stanford University with distinction and went to medical school at the University of Washington School of Medicine, where he graduated with honors. His residency was undertaken at Duke University Medical Center, where he served as the assistant chief resident and traveled abroad to study evidence-based medicine under Dr. David Sackett at Oxford University. He completed his fellowship in gastroenterology at the University of California San Francisco before undertaking his advanced endoscopy fellowship at the University of California Irvine, which he completed in 2001. Dr. Mathesami is board certified in gastroenterology and has been frequently recognized by Best Doctors since 2011. He is also a past president of the Orange County GI Society and a counselor and the current president of the Southern California Society of Gastroenterology. He is a fellow of the American College of Gastroenterology, American Society of Gastroendoscopy or ASGE, and the American Gastroenterology Association or AGA. He serves as one of two ACG governors for Southern California and is a former member of the ACG Research and Public Relations Committee and currently serves on the Educational Affairs Committee for the ACG, as well as an associate editor for the American Journal of Gastroenterology. He has previously served as co-director of the ASGE's Improving Quality and Safety in Your Endoscopic Unit course and most recently served on the ASGE Quality Insurance in Endoscopy Committee. That was quite a mouthful. Dr. Mathesami's achievements could last us the rest of this talk. I'd like to move on to my other very, very impressive content expert, Dr. Thakkar, who's also- I don't know how I can follow that one, Sujan. Yeah. Yeah. Well, if anyone can, it's you, Adarsh. Dr. Thakkar is an interventional endoscopist with a particular interest in bariatric and metabolic endoscopy. Dr. Thakkar's research has focused on weight loss and metabolic therapies, eliminating endoscope-related infections, and improving clinical outcomes in bariatric esophagus. Dr. Thakkar serves in the American Gastroenterological Association's Center for GI Innovation and Technology, CGIT, and was a leader in their conference, which supports the innovation and development of new technologies for use in gastroenterology, hepatology, nutrition, and obesity management, and is a thought leader in this field. So without further ado, I'd like to proceed to our talks today, starting with Dr. Mathesami. Great. Thank you so much. I think, Sujan, you just won the award for the longest intro I've ever received, so thank you. I appreciate that. I was going for that. But anyways, I feel like I should just start the Q&A now, but can you guys see my slides here? Yes. Okay, great. Well, it's good to be with you, and as Sujan mentioned, I do have an interest in fellow education as being a former program director, and it's an honor to be invited to be part of this endo hangout today. All right, so I'm going to talk to you about management of bariatric esophagus, and I think bariatric is an interesting condition, because usually in medicine, we have a lot of diseases that we can effectively diagnose, but then we lament the fact that we really don't have a great treatment once we have a diagnosis. But in bariatric esophagus, we've actually developed excellent and durable treatments that can eradicate the disease in its entirety over the past two decades, but we still struggle to find the actual patients who would most benefit from these technologies and treatments. Furthermore, once we've identified the condition, we face many challenges in detecting dysplasia and those under surveillance, and so the very advantage of finding these people early is often lost because we don't really have good visualization when they're sort of harboring early changes. And then finally, many patients are incorrectly diagnosed with the disease due to improprieties in terms of the anatomy and where the biopsies are obtained, leading to variability in the risk estimates in the many studies that are out there with regards to the actual risk of bariats and progressing to dysplasia. So all of this serves to sort of confuse and muddy the waters in terms of exactly what's the level of risk, who are the best patients in terms of optimization of treatment. So I'm going to focus my talk today primarily on three major points, identifying the challenges in regarding screening for bariatric esophagus, recognizing common errors in diagnosing bariatric esophagus, and then also identifying techniques that may be able to improve recognition of focal lesions in those under surveillance who have known bariatric esophagus. And I'll talk briefly about eradication therapy. We'll spend about 30 to 40 minutes talking about this, and then I'm going to let, you know, hopefully we'll have a group discussion among the attendees led by Sujin, and we'll hear from Dr. Thacker regarding his expert viewpoint on managing a variety of common clinical scenarios. Okay, so in today's talk, I'll cover screening, correctly identifying bariatric esophagus, detecting dysplasia. I'll talk briefly about eradication therapy, but not much, and we'll cover that in some of our cases, and then summarize what we think are latest best practices. So this is the goal, of course, is we want to catch people before they present with this. And of course, we know that patients who present with esophageal adenocarcinoma usually do so after developing dysplasia, 90% of them will be locally advanced by that time, and the overall survival for esophageal cancer still remains under 20% at five years, usually estimated around 17%. And esophageal cancer, despite the progress we've made in other areas, continues to rise. And as you can see here, in those over 70, you can see the incidence has gone up in higher, but even in younger people, you know, other than anybody over 50, you can see that there's an increase in time over the past 30 years in terms of the number of cases in that age group. So the question is, it's a bad cancer, it's increasing, how do we find it, and how do we treat it? When we have the treatments, really the question is, you know, how do we find it? And so the questions really then relate to screening. Should we do it? If so, who should we screen, and how should we screen? And these are all areas that we don't have solid answers to. So you know, the first question is, should you even do it? And of course, the theory is that you would be able to reduce esophageal cancer deaths, you'd be able to provide patients with some risk quantification of their risks, and reduce anxiety in those who think they might have it, but don't actually have it, by giving them a definitive answer. But the other issues are that there's a lot of studies showing that people who are in surveillance haven't benefited that much from it. It obviously increases the cost of both screening and the number of people in surveillance. We've traditionally used screening based on a GERD symptomatology, which most studies suggest will result you in missing the majority of patients with Barrett's, because they may not have symptomatic GERD. And of course, it exposes people to the risks of endoscopy, since that's primarily how we screen. False positives and negatives are less of an issue, but one could argue we still have a lot of false positives with Barrett's and endoscopy because of improper biopsies, and you know, risks of labeling and concerns of insurance if you have this condition. So, that's a little bit of the pros and cons for screening, and then the next question is if you are committing to screening, who should you look at? And we know that Barrett's is present in 1 to 2% of the U.S. population, and between 6 and 18% of those with GERD, but as I just mentioned, many people with GERD have atypical or no GERD symptoms, and Barrett's is often seen in asymptomatic individuals at 6 to 25%. 20 to 50% of soft gel adenocarcinoma patients and studies have shown have no GERD symptoms at all, and actually less than 10% of patients who develop a soft gel adenocarcinoma had a prior known history of Barrett's, so as a result, they weren't in a screening program and they presented with dysphagia and usually T3 or N1 disease. So our current clinical referral practices are missing the majority of high-risk patients, and so the question is should all GERD patients be screened or only some, and should GERD even be a prerequisite, which I think is where we're headed is to getting rid of that. So here's a look at sort of a nice study by Doug Rex several years ago looking at the overall incidence of Barrett's in patients with heartburn. He basically asked a bunch of people who were getting a colonoscopy, can we take a look from the top when you're here? But when they looked at the people who said they have no heartburn, you can see that the Barrett's percentage is not that much difference, and when you look at short-segment Barrett's, it's essentially the same in the two groups. The presence of heartburn seemed to be, if anything, a predictor of more likely having long-segment Barrett's. Several other studies have sort of looked at this exact issue, and you take a look at the overall prevalence of Barrett's and GERD's versus non-GERD patients, 8 versus 6, 2 versus 1, 20 versus 15, you can see that they're not that dramatically different whether you have GERD or not. And so, you know, we've traditionally used GERD as the initial, you know, criteria to screen and then said, okay, if you're a man over 50, you're Caucasian, you've had GERD for more than five years, you have nighttime reflux, a big hernia, central obesity, elevated BMI, tobacco use, these are all additional factors, and the more of these factors you have, the more likely you should offer screening to these people. But if you take this down, this is a nice slide from Prasad Iyer at the Mayo Clinic, sort of looking at risk factors for Barrett's, you can see the odds ratio being over 50 is 1.5, male gender 1.96, Caucasian rate is 2.01, if you have, again, weekly symptoms for more than five years, and particularly if you have onset at age less than 30, your odds ratio is 30 for that, so GERD symptoms are a little higher than some of these other things, central obesity, odds ratio of 2, smoking 1.4, and again, family history is, again, quite significant here, an odds ratio of 12. So really, chronic, frequent GERD starting at a young age in family history are the two biggest risk factors. And the number of risk factors, again, each increasing factor increases your risk of Barrett's by about 1.2%, so for every additional risk factor. So adding these up sort of is, the more of these factors, the stronger the indication. Now, again, we've used this crude tool of GERD as the prerequisite, and several studies have looked at this issue of how useful is that. And you can see that the odds ratio for, again, weekly GERD versus not weekly GERD was better than age or waist-to-hip ratio or pack years of cigarette use, but if you can create models where you incorporate more than this, which then perform better than GERD alone. So I think what we're moving to is models that don't simply just incorporate the presence of GERD or not, but other factors as well, and here you can see age, waist-to-hip, and tobacco use. There's a whole bunch of models, and if you take a look at GERD, which is in the green here, if you take a look at the area under the curve, which is a sign of how good the model is, essentially every model beats GERD, okay? So GERD alone is, again, a very imprecise and crude tool. And again, this is just a summary of this slide. All of these tools were found to be more sensitive in predicting Barrett's than GERD symptoms alone. The optimal number of risk factors required to screen is unclear, and again, models that currently utilize information from the EMR to automatically calculate and create scores that can prompt you to refer patients for screening are desirable, but not yet in place, and we need most of these models to be validated in more diverse populations than they have been. So that's a little bit about who we should screen, and then the last question is, how should we screen? And traditionally, that's been with standard endoscopy, but, you know, you could also do unsedated transnasal endoscopy, although there have, you know, been just general perception issues about how palpable that is. But in the studies that have done it, patients have tolerated reasonably well. In what's popular now are these tethered cell collection devices, which can be done in an office setting and not even by an endoscopist or even a gastroenterologist or perhaps not even a physician, which may allow it to be more easily performed. And maybe something else in the future, a blood salivary or even a gas-based test, although none of these are actually currently close to prime time. So minimally invasive screening tools other than endoscopy have advantages because your ability to detect something is based on the sensitivity of the test as well as how many people participate and how easily access is there. What we'd love is a test that's accurate, that facilitates participation, that doesn't need to be done by a physician to improve access, and then allows for an increased eligible population to be screened and is at a reasonable cost so that it is cost effective and can be afforded. Transnasal endoscopy, as I mentioned, is highly sensitive and specific. It's well tolerated. It's actually, in the studies, been comparable preference. It's not that expensive, and it can even be done by non-physicians. But for whatever reason, based on perception or availability of the technology, it has not achieved wide utilization. This is a study done, again, by Prasad Iyer at the Mayo Clinic looking at basically a transnasal endoscopy versus sedated AGD versus in a mobile unit. So basically, this was in a hospital-based unsedated. They had actually a mobile van. They went into communities. And you can see that, interestingly, the participation rates were not that different. They had – so it didn't really improve participation. There was comparable tolerability and safety as well, and they found about 8.5% of patients had Barrett's and 30% had esophagitis, which may be a function of being in Olmstead County. But what is interesting here is that the transnasal endoscopy didn't really facilitate that much uptake. These are the cell-based collection devices. There's currently three that are most widely used. Again, the general idea is that you either swallow a pill, which then sort of dissolves and then subsequently becomes a cell collection device or, in this case, this sort of capsule balloon, which can be extruded to achieve cell collection. Again, there's a couple of studies that have looked at this, particularly in the U.K. for cytosponge, showing that it can be done by PCPs in less than 10 minutes. Ninety-nine percent of patients swallowed the sponge. They had a 3% diagnostic rate for Barrett's. And if you use more than two centimeters of Barrett's as the threshold for diagnosis, the sensitivity and specificity were 90 and 93%, but it was lower sensitivity if it was one centimeter. Again, this is a cytosponge study versus usual care in the U.K. It was a pragmatic randomized controlled trial looking at sort of routine sort of referrals for screening with endoscopy versus utilization of the cytosponge, and they actually found that they're compared to the usual care group with only 0.2% of patients were diagnosed with Barrett's. They were able to increase, excuse me, the diagnostic rate for Barrett's went up tenfold to 2%. So there's been several studies. This is really from the recent ACG guideline on Barrett's, looking at the various different devices, cytosponge, esophageal cap, these are checked, all of them. And you can see that in general, performance characteristics are not bad. You see sensitivity and specificities, typically in the 90s, esophageal cap, the larger one, did have a lower specificity, and the U.S.-based cytosponge trial did have some reduced performance characteristics as well. So the most recent guidelines, you know, looking at this, the ACG guideline suggested that the swallowable non-endoscopic capsule devices combined with biomarkers are acceptable alternatives to endoscopy for screening for Barrett's in those with chronic reflux or other conditions. And the recent AGA clinical practice update commented that non-endoscopic cell collection devices could be considered as an alternative to screen for BE. And this is in line with sort of an evolution in sort of the various guidelines. You can see the AGA ASTEs in 2019 in terms of who to screen. And again, you can see that in general, family history, as I mentioned, which is a big risk factor, GERD, and at least one risk factor should be candidates for this. Although, again, the more risk factors, the better, as I mentioned to you in this. But still, all of these typically have used more than, you know, GERD and several risk factors as usually a prerequisite. The recent document that several colleagues and I wrote, you know, is the first to sort of argue that screening with standard endoscopy can be considered in individuals with three risk factors, including male, non-Hispanic, age greater than 50, smoking and GERD, obesity or family history. But you can see that GERD is not a prerequisite, it is simply one of a cast of many. And I think, again, showing that most of these patients may have asymptomatic GERD. So I'll transition now over to talking a little bit about correctly. Identifying Barrett's esophagus and we'll transition again. This is a big issue. So the definition of Barrett's esophagus is that you have to have a replacement of a portion of the tubular esophagus, which is defined as the region proximal to the proximal most gastric folds, typically at least a centimeter, and replacement of this by specialized intestinal menoplasia. And so here you can see the top of the gastric folds. So again, this is all essentially hernia. And if you're going to talk about a region of potential Barrett's, it's really in this box right here. And is that box a centimeter or not? Otherwise, it's just an irregular Z line. So you're going to suspect it endoscopically, but you take a biopsy, but you have to find these sort of evidence of intestinal menoplasia in order to confirm that. Again, when you're doing a report for any patient with GERD or Barrett's esophagus, you really want to identify several landmarks. You obviously want to know where the diaphragmatic hiatus is. You want to know where the end of the gastric folds are. And then you want to know where the squamo-columnar junction is. Obviously, if there's no Barrett's, the end of the folds and the squamo-columnar junction should be the same. But obviously, if there's Barrett's, they will be separate. And then you'll describe the extent of the columnar mucosa. So here's a patient that we see here on the left here. This is pretty much all a picture of a heidel hernia. You can see the folds come up. This is stomach that's basically above the diaphragm. If you say, well, where's the GEJ? It's where my arrow is marking off around here. So don't call this as a Barrett's length. This is the hernia sac. The Barrett's begins here. And this is part of the reason why we get a lot of misclassification, both of Barrett's or not Barrett's, but also with regards to variability in length, because we have misunderstandings about this. So again, you want to know where the diaphragmatic pinch are, where is the end of the gastric folds, which essentially is the EG junction. This difference defines a heidel hernia. And then you're looking for the total amount of circumferential and contiguous Barrett's, which is then used by circumferential, if you say four centimeters, and then the total length that's in contact with the GE junction is seven. You would use this Prague criteria terminology, circumferential four, metaplastic seven. So C4M7. And it doesn't include islands. So the islands are reported separately, but they're not included in the length of the M in the Prague criteria. So common mistakes that I see, and I always guide our fellows against, don't biopsy across a normal appearing Z line, because if you do get intestinal metaplasia, it's not Barrett's. You don't have a centimeter tubular esophagus. You may be diagnosing cardiac intestinal metaplasia, but again, there's a lot of debate as to what to do with managing that. And again, this is a hiatal hernia, so don't include this as part of your Barrett's length. This patient does not have a two centimeter region of Barrett's. They have a two centimeter hiatal hernia. And we know that we're misclassifying Barrett's. There have been several studies of looking at this. So one study suggested that up to a third of patients with Barrett's were not able to be confirmed as having Barrett's in a community study. A separate VA study found that 20% of 18% of long segment and a third of short segment could not be confirmed on subsequent imaging or review of prior imaging. And there is some data suggesting that a quarter to a third of patients may not have actual Barrett's. And of course, this leads to a lot of confusion on the risk estimates. If you don't actually have a condition, naturally you're not going to develop the downstream risk factor for that condition. So this leads to how to do a good high quality examination. And this again is in our recent clinical practice update. And everybody likes top 10 lists, so we sort of developed one here as well. So obviously, identify those landmarks, just as I told you. The use of a cap is very helpful, particularly at the GE junction, to stabilize you and allow better visualization. Clean the mucosa using your water jet and suction the fluid in any mucus. You can use carbon dioxide insufflation and desufflation to sort of see if you think you might be dealing with a subtle nodular lesion of some sort. Spend adequate time inspecting the mucosa, and I'll come back to that in a minute, in terms of what that means. Again, you want to examine the Barrett segment using high definition white light endoscopies, so you should have up-to-date endoscopes. And you can also use chromoendoscopy, which is really available in most modern endoscopes. Usually virtual chromoendoscopy, we don't really use spray dye as much, although acetic acid has been shown to be very helpful in these cases, but usually either narrowband imaging or other equivalents from other manufacturers. I talked about the PROG system to best describe what you're seeing so that it can be easily understood by another endoscopist. And if you do find a lesion, there's the Paris classification also used for colon polyps that can be utilized to better describe the focal lesion. And you want to take appropriate biopsies by set biopsy protocols, such as the Seattle Protocol, which I'll come to in a minute. So here's a video on sort of how to perform a high-quality Barrett's exam. So again, you see I've got a cap here. We're trying to define the landmark, so there's the diaphragmatic pinch at the bottom. We pull back. We're looking for where the end of the folds are, and that can help define. So right around here, when I suction, is around where the end of the folds are. And then now you're starting to come into a region of Barrett's. You're keeping centered. You can clearly see there is a nodule lesion here, which is fairly large and extends almost up to the SCJ here, and this is something that would require resection. You can use narrowband imaging as well to help image the same areas, and again, you're looking for, in addition to obviously topographic features like nodularity, increased vascularity in certain areas or change in glandular patterns that may help predict dysplasia, and I'll come back to that. There's this Bing criteria, sort of the Barrett's International MBI group that define these. So I talked a little bit about time. This is the study looking at patients who had greater than five minutes of inspection time for their Barrett's or less than five minutes, and you can see the number of visible lesions was more than two and a half times increased when you took more than five minutes. The incidence of high-grading cancer detected was also substantially increased as well, and you can see that the length of Barrett's segments were relatively similar between these two, and these authors suggested that we should take one minute per centimeter of Barrett's, which is really a good amount of time since it's only one centimeter. We're talking about six minutes for the entire colon, and so if you had five centimeters of Barrett's, you'd be spending near the same amount of time for a short segment, but I think there's really a good yield for that, and it's still not a lot of time. This is a study just highlighting the fact that we miss a lot of lesions. This was nearly 200 patients from 37 community hospitals that got referred to an expert center in the Netherlands, and in the Netherlands, they tend to consolidate their care to Barrett's centers of excellence, and they found that while community visible lesions were seen in 60%, the experts found lesions in 90% that warranted focal therapy or resection. So you can see that this has increased, and again, it's interesting here because out of the 200, roughly 200 patients, there's about 80 that were referred without a visible lesion, and they found visible lesions on three-quarters of those patients, but most astoundingly, if you take a look at this, they found 11 T1B cancers and four that had such advanced lesions that needed surgery. So 15% 15 out of, sorry, the 60 here that had visible lesions and 15 out of the total 80. So you're talking a sizable fraction, essentially approaching a quarter of patients who were referred with no visible lesion for eradication therapy had a lesion that was so advanced that it wasn't even amenable to endoscopic therapy and needed surgery. So this is a big problem. So the question is, how do we do a better job of finding dysplasia? And I'll talk a little bit about some techniques that we have to close up here. And so again, we obviously use narrow band imaging, which uses blue and green light to display surface and subepithelial vessels respectively. And so you can see here, the surface capillaries look brown, the subsurface vessels sort of have this cyan color, and you can characterize, differentiate and diagnose among different types of polyps or potentially other lesions using this. So this is, again, this NBI group, the Bing Working Group, looked at images and looked at patients who had dysplasia and not, and basically kept it fairly simple. They said, just tell us if the mucosal pattern is regular or irregular, and is the vascular pattern regular or irregular? And then use that to help predict. So here you see something that looks pretty normal. I often joke that it should look like a housing subdivision as you're flying over it, it should have sort of this sort of very monotonous sort of a regular sort of pattern. And then here you see that there's variability in sort of the land sizes. You see some architectural changes here. And when you don't see sort of similarity and it looks different in different places, then you should be more concerned about focal dysplasia. And just simply using this Bing criteria, these endoscopists were 85% accurate in being able to predict dysplasia within a region of Barrett's. And if they had a high confidence, that accuracy went up to 93%. If they were low confidence, it was about 74%. So if you can be confident in your assessment using this, you're gonna have success. Another technology which is very appealing is this sort of in vivo histologic imaging using confocal laser and endomicroscopy. And this was compared against Compromo-Endoscopy NBI and others. And you can see here that it didn't quite meet the thresholds that were needed, which was really, it didn't have the negative predictive value of 98% needed for this PIVI criteria developed by the ASGE to be a standalone technology. So it's expensive, it has capital and probes and requires a fluorescein injection. So as attractive as it is, I think it's not so much ready for prime time as of yet. There's other ways to detect dysplasia. I won't talk about this VLE, although it's a very cool technology trying to identify dysplasia with all these things because it's not currently available, but I'm hopeful a future iteration of this will come out because this really allowed for laser marking and visualized lesions and one of the earliest applications of AI to Barrett's imaging. So in addition to doing a careful visual exam, you also want to take appropriate bopsies, which are usually every two centimeters starting at the GE junction in four quadrants throughout the entire length of the Barrett segment. If you have known dysplasia, I would argue that technically if you have known dysplasia, you should be treating those patients. But if you are doing surveillance, then you wanna do every one centimeter surveillance usually at six to 12 month intervals. Unfortunately, what we do know is that the adherence rate to doing this is pretty low. And unfortunately, the longer the segment, the less likely you are to be adherence because it's just too many bopsies. And so you can see that when it's less than five centimeters 80% compliance, but when it was 10 to 15 centimeters, that drops to about 30%. Again, when you're done, you should have again four at each level and you should have something that looks like this or that. Usually actually, as Sujan can tell you and Darsha worked with me previously, I usually like to have people take a picture when they're done with all their surveillance bopsies. This is a post eradication set of bopsies, but just so that I know that things were sampled in a wide fashion. So in addition to taking bopsies, what if we could take a brush and just brush it across the surface area, perhaps we would catch things that were missed on a bopsy, maybe even sample a larger area. And that's the concept of this white area trans epithelial sampling, where you use this abrasive brush that can sample deeper layers. It undergoes computer scanning to identify abnormal cells. And this is overread by pathologists when suspicious cells are found. And studies have shown that when you use this in conjunction with bopsies, the incremental yield of dysplasia is up to 7% from a baseline of 15%. And in particular, you may find high grade or cancer that was increased 2.1% from a baseline of 2.3%. So essentially doubling the rate of finding these most valuable identifications of advanced dysplasia. So that's about what we do during an exam today. But what do you tell a patient who's just undergone their surveillance exam about their risk over the next five years, 10 years, 20 years? And again, this is really, I think the Holy Grail, which is to tell us where your Barrett's is going, not where it is or has been. And so there are some models that have looked at this, and this is the PIB score, which basically combines low grade dysplasia, the length of the Barrett's, cigarette smoking, and male sex. And basically you can see that if you score zero to 10, your risk of progression is 0.13%. But if you score more than 20, your annual risk is more than 10 times as high. It's actually more than 15 times as high if you have that. And you can see the importance. So obviously low grade dysplasia gets you a ton of the way there. And if you have a male with low grade dysplasia, you've already hit your 20 points. So even if you have one centimeter of Barrett's, you're going to score in this highest risk group. So again, you can see the power of really male gender, low grade dysplasia, and potentially very long segment Barrett's. So again, there's some biomarker-based risk stratification panels that have been developed. Again, they can be done on sort of existing tissue that has been obtained. So you don't have to take a new procedure. They can look at your formalin-fixed paraffin embedded tissue. And they run it for a variety of different markers. And they also look for a combination of morphologic features, morphometric features that are extracted. And there's sort of 15 features in a proprietary algorithm that classifies patients into high, intermediate, or low risk progression over five years. And this is a study utilizing that panel among patients to predict the risk of high grade. And they found that patients who scored a high risk with this had an odds ratio of 4.7 compared to 4.7, had an odds ratio of 4.7 compared to those with low risk for the development of high grade or esophageal adenocarcinoma and the overall, when you were positive, your risk of developing high grade or cancer was 23%. Interestingly, a nondisplastic patient who scored high risk with this technology had a higher chance of progressing to high grade or cancer than someone who just had standard pathology with low grade. And again, the odds ratio was six in the high risk class for development of high grade or cancer compared to 2.9 for just expert confirmed low grade. So this is just, again, that you may be able to now find a subset of nondisplastic Barrett's patients in whom to treat. There's other studies that have looked at video-based modules that can use different techniques to sort of train endoscopists. And this has shown that perhaps you can increase median lesion detection by 30%, as well as describe the margins of the lesions. And this training was done among a group of people from different countries, and it didn't seem to matter what country you were from. This training helped. Artificial intelligence in Barrett's is obviously something that's very attractive, in particular for detecting dysplasia. Jason Samarasinha at UC Irvine has been very interested in this. And this is the video that he kindly shared with me. And again, you can see that, again, we're putting the use of a cap, narrowband imaging. You can see the box comes on, and the box has a little number on it giving sort of the likelihood that this area would have dysplasia. So you can see there's a little bit of variability on the narrowband imaging here of sort of the regularity of these glands here. And that's probably what this is picking up. And so this may be a way to help you take targeted biopsies or perform EMR compared to just your own standard visualization techniques. So again, they did a study with 40 videos and 40 unique patients and two different outside facilities. And 20 of them had at least one dysplastic lesion and 20 had just normal Barrett's. And this algorithm was able to detect 19 out of the 20 lesions that were present. So for a 95% specificity with a very low false positive rate based on the number of visualized frames. So I think there's some real promise here. We'll obviously need further validation as we go forward. But again, this is very similar to the AI that we see in the colon, the use of these boxes. So I'll close by just briefly talking about endoscopic eradication. And we're gonna talk more about that in our discussion section. But again, EET is endoscopic eradication therapy and really comprises of resection techniques of which primarily we do EMR, but I should mention that ESD is increasingly utilized or at least potentially has capability here. And then the ablation, of course, can be thermal ablation of which radiofrequency ablation is by far the most commonly used. Photochemical ablation or cryoablation in which there's liquid nitrogen and nitrous oxide, which is this balloon based. And both of these technologies are utilized. And I think this combination of cryo plus RF and to a lesser degree, APC with submucosal injection or hybrid APC are the main technologies used today. So again, when you see a focal lesion, ideally we'd like you to EMR it which will help both in diagnosis and treatment. And you can take one or more pieces. You can use a CAP EMR technique or more commonly using the band ligation where you use a suction device and just utilize that. And again, anytime you see a focal abnormality, raised or depressed, we'd recommend it. If you're concerned a depressed lesion won't be resectable, you can try injecting underneath it to see if it lifts. You can get up to 20 millimeter lesions resected with a single EMR. So larger lesions, however, do need to be resected piecemeal. But I will say we can talk about it in discussion, but the early data, even though ESD sort of will give you pathologic R0 resections, multifocal band EMR does seem to achieve comparable outcomes from an oncologic perspective over time. That's what I mentioned there. And again, it's very safe because it's very hard to resect the muscularis propria and the band strength prevents capture of the MP and you don't typically need to inject underneath this. So for those who are not familiar with this, I'll just kind of briefly sort of show this, although I don't know if I wanna show all of it, so again, you can use this multibander. Typically the wires will sort of be in line with the endoscopes working channel. And essentially, again, here you can see a little bit of a nodular area here on the right wall. You sort of line it up. I usually like to take the three o'clock part of my cap to define the upper margin, and then I can suck the lower part up. So I've defined the upper margin to make sure I've got everything. Now I can suction up, then I can just turn the knob just like you were deploying a band for a variceal case. And then you can put a snare through this and resect the lesion. And then you can do this iteratively until the entire area that you wanna resect has been removed. So I'll just sort of show this one cut and go from there. So again, here's typically wanna tent away from the wall to avoid the risk of any muscularis entrapment. But again, the band is really your biggest insurance policy with regards to that. So you sort of pull away and then you slowly kind of jiggle back and forth when it's time to cut as we're sort of doing there. And again, the pop will typically come off and you can inspect the base and suction up the lesion here. So now we look at the base there and we can go grab our lesion and then we can assess the margins to determine like here, we might say, okay, we want a little bit more. You line up the cap with the top of the prior margin and then you can even repeat and continue to get sort of a confluent resection bed. Okay, and this is important because it'll tell you how deep a tumor may be present. And that will tell you the risk of lymph node metastases which will determine whether endoscopic therapy is sufficient or if surgery may be needed. Typically, cancer that involves the submucosa or superficial T1A cancers, superficial submucosa, excuse me, T1A are appropriate for endoscopic therapy. If it involves the submucosa, it's T1B, those have an increased risk of lymph node metastases up to 25 to 40%. And in select cases may be managed endoscopically but traditionally have required surgical treatment. So a few years ago, Sachin Wani and Sri Kumunduri and I came up with some quality metrics that were adopted by the ASG and ACG for endoscopic eradication therapy. I refer you to those documents, but again, what should you, if you're doing endoscopic eradication therapy, you wanna do it, what are your quality metrics? Well, you should confirm the diagnosis of dysplasia with a second pathologist or a dedicated GI pathologist. If you are going to be doing this line of work, you should have high definition scopes and you should have both ablation and EMR techniques available. So you shouldn't just do, for example, ablation, but no resection. And again, of course, you wanna have an appropriate discussion of the risk benefits alternatives to this approach. Once you're in the procedure, you wanna document the landmarks. You wanna document the presence of visible lesions. You wanna use high definition white light scopes. And again, you wanna complete endoscopic resection of all visible lesions when you are doing resections. You wanna subsequently define the interval for when the next procedure should be. And if you're starting this, you should be able to get rid of all of the neoplasia within 18 months of beginning your first ablation or eradication session. And you should have all of the barrettes removed in 70% of patients within a year and a half of starting. Finally, after the ablation or resection procedures, you should recommend when the next procedure should be. During follow-up, you should stop seeing any visible abnormalities. These patients should be on an antireflux regimen to avoid recurrence and adverse events should be tracked. We recently, there's been two new articles that are more recent than the ASGE barrettes guideline. One came from the ACG, one from the AGA, which I was involved in. These are the ASG documents though, which are both excellent as well and highly relevant. This is what we wrote in 2022 that you can screen with any combination of three risk factors. GERD is not a prerequisite that you can use cell collection devices that when you're doing examinations in barrettes, you should use high definition white light scopes and virtual chromoendoscopy, spend adequate time, typically a minute per centimeter. You should use standardized documentation using Prague criteria and clearly document when you see visible lesions. You can use adjunct technologies like endomicroscopy. And again, you can do sampling and screening during surveillance exams as well. Again, it should be performed using those one to two centimeter biopsies from the Seattle protocol. You can, in addition, you can do brushings. Right now they can't replace biopsies, but they'd be used as an adjunct. If you've got a patient with erosive esophagitis, bring them back in eight weeks to document there's healing unless it's obvious cancer. We talked about the tissue-based prediction assays, which may help us re-stratify patients without dysplasia. And you may use these other models like the PIB score to help identify who may be at greatest risk for progression. You want to make sure your pathology diagnosis is confirmed by expert pathology review. And again, you should be referring patients to endoscopists with its expertise in imaging, resection, and ablation for treatment of barrettes. And finally, during surveillance, you should be on a PPI at least once a day. Your patients without dysplasia and barrettes should undergo endoscopy in three to five years. And when you're following patients who've been eradicated, even if it looks perfect, we recommend you take four-quadrant biopsies in the cardiac at the GEJ and at one and two centimeters to rule out microscopic recurrence. I'll close with this algorithm. So if you've got a patient who has at least three clinical risk factors for barrettes or a family history, you should offer that patient potentially barrettes esophagus screening. You can calculate their risk using one of those risk scores which are better than just GERD. And you could offer them either non-endoscopic screening or which could then lead to endoscopic screening, manage their GERD and lifestyle risk factors. If you do an upper end, if you get a positive and you do an endoscopy, you can do Watts and or tissue cipher to allow for prediction. If you find something of concern, eradicate it. If it's nondisplastic, follow it in three to five years, perhaps continuing to use either the Watts or the tissue cipher risk prediction. If you've got known barrettes, obviously you do the clinical evaluation, control the GERD, do the surveillance. And of course, if you've got neoplasia, you should undergo endoscopic eradication therapy with control of GERD. And if that works, then you do them in surveillance. And if it fails, you go to surgery. So in conclusion, our current GERD-based screening strategy hasn't shown benefit. The optimal method and timing for screening are unclear, but future approaches may benefit from a lower cost initial method and screening technique and a broader population that is not just restricted to symptomatic GERD, it should probably be targeted. Greater attention needs to be paid to our training in identifying landmarks and inspection of the barrette segment and documentation. And that includes both high-definition white light and their band imaging. The cell collection techniques, risk prediction models and adjunct imaging technologies will allow us to perhaps more intelligently practice and stratify patients with barrettes to match their risks. Hopefully we can deescalate surveillance in patients with lower scores and either increase the frequency of surveillance or simply undergo ablation therapy or, excuse me, eradication therapies in those at higher risk. And again, AI and visual inspection technologies I think will hold great promise in future advances in identifying dysplasia. So again, in summary, we've got extremely effective measurements, techniques for treating barrettes. We really need to focus our attention now on finding those with the disease and identifying dysplasia when it develops. And I'll stop there. Thanks again for your attention. And I'll kick it back to you, Sujan, to maybe take questions and maybe talk about some cases. Okay, so if there are no questions, I'm gonna move on to some cases. Some of this will reiterate some of the points that Dr. Muthusamy brought up, which I think will be useful for reinforcing some of these important points. I'd love if anyone could jump in at any time during this presentation. So our first case is of a 65-year-old white gentleman who presents to clinic requesting screening for barrette's esophagus. He has a medical history of hypertension, hyperlipidemia, obesity with a BMI of 33. He has a family history of reflux disease, but no family history of barrette's esophagus or esophagus cancer among his family members. He occasionally drinks, but he's a never smoker. He endorses heartburn and regurgitation with 50% of improvement in his symptoms with Tums, so he does have great symptoms. He has no red plaque symptoms, so no dysphagia, no weight loss or signs or symptoms of bleeding. So considering what Dr. Muthusamy spoke about early in his talk, do you guys think that this patient would benefit from barrette's esophagus screening? If you were seeing him in clinic, would you screen this patient for barrette's? And I'll go back to the slide description. What do you guys think? If you wanna use, you know, put any comments, you can use the Q&A or even answer perhaps in there with any thoughts. Adarsh, while we're waiting, you know, what would you, how do you view this in your practice? Yeah, I think that, you know, you kind of reviewed what are the highest risk factors, so this is a typical history that I would take when someone's coming in and he's got multiple risk factors, certainly he fits the age description, he has the, he's Caucasian, he has obesity and he has a family history, I was gonna say he has no family history, so, but the fact again that he's, you know, a white male over the age of 65 with obesity, I think that, you know, I would counsel him that those are enough risk factors to consider screening. And, you know, we just talk about what it would mean and what it would take. And I'm seeing some of our attendees are jumping in with some of the same points that a white obesity male are risk factors, I see another one with the gender age obesity. So somebody else asked kind of a different question which I'll get to in a second, but in terms of another part of this is how you would screen this patient. So I know Dr. Muthusamy went over this, so I won't spend too much time on this, as he mentioned, standard upper endoscopy is an option, transnasal endoscopy is an option, esophageal capsule, cytospine, et cetera. So I think all of those are very, very, you know, reasonable options, standard upper endoscopy is probably in practice what we would most often use, but as Dr. Muthusamy mentioned, there's evidence behind some of these others. Now, before I go into the next case, somebody asked Dr. Muthusamy, Dr. Thakkar, what is the optimal insufflation during determination of Barrett's length? I'm not sure if that's referring to the time that you have the esophagus fully insufflated or how specifically you would approach that, but do you wanna go into that a little bit? Yeah, I can take this one. Essentially, it's whatever's needed to get the job done. And so we use CO2 gas universally for our interventional procedures. And essentially I use as much insufflation as I need to make sure that I'm getting good visualization. And so, you know, you have to really splay out and get it to truly be a tubular esophagus. And then we talked about, I think Dr. Muthusamy discussed the time of really spending enough time per centimeter, really closely examining. Now, insufflation can be difficult right at the GEJ and particularly in the case of a hiatal hernia. So that's where the use of a distal cap is quite helpful. Particularly scopes often now have the near focus feature or some kind of optical or lens-based zoom. So with a cap, you can kind of get up right on the mucosa. And so even if you can't insufflate it very well, you could use that cap to kind of splay out folds and get very close. So it's a good question. And for the question of, do I use a cap on every screen? I try to, if I can. Sometimes, you know, you may not have it depending on, you know, for us, some sites don't carry it, but in an ideal world, and certainly if I'm considering endoscopic eradication therapy, I do try to use a cap to get a really close look for any visible or focal lesions. Yeah, a couple of small additions that I think Darsh is exactly right. I think, you know, again, when you're, you want to desufflate enough so that you can see where your gastric folds stop. So if you really inflate very tight, you may have your hernia and your esophagus will sort of almost become tubular. And so if you sort of suction, you want to do that. Also, if you're trying to measure lengths and just for your reports and stuff, I think you'll find more uniformity if you sort of deflate the stomach at the very end when you do your things, because people tend to agree more when things are deflated than when they're partially inflated. And again, the cap is, again, very useful and also can allow you to put a little water in the cap to give you improved refractive index. And so sort of underwater, high-definition imaging, near focus, and, you know, with a cap with water is probably the maximum quality imaging that you can get. You'll get some really, you know, journal cover type photos when you do that. Thank you. Another, we have a couple more questions before I move on to the next case. The first question was about, in this patient on the initial screening UGD, would you use something like tissue cipher? Dr. Masami, Dr. Thacker, what do you