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. American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, titled Esophageal Structure, Simple and Complex. 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 hand over the presentation to our GI Fellow moderators, Dr. Zeng Li and Dr. Eric Przybyszewski, both from Massachusetts General Hospital. Thank you. Thank you, Marilyn. Hello, everyone, and welcome. My name is Eric Przybyszewski. I'm a second-year GI Fellow at Massachusetts General Hospital. Thank you to the ASG for hosting tonight's webinar, and thank you to our panel for their commitment to education. Hi, everyone. Welcome. My name is Zeng Li. I'm one of the first-year fellows at MGH. It's my pleasure to introduce tonight's moderator, Dr. Kumar Krishnan. Dr. Krishnan is an assistant professor of medicine at Harvard Medical School. He is an interventional endoscopist at the Massachusetts General Hospital and also serves as the director of endoscopic innovation, technology, and education. And it is my pleasure to introduce one of our panelists, Dr. Joan Chen. So Dr. Chen joined the University of Michigan faculty in 2013, where she is the director of esophageal motility. Her clinical and research interests include swallowing disorders, GERD, EOE, and esophageal motility disorders. Her research has been awarded by an institutional philanthropy grant and the Rome AGA pilot grant. She's a site PI for several EOE clinical trials. She participated in the development of the Chicago classification for esophageal motility disorders and the ACG guideline for clinical use of esophageal physiology testing. Dr. Keval Visrodia is an assistant professor in the Division of Digestive Diseases at Columbia University Irving Medical Center. He is an interventional endoscopist who specializes in the endoscopic management of pancreas, bile duct, gallbladder, and gastrointestinal disorders. He has a particular interest in the endoscopic removal of precancerous and cancerous lesions throughout the gastrointestinal tract using endoscopic mucosal resection and endoscopic submucosal dissection. Thank you, Eric and Singh for that lovely introduction. I want to thank the ASG for putting this program together. I want to thank all of our participants and trainees who have logged on. Lastly, of course, I want to thank Dr. Jung Chen and Dr. Keval Visrodia for joining as well and providing their expertise. Today's webinar is on esophageal stricture management. I hope that we really put together a program that you all find helpful and useful. I think that we've touched upon many, many areas of esophageal stricture management that could be helpful for a first-year fellow, a third-year fellow, an advanced fellow, and even junior faculty or perhaps more senior faculty. With that, I think we will jump right in. This is meant to be interactive, so please send us your questions. We'll hopefully integrate them. Eric and Singh will sort of let us know when they come in, and we'd be happy to answer them sort of real-time. So I'm going to start with the first case. Oh, these are my disclosures. The first case is a 69-year-old man who has a history of diabetes and hypertension. He has long-standing GERD symptoms and is intimately compliant with PPI. He notes intermittent dysphagia to solids with some episodes of self-limited food impaction. He has had to excuse himself from meetings for fear of regurgitation. He's never required an ER visit. He has no weight loss, and normally he feels well. He said that he had an EGD one year ago for similar symptoms and was told he had LA-grade A esophagitis with no evidence of EOE on biopsies, and they noted the scope passes easily through the esophagus. The recommendation was to just continue PPIs. However, despite that, he still gets these episodes perhaps once, sometimes twice a month. So Joan or Cable, I don't know if you guys sometimes see patients like this in the office. They have dysphagia, even a description of food impaction, but they said, I had what was told to be a normal EGD. Curious how you guys would sort of approach this and what you think about it. Yeah, I can take a stab at it. I think this is kind of a garden variety patient, actually, that I do see in clinic. Patients with intermittent dysphagia and the history of EGD in the past. I mean, it depends on how long ago the EGD was. Dysphagia being one of the red flag symptoms still, I think it warrants a repeat EGD. The fact that the prior endoscopy scope easily passed through doesn't mean that there can't be a stricture that is either progressed or is larger than the size of an adult scope, but it's still smaller than what a normal esophagus should be. Biopsies for EOE, also, I'd like to know where the biopsies were taken and how many bites, because as you all know, it can be a patchy disease. And we want to take them from distal and proximal esophagus to truly rule out EOE. Finally, just with the LAA esophagitis, consider it mild and can be nonspecific, not diagnostic specifically for GERD. I'd want to know more about his response and heartburn, acid reflux, typical reflux symptoms response to PPI to kind of dig in a little more about reflux diagnosis and possibly this being related to peptic stricture. I would agree with Joan. Great points, especially the point about the stricture maybe being just larger than the size of the scope, which is, you know, just shy of 10 millimeters and you need a diameter typically of 13 to 15 millimeters to evade dysphagia. The one thing I would add is, if somebody's had a recent EGD and they're still having symptoms and the concern is for mechanical