guys think about that? Do you think that that's something you would use upfront or maybe in subsequent examinations? Darsh, why don't you start? Yeah, I think, you know, my personal practice is still kind of the standard upper endoscopy with Seattle protocol biopsies, but I certainly think that it would be appropriate to do something more kind of wide area, if you will. And so I think tissue cipher, I think, or cytosponge or even the wide area, the Watts 3D sampling are all emerging in my mind. And I think that the jury is still a little bit out, but as one example, I think if I had to pick, I would probably use the Watts 3D. We're currently conducting, and we've now started a large randomized control trial comparing Watts 3D to Seattle protocol biopsy. So it's a tandem study. So patients are randomized to either get biopsies first, followed by the brushings for the Watts or vice versa. And we're trying to see if there's a good correlation and potentially if these wide area sampling techniques can replace Seattle protocol biopsies, which can be a little tedious, time consuming, et cetera. So I don't know if you agree or disagree with that, Dr. Muthusamy, what your practice is, but I think certainly in the next few years, we're gonna see some better answers for maybe a more efficient and potentially higher detection rates as well. Yeah, I think, you know, we're hoping that Watts will, at least right now, it appears to be a useful adjunct, whether it'll entirely replace or not, as you mentioned, the study will help answer that. I think tissue cipher is more of a predictor, and I think it really just depends for the person who's super worried. Sometimes you will get, say, a young person with nondisplastic Barrett's who's really anxious and says, I wanna get treated and eradicated. And, you know, if you need something to help you decide whether you wanna agree with him or not, you know, you could run a test like that. If the score comes back low, you could probably reassure him, but if it's high, you know, maybe you proceed. Yeah, and I think also with tissue cipher, if it's low, you might, you know, maybe we can, that would be someone where you can relax the surveillance interval a little bit or vice versa. So I think tissue cipher kind of gives me my concern level, whereas the others are really, is it time to treat now or not? I think it's the way I kind of look at that. Thank you. And then the next question actually takes this case a little further. Assuming that the first EGD was normal in this patient, is there a need to repeat the EGD in a certain number of years, assuming there's no change in symptoms? So remember, going back to this case, this patient does have symptoms, though they aren't on a maximum acid suppression. So Dinesh is asking, would we want to repeat an EGD or would we need to repeat an EGD for screening if the, I guess, the index EGD is normal? Yeah, I think by official guidelines, there really is no reason once you get a one-time screening. The idea being that it's, you know, kind of like Dr. Muthusamy alluded to, it's really long-standing GERD that probably contributes to Barrett. So that's why that young age of symptom onset of reflux is such a strong predictor. So I think that, you know, if they're in their 50s and they have a clean EGD, you know, I suppose if they're planning on living to 100 and they're in great shape, maybe we reconsider it, but otherwise I would just provide reassurance that they don't have Barrett at that time. Yeah, I agree with that. There was a study by Betsy Rodriguez many years ago that looked at the CORI database and basically echoing what Adarsh just said, which with the one caveat being in someone who had erosive esophagitis on a screening, you do want to follow those people because up to 10% of them may have Barrett's, but again, you would typically follow erosive esophagitis anyways to follow up to. So, but your point's well taken that if something is negative, at least over a five to seven year period, there's not a lot of value to re-screening them. Great. Well, thank you everyone for the questions. I'm going to move on to another case. This is of a 49 year old Asian female with a past medical history of hypertension who presents with functional dyspepsia. Subsequently, the plan was to undergo EGD, which showed an unexpected finding shown here, both white light, high definition white light, and narrow band. So maybe in the chat box, what do you guys see here and what features are you looking for? Maybe, you know, using some of the things Dr. Matsusami discussed. What are you looking for and what do you see? I think this is a great case, Sujan, because I think that probably this is how most of us experience or encounter Barrett's esophagitis. You know, we're working on kind of improving screening, but I find even in my own practice, when I find Barrett's, it's almost by accident because the patient is coming in for an EGD for something else. So functional dyspepsia, or, you know, maybe we're doing just a standard GERD, not responsive, or we're doing a pre-TIF workup or something completely different, or maybe, you know, US of a lump or bump or pancreas cyst, and then you encounter this. So I guess one other question I'll ask the attendees is, let's say you come in and you're just surprised to find Barrett's esophagitis. What would you do in that moment? And then what are you looking for in this lesion? What are some of the things when you're inspecting it that you're actually looking for? We'll give a few minutes for people to answer that question. Go ahead and put any comments you have in the, yeah, there we go. Somebody, I think, yeah. So one person says, look for nodularity, neovascularity, and architectural distortion. So those are all correct. Yep, that's excellent. And then also, yeah, looking for other complications of reflux, like strictures, esophagitis, probably abnormal pit patterns. So these are all correct. So what would you do if you saw this lesion? So I guess, Sujan, how would you describe this lesion? I think you probably have the best view of it. Yeah, no. So it looks like there's definitely a distortion in the glandular pattern. The place that I got this picture from didn't have it zoomed up. So it's a little hard to tell the vasculature just looking at it, but I definitely think that when you compare it to the tongue, the vascular pattern seems a little bit more amorphous and a little less organized, not so much a well-organized neighborhood like Dr. Nathasamy was saying, maybe a little bit more scattered. So looking at this, I would be concerned possibly for dysplasia, which I think is what the authors were getting at. Okay, so second question to the panelists or the attendees now. So let's say you identified and you were looking for all those things that you just named and you think, you know what, I do think there's something here, a focal lesion. What would you do next? In that, you know, this is a functional dyspepsia EGD, would you A, biopsy it? Would you B, resect it? Would you C, ablate it? Or D, would you do nothing and bring her back? Yeah, so we've got, so most people are kind of getting at biopsy. We have one vote for band EMR and then one question of whether a biopsy could potentially affect future resection, which we often talk about with like colon polyps and things like that, don't, you know, scar it down too much and things like that. So I would agree. I think you have the option of doing a biopsy. I don't think, as long as you're not going crazy, I don't think that you're gonna affect too much our ability to resect it later. You know, I think that you could also make an argument that you could EMR this if you really wanted to. Of course, I think it depends a little bit on how you consent to the patient. I try to, you know, as interventionalists, we often encounter surprises and it's not fun to have to bring patients back for something you can handle right there. So I try to be a little bit more thorough and comprehensive. So if I find any lesion, I describe, you know, we have a variety of ways to remove them. And so I agree that biopsy would be appropriate and then bring her back if it is abnormal. But I think it would also be appropriate to resect it on the index because there is a lesion there. And presumably, you're worried about any type of neoplasia from low grade all the way up to an early cancer, right? So that would be my practice. What do you think, Dr. Muthuswamy? Yeah, I think that, you know, the key is, is, you know, don't start doing some treatment unless your treatment happens to be EMR, but don't like ablate it without getting a tissue. So obviously you do wanna take, at the very least, a targeted biopsy. But I think, Adarsh, you were kind of hinting at something which I think is important to say. And, you know, the three of us who are, you know, on the panel tonight are advanced endoscopists, but I would encourage, you know, those are colleagues who are joining us tonight, even if you don't go into advanced endoscopy, you all know how to band varices and you all do snare polypectomy of polyps. So you have everything in your toolbox that you need to do an esophageal EMR, okay? We don't have to teach you anything, okay? You already know how to do it. So I understand that may come as a little bit of a mental, you know, frameshift, but don't be afraid to do it. And I wouldn't discourage you for doing EMR. I don't, I'm not gonna tell you, oh, don't do it. You may able to provide more accurate information and institute therapy weeks before you may be able to get them to a referral center. So really consider doing that. And I wouldn't, for those of you in fellowship, try to do a few esophageal EMRs with your faculty so that you're comfortable with it. Because I definitely think this is something within your skillset when you go into practice. Yeah. And then I think we already kind of had this discussion point about WATS, the wide area trans-epithelial sampling. If anybody has any specific questions about WATS that Dr. Thakkar and Dr. Muthuswamy maybe didn't address, please feel free to type it in now. It is a kind of a field of ongoing investigation. And as Dr. Thakkar mentioned, we're looking into that here at UCLA. There was a question about lead time bias in Barrett screening. I think it was asking about the benefit of Barrett screening and the potential for lead time bias. Yeah. I think part of what I would say, and that's part of sort of the conundrums that I was mentioning in the beginning is, it's fine to screen, but if you screen people, but then can't find the dysplasia within the segment that you're doing surveillance on, you haven't really achieved very much, right? So it's one thing to find it, but then you have to detect the dysplasia and then institute the therapy. And I think that's one of our weaknesses in terms of doing that. I would say that for, I would be curious to ask those who are online with us, how many of you have used the Watts brush as part of your, have had a chance to use it and maybe what your thoughts were? So this is increasingly utilized now. Again, it's not meant to replace biopsies at this time, it's used as an adjunct, but it certainly can probably sample a much broader area because our forceps are only sampling around 4% of the surface area when we take that. So one would argue we're probably sampling more straws in our haystack using this approach. Yeah, I hope this works out. You know, I'll be interested to see what the results of the study are. I anticipated well, but it's just so easy to do. And I think we'll, like it says right in the name, I think we can just sample wide area and it may take a little bit of the burden off of the super close inspection of completely flat looking stuff, you know, nodules and things like that where you should resect your biopsy, but it may help relieve the burden of screening and detection really. Thanks so much, Dr. Thakkar and Dr. Matsami. So moving on to the third case, again, this is something Dr. Matsami touched upon, but I think it'd be useful to reiterate some of this. So the patient you're seeing is a 33 year old white male with no medical history who's presenting with Barrett's esophagus. He has a family history of esophageal adenocarcinoma in his father diagnosed at age 59, his dad was. Despite high dose PPI, he does endure some regurgitation. Upper endoscopy shows a four centimeter hiatal hernia and long segment C10 and 12 Barrett's esophagus. They did every two centimeter Seattle protocol biopsy which showed intestinal metaplegia as expected, but no evidence of dysplasia. So you have a young patient with long segment Barrett's esophagus with a family history of esophagus adenocarcinoma. What would you guys do next? You're in this situation, you have to make a decision. Do you bring him back for endoscopy? Do you consider endoscopic eradication therapy or something else? What do you think? Yeah, I'll let the attendees, I actually have a couple of patients exactly like this, it's almost carbon copy. And so this is a real scenario. So to the attendees, essentially you've got someone young, maybe your own age who has a four centimeter hiatal hernia and already, you know, C10 and M12, I think Barrett's esophagus are quite long segment, but without dysplasia. So you have this patient sitting in your office, how would you counsel them? What is your next step? And it may be useful if you can to, I mean, also try to justify your answer as well. Yeah, I was just gonna say that. We already have one foot for just a blade, but what's your reasoning there? I think the obvious possible solutions are, you can put them into surveillance protocol, or you can proceed with endoscopy. So can you go back to the description of the case? Yeah. Sure. Show the clinical features. So we've got a family history, right? We've got a 33 year old and we have 12 centimeters of Barrett's. Let's try it this way. So there's two hands already raised, but actually you can lower them, but how many of you would this patient into a surveillance program? Let's see if anyone else raises their hands. And then how many would go forth with some kind of endoscopic eradication therapy? Yeah, so we've got, it sounds like we've got a few more hands raised. And then in the comments, we have a vote for ablation. You said he probably has high risk for progression, or risk for progression neoplasia given the length of BE, family history, and lots of years ahead of him. And then we have a couple of folks that have mentioned anti-reflux surgery. So that's interesting. So this is exactly the type of conversation, with this, I only had one slide on there, but one rough number that I give to patients is that when looking at the factor of length, you remember that risk score, that when you look at length, the number of points you get, if you will, and your percent of progression. So maybe an estimate could be about 0.1% per centimeter per year of progression. So if you have 10 to 12 centimeters, that's already 1%. And then he's only 33 years old. So you've got decades ahead. So in his lifetime, by that math, if it is truly linear, you may have some reasonable chance of him progressing to dysplasia. So on one hand, yeah, we're gonna have to really make sure, we can't just let this patient go. He's gonna have to be in some kind of program. We're never gonna not continue to survey him. But then the onus really is on us to catch it when it does happen, right? So on one hand, I think it's absolutely appropriate that you could put him in there. But the kicker here is also that four centimeter hiatal hernia. And as Dr. Muthusamy mentioned, that even if you do start ablating this patient and say, let's just get rid of it, even though it's nondysplastic, so you don't have to worry about that, does the ongoing likely acid reflux, which he still has some breakthrough regurgitation symptoms, does that kind of feed the fire and accelerate his chances of progressing to dysplasia? And the short answer is, no one really knows in this patient, right? The young patient, most of our data and our evidence is in older patients, et cetera. But that's exactly the conversation I kind of had with him. And between the symptoms and his fear of progressing to dysplasia, this patient did opt for anti-reflux procedure. And after reviewing the various options, we actually ended up settling on doing a combined hiatal hernia repair with TIF procedure. And the reasoning also there is that the patient is quite young. He also had some lower GI symptoms. So he was worried about side effects from such a Nissen fundamentation. And also the fact that at 33, there's a likelihood that whatever surgery we did for him may have a chance of breaking down or needing to be redone. And I think that our surgeons have come to agree that it's much easier to redo or touch up a TIF or convert a TIF to a Nissen than to redo a Nissen. And so we ended up doing a hiatal hernia repair with TIF. His symptoms got significantly better and we decided to keep him on at least a low-dose PPI because of the Barrett's esophagus. And then the hope was to continue with ablation. But of course, the other kind of, you know, underside to this is insurance coverage for ablation with nondysplastic Barrett. So we appealed it. And for now, his insurance has denied authorization to ablate him. So at least for the moment, he at least has his hernia repaired. His LES is nice and snug with the TIF and his symptoms are much better. And we're gonna just put him into a surveillance program for his long segment Barrett's esophagus. And so, you know, we'll keep trying probably at some point with getting approval for ablation. But for now, I think we at least maybe took the foot off the gas pedal for a little bit for him. Dr. Mazzotti, what are your, I don't know if we've discussed that case. What do you think? Yeah, interesting case. So just for our audience, so you kind of brought this up. So if we put this patient through the PIB score, right? We said that you'd get a point for every centimeter for Barrett's length, right? So we're gonna get a lot of points there. We're gonna get 12 points right off the bat and it's a male. So 12 plus nine, I don't know if you created it just this way, but it's exactly 21, which just clears the bar above 20. We put him in the annual progression category of 2.1% compared to the lowest group of 0.13. Coupled with the fact that he's 33 years old, I don't know, we know that these things aren't exactly linear, but if you argue this guy's gonna live to 83, those numbers suggest he's certainly gonna develop high grade or... So there's no question that this is a person that clearly does carry some risk. I'm actually a little surprised that the insurance refused your request because this is actually the exact person. Ellis Hurston with long segment Barrett's who's young and has a family history of adenocarcinoma. That's actually one thing where most of the guidelines agree that it should be considered as offered. So I would suggest that if one of our audience members were in this situation and someone really wanted it, I suspect if you really wanted it and appealed and this and that sort of thing, you could probably ramrod this home because there's actually a pretty good story here. So I do agree with a lot of nondisplastics, it's very hard, but this is actually a pretty solid case. Adarsh brings up a good point about the reflux being under control that may protect you against additional development of longer segment Barrett's, but I do wanna emphasize that despite what you may hear occasionally from surgeons, Barrett's does not regress after this sort of... So I don't want you to think that, oh, maybe we'll get rid of the Barrett's once we do the fundo. I don't think that's the case, but you may prevent progression either based on length or perhaps progression based on grade of dysplasia in the future. So I do think there's value in a 33 year old to consider that. One could also point out that one of the biggest risk factors for prolonged or failed ablation based on the data from Northwestern is the presence of a large hernia. So should this patient decide with Adarsh in a year that you know what, I wanna file that appeal and I wanna do this and you get approval, the fact that they have already taken care of that hernia should allow them for a more expedited and efficacious eradication program. Yeah. And then Dr. Moussami, occasionally we will have put someone into, let's say you have a patient with lower high grade dysplasia and you start RFA and it just, it keeps coming back. Every time you bring them back, it keeps coming back. I think typically there's like we talked about, typically then you consider, okay, inadequate acid control and maybe consider an anti-reflux procedure. But are you worried that either a Nissen or TIF or some other anti-reflux procedure is somehow gonna bury the Barrett's or affect your ability to treat it or detect it, et cetera? Yeah. I mean, I think that that's always a concern. The anatomy is a little bit less visualized, but I don't think that you should be worried enough to not do it. And both based on, again, data out of Northwestern and our own personal experience, and there's been several cases where I've just not been getting any headway. And then subsequently we did a pH study show there was refractory GERD. We did an anti-reflux procedure and were able to subsequently achieve eradication. So I think that that is a useful technique and should be considered in patients who are having poor response. And then I'll skip over this about how often we should do endoscopic surveillance. I think the point I was trying to make here is if you were pushed into doing endoscopic surveillance in this case, which you might be, I would make sure it's on the sooner end. When we talk three to five, we probably shouldn't let this patient go five years, which probably up more like three years. Though the guidelines usually say if it's greater than 10 centimeters to refer to a tertiary center, in which case the tertiary center then has to make that decision if they're not ablating. But I'm guessing I would probably do a kind of a closer, keep a closer eye on this patient if I am going to be doing surveillance. Yeah, I think we might deviate from the guidelines and even do it a bit sooner for him, just for other reasons unrelated. But I'm going to keep a close eye on him. So if we can't get it approved with nondisplastic, I'm going to catch that dysplasia. But this is critical again for someone to do a very nice, careful, methodical exam in this. You've got a lot of territory. You should probably spend a good 10 minutes on his esophagus to look at it. And most importantly, take the appropriate number of biopsies. It is going to be a fair number. Even at Q2, you're going to have about seven levels here. So you're going to have about 28 biopsies when you're done, but you do want to do that. So it's critical if you're going to come every three years or so to make sure you give him a real good look over when you do see him. Yep. Thank you. Thank you guys. The other question I think we went over as well about the role of precision medicine, like tissue-side parent risk stratifying this patient, that is emerging technology. And as Dr. Matsutani mentioned in his presentation, hopefully that would help, maybe even help get insurance authorization for certain patients. Moving on to our last case. This is a case Dr. Thacker actually alerted me to that he had dealt with recently. It's a 71-year-old with Barrett's esophagus who underwent a surveillance EGD that showed C0M6 Barrett's with biopsy showing low-grade dysplasia. This is the EGD after the biopsy, so not the EGD with the biopsies. And you see these squamous islands that Dr. Thacker felt was likely due to, maybe even due to prior biopsies, but this is a C0M6 Barrett's. What eradication modality would you select for this segment of Barrett's? And I'll give a disclaimer that this was carefully observed. No nodular lesions were seen amenable to EMR. So the decision was made to potentially go towards ablation for this. So we spoke a little bit about EMR. What do you guys think about ablation? Would you do 360-degree balloon RFA, focal halo 60 or 90 RFA? Would you do cryoablation or cryo-balloon ablation? What do you think for this Barrett's segment? Yeah, while people are answering, Dr. Muthusamy, what do you think when you see like this type of Barrett's? It's like technically it was C0 because there's squamous going right down to essentially the GEJ, but it was a long segment, but I found all these islands like a chicken pox Barrett's. Yeah, very interesting. This is an unusual pattern to see this many islands spread out. What's the total length again here? I'm sorry, I think I may have missed that. This is M5 or 6, C0 and 6. We've got 6 centimeters here, and so you've got a fair amount of length here. And I think, like I said, you're not going to have a modality that is going to skip the island. So essentially you have to treat this as essentially circumferential, even though, as you said, by the true technology, it's not. So you're really looking at what can I use to ablate circumferentially 6 centimeters of the esophagus, right? I think that's your question. Yeah. And just because we're running a little late on time, I'll just tell you what I did. I ended up using the 360 Express Balloon, and you could very quickly move through, especially with just a 5-centimeter length, was able to quickly move through ablations. And there was one side that didn't quite oppose fully, so it didn't look as great as I wanted, but I kind of had already coached and counseled the patient that it may take two to three sessions to get rid of this. So I'll probably plan on probably doing focal RFA the next time around. And so he's ready for that. You and I just had a discussion on Cryo Balloon, and I think it's really, the jury's still out, but it may be a nice alternative for focal therapy, particularly in patients who had a lot of discomfort with RFA, but I think we're still kind of working on how to position that. And then I'll ask a question to the audience. Let's say you encounter this as your index EGD. Again, let's say you're scoping someone for a completely unrelated reason. Let's say it's just Pepsi or iron-deficit anemia, and you encounter this. It's a late day. You're already running an hour behind. You've got this long segment, and you really, okay, we've got to deal with this. Where in this photo would you think, or either of these photos, do you think you're most likely to find the dysplasia? What are the hotspots in someone with untreated or new Barrett's? So the question for the participants is, where do you think we should be biopsying? Or no, I mean, not biopsying, but where do you think you'd be most concerned about dysplasia in this segment or any segment of Barrett's? Yeah, I'm not suggesting you rush. I think that I would take the time to really do a good inspection, take Seattle Protocol biopsies, but, you know, what are the hotspots? Dr. Mutasavi, what do you think? Well, in terms of determining where the dysplasia is most likely to occur, you generally want to look at usually the top two centimeters of any region. So just below the squamous columnar junction, there seems to be a higher preponderance of dysplasia in that top one to two centimeters. And then also the other area is to sort of look kind of where you see that, where those folds ending on the right wall there, kind of the right inferior portion. So on that left photo, kind of you can see those two folds ending kind of in that box about one to two centimeters there. Those are two areas where they're not really exactly sure why there seems to be a geographic predominance here, but there have been some manuscripts suggesting that, and I've sort of tend to agree with that based on my own experience. Yeah, and the reason I mentioned that specifically and kind of talked about the late day and running behind is that I think that people can get some biopsy fatigue. And we've seen this in some of the referrals for endoscopic eradication therapy or question of dysplasia where, you know, people will take biopsies, they'll start the maybe Q2 centimeters, but it kind of peters out at the top, right? They'll biopsy the bottom and then you don't do too much time, or you just do quick ones at the top. But the top is one of the hotspots. And so I think it just reinforces the need to really do a thorough exam and inspection, but really with the random biopsy protocols, to be sure to do the whole segment because you could potentially miss something if you, you know, kind of peter out or get biopsy fatigue and peter off. So that's the point I wanted to make there. This is an ongoing case. I don't know what it's going to look like when I bring it back. I just did this last week, but we'll see, and we'll keep going. Yeah. Well, I think we've come up to the time, yeah. Yep, any other questions anyone has? Nope, doesn't look like there's any other questions from anyone. Thank you so much, everyone, for joining us. Thank you. Have a good evening. Thank you again to all our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASG educational events. Visit the ASG website for the complete lineup of events and to register. The Advanced Endoscopy Fellows Program scheduled for September 22nd, 23rd will be held at the ASGE facility in Downers Grove. Registration will be limited to 70 advanced fellows, so make sure you sign up in March. The next Endo Hangout session will take place on March 2nd, Polypectomy Techniques presented by Mohamed Othman, Baylor College of Medicine. Registration is open. At the conclusion of this webinar, you will receive a short survey, and we would appreciate your feedback. Your experience with these learning events is important to ASGE, and we want to make sure we're offering interactive sessions that fit your educational needs. As a final reminder, ASG membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and make sure you sign up. In closing, thank you again to our panelists and moderators for this excellent presentation, and thank you to our audience for making this session interactive. We hope this information has been useful to you, and with that, I will conclude our presentation. Have a good night, everyone. Thank you.

Barrett's esophagus

management

identification

treatment

techniques

detection

endoscopic eradication therapy

examination

visualization

narrowband imaging

resection techniques

biopsies