obstruction, I have a low threshold to just get a variant esophagram before the next endoscopy. And if that's completely negative, I may start thinking about a motility disorder, even though the history here isn't necessarily classic for them. I think you both have brought up some very good points and subtleties. I think the idea of a normal EGD with that scope passing through should just kind of raise a little bit of a concern. But also for me, at least when somebody says they've had self-limited food interactions, that really points to a mechanical cause of dysphagia and that's kind of why I wanted to present this case. This is the endoscopy. You can see here, the scope does pass through. There is a little bit of a ring, but what I wanted to highlight was that this is a way that you can, I'm going to pause this just for a second. It is very difficult sometimes to size up the esophagus, especially the distal esophagus. And we don't have great rulers or markers, but when you retroflex and take some time and insufflate the stomach, you can see the scope in relation to the fixed stricture or ring inside of the distal esophagus. You can use that as your guide. As Cable mentioned, 15 millimeters sometimes can still result in dysphagia. Certainly if somebody is taking large bites, they can have self-limited food interactions. The fact that he didn't need to go to the ER suggests that it's not so tight that it's going to result in that typical EGD presentation. But this is a simple trick to kind of size this up. So if your standard gastroscope is 10 millimeters, you can maybe assume that maybe this is 16, 15, 16 millimeters, and you can use that when you're trying to determine exactly how much you're going to dilate this esophagus. And so that's exactly what we ended up doing. I think we tried to go up to 18 with this dilation. And again, while the scope passed pretty easily, you guys will see the treatment response. Any preference from the panelists about a savory versus a balloon in this situation? I know the data will say it doesn't matter. But for me, I kind of cater it to the type of structure and maybe the location. Generally, nine times out of 10, I'm using a balloon, like is used here. But for more proximal structures or maybe multifocal structures, things that are a little bit more challenging to get to with the balloon, I may favor a savory dilator in those situations. That's the same as my practice. I often will have endotechs ask me, this patient is in here for dilation, do you want to use, do you use balloon or savory? And I would say, I don't know, it depends. You know, you can't ask me ahead of time before I see the structure. And that's because I think they're both great tools. But for me, depending on the length of the structures, location size, like you mentioned, I choose my tool then. Perfect. So if I can get back. You can see here after we deflate, we did get some disruption. And so I think I thought this was a good case just to kind of highlight a simple stricture, a common problem. Don't let the passage of the scope be really the only guide that tells you whether or not the patient has a mechanical stricture. I'm going to pass off the next case and teaching points to Dr. Chen. Can I ask a question about that last case quickly before we go to the next one? Yeah. So if you hadn't seen a stricture, say on the EGD or an esophagram, you know, can you just comment on the role for empiric dilation and how you kind of how you view that, how you think about it? That's a great question. You want to take the first stab, Jo? Sure. So, you know, historically, you know, there's not great data on empiric dilation and improving dysphagia. There are certain situations that I will do empiric dilation. And that typically for me, it's more subtle, potential subtle stricture, like proximal stricture, especially in somebody with history like radiation, you know, to the chest or like in planus or, you know, EOE with potentially near a caliber esophagus. This patient doesn't have those history, but I'm generalizing it. But if I am to do empiric dilation, I do do savory dilation. So when you're talking about picking the different types of dilator, if I do empiric, I do savory to make sure I take care of proximal strictures. And we have one more question. How long do you tend to leave the balloon up when dilating? I've seen mixed reviews between 30 and 60 seconds. That's a great question that I don't think has a great answer. Unfortunately, I have a feeling that the techs in the room have more say in that than I do. I think 30 or 60 are equally effective. I haven't found the difference. I don't know if Joan or Kumar have any other thoughts on that. Yeah, I mean, I think there's no data. There's no study. But for me, I dilate until I get a disruption. I don't really use time. I use a mechanical disruption to guide if I've dilated enough. Same. And I think with balloon, you're more at the risk of not having the balloon expanding with the widest diameter right at the stricture. So I think a lot of times as I'm expanding, I am focusing on keeping the balloon, centering the balloon at the stricture. And so I think a lot of the time is spent kind of, you know, inflating some air, visualizing it well, just to make sure it's where I need it. And then you can see through the balloon that it's disrupted the mucosa, the stricture. And so that's what I aim for over timing the exact duration. Great. So I can take over to talk about eosinophilic esophagitis dilation. So why do we talk about dilation in EOE? And, you know, this is a review for everybody, but dysphagia is obviously very common in EOE. As we know, strictures are common. Up to a third of patients with EOE will have strictures. And small caliber esophagus, a smaller portion, about 10%. Food impaction can be experienced in about a third to up to half of patients with EOE. So we also know that medication and dietary therapy, although can improve the stricture caliber, it typically does not resolve scars, stricture, fibrotic stricture completely. And so, on the other hand, dilation is an effective therapy and has been shown over and over. And treating symptoms of dysphagia and stricture, it is not effective for underlying inflammation. And so it should be used as an adjunctive therapy, typically in addition to either medication or dietary therapy. So historically, there's been a lot of fear in doing dilation in EOE. And that was based on really early studies in the 90s and early 2000s of case series showing esophageal perforation. In patients with EOE. However, over the last couple decades, there's been several meta-analyses now that have shown that dilation is really safe. And that's both the case for balloon and savory dilation. So here's the polled complication rate for esophageal dilation in EOE. Perforation rate was well below 1%, so 0.4%. Hospitalization, usually not for perforation. It's usually for symptom of pain, only about 1.2%, and hemorrhage, 0.1%. One thing that is important to know is that patients with EOE will oftentimes have chest discomfort pain after dilation. And this is as high as 74% in the meta-analyses. So I am presenting a case here in a pretty typical EOE patient, 20-year-old male with 12-year history of solid dysphagia with intermittent self-limited food impactions. He said about every two to three months, he would have an impaction episode that requires either regurgitation or waiting a while before the food goes down. No ED visits. He has had a history of eczema, no asthma or food allergies. And prior to coming to us, he had an esophagum that essentially already showed a narrow caliber esophagus. Endoscopy that we did here showed a pretty narrow esophagus. We tried with a regular upper scope. The top picture here, you can see that it's hard to appreciate when the entire esophagus is narrowed, but it is small and prevented the regular adult scope, which is about one centimeter from advancing past the really just below the UES. And if you are familiar with the ERAF scoring system for disease activity and eosinophilic esophagitis, the initial EGD showed edema in the esophagus, ring rate three, which essentially says that we were unable to pass the regular adult scope through. Exudate was mild, furrows of one also mild, and stricture, the entire esophagus was narrowed. So with the estimated diameter of six millimeters. So, it's funny that I think you guys can tell that Kumar and I went to did this similar esophageal fellowship because my last picture there you can see we switched over to an XP scope and this is perhaps not the best picture but you know on retrospect, on retroflexion is how I size up the esophagus. And with the XP scope in on retroflexion the esophagus is still right, you know, snuck around the XP scope so therefore the estimated diameter of six millimeters. I would say great minds just think alike. That's right. So, so this patient actually first came in to see me in 2016 I think, or 17 and then over the next year and a half or so he's undergone several entities with dilations. He had about eight HDs with savory dilation starting from the smallest diameter, and then up to 48 French, and then concurrently as I mentioned to control inflammation. He also tried on BID PPI as a trial, repeat endoscopy with babsies essentially every time I dilated him I also biopsy to check for response to medical and the dietary therapy. Then he had wanted to try dietary therapy, and actually undergone maybe a session and a half, and realize that as a 20 year old, you know, he just could not stick to a strict elimination diet so abandoned dietary elimination and tried topical steroids and really was having a hard time sticking with it daily BID therapy, but also have persistent eosinophils high counts of eosinophils. So eventually he enrolled in our diploma map trial which is the entire for entire 13 monoclonal antibody trial, but I am going to share some of the pictures throughout the dilation here and so I think, you know, we, you know, we talked about dilation, we bring up pictures of dilation, using EOE patient cases a lot of times, because of how impressive post dilation exams can can be right. And, you know, our, my prior predecessors here at Michigan used to say, don't look because you're just going to scare yourself don't really look and that when I first came to the University of Michigan that was what all of the fellows would say don't why why would you look. I always look because I always wanted to know what I've done and if I've done enough or if I've done, you know, not done anything I wanted to do more dilation so I kind of started getting our fellows used to seeing what post dilation esophagus looks like, and these are some of the pictures. And I'll say in the beginning I think years ago when I first started I've had a one of the fellows begged me to get an esophagus. So that it can help them sleep better that night. And so we, we got one and it was fine. Can you comment on your interval for these eight EGDs. Sure. Yeah, so I think I would bring them back as soon as every three to four weeks if I could. We are sort of limited by the slots endoscopy slots that we have and, you know, and typically I do these dilations myself. So, I think this patient ended up having one endoscopy probably every three months but I would do it every, you know, three, four weeks if I could. I have a follow up question to that. After the initial diagnosis of EOE. And let's say the institution of some therapy PPI or steroids How long do you wait before bringing them back for their first dilation or do you wait at all. I do wait so back to Kumar's question actually I do try to couple the dilation with my follow up endoscopy to check for treatment response so I guess that's also why we wait eight weeks or so so for PPI BID. You know the recommendation is to wait eight weeks before repeat endoscopy at least eight weeks so typically that ends up being eight to 12 weeks. Similar to that is topical steroid food elimination diet, generally if we are doing a washout eliminating foods we want to wait six to eight weeks before repeating endoscopy. If we're adding back we can repeat sooner which is about four to six weeks. And so usually if I am sometimes scheduling a few endoscopies out just to grab the slots I tell patients to schedule them every six weeks. And so that's kind of right in the middle the sweet spots of, you know, whether they're eliminating or reintroducing foods. That's a good question. So, this patient ended up with a narrow from a narrow color of esophagus to a normal caliber esophagus I did dilate him all the way to 51 French previously I said 48 but eventually I dilated him to adequate diameter. And part of the reason is because as a clinical trial we're not allowed to dilate the patients further so I, which is why we kind of brought up the diameter. And as you can see in the top pictures here. The diameter of the esophagus is pretty close to normal caliber now. But you still see the furrows, not much white plaques there but you can still see endoscopic signs of active inflammation there. And histologically he still had greater than 50 years distilling and 30 approximately. And this patient, like a number of my diploma trial patients. After the trial, you know you can see that the all the endoscopic signs really significantly improve the new rafts now when from high, high score to zero and so I should also add that the patient was already asymptomatic pretty much eating, whatever he wanted to eat after the diploma trial but we do recommend treatment for inflammation to prevent further scarring from forming. So just to kind of round up a few of my personal advice for you a dilation. First of all, both, you know, savory and through the scoped balloon dilator for patients with, you know, distal short segment strictures are safe and you'll eat. Usually I always tell my, my fellows to not rush a scope. I have seen narrow caliber esophagus be missed and in somebody that's trying to rush in with a scope or approximate structure, and then the endoscope itself can cause some trauma to the esophagus so I would be very gentle and patients with dysphagia and trying to just go straight into exam on the way out or something like some, you know, some, some of the other attendings have advised. One thing that with EOE dilation is most experts will say to start dilation, a little gentler because of active inflammation prior to treating the inflammation. So, without, you know, aggressively dilating right off the bat when the esophagus so inflamed from us and it fills. I would definitely warn patients of pain and potential pain following dilation. And again, back to the starting start low and go slow mantra, and always, you know, relook I would advise, don't be afraid to look at least, and know that multiple dilations may be needed to bring the patient up to adequate diameter and an EOE at least the targeted endpoint diameter is 16 millimeters. I think that the, the, the take home at least when I look at this is the persistence. I think a lot of people can get kind of dejected when they see a narrow caliber and, you know, like you get flustered but I thought that was a great example of being persistent with structure management. Can you talk a little bit about your target endpoint of 16, and sort of why, why 16. Yeah, so there have been studies looking at dysphagia correlation with dilation and improvement and dysphagia has been seen all the way from, you know, 12 millimeters up to 16 and then it sort of plateaus after that most page. Most patients once they're dilated past 16 no longer will have dysphagia. So I sometimes stop at 16 I sometimes try to go a little more to 18 but my typical endpoint is 18 but an EOE patients I, you know, pretty much know I'm getting there once I'm hitting 16. All right, Eric and seeing are we good to go to the next case or any questions that we. One quick question about this case. In patients with EOE, do you have reservations about both biopsying and dilating, you know, in the same procedure do you worry about excessive mucosal disruption. That's a really good question. I already know that I do both, so I don't want to waste the scope, you know, because they already are getting so many scopes these EOE patients. So what I do is I, and it's not because of concern for for mucosal injury but because I look for him after passing a dilator. I always dilate before I biopsy and I'm going back there to look anyway. And this is so that when I pass a dilator and I see him I'm not, you know, I know it's because of the dilation not because of biopsies that I had already taken. Great point. All right, I think we'll go to the next case. So, this is a different type of a case, 65 year old with a prior mediastinal tumor resection. They underwent radiation one year ago, and now they're having progressive dysphagia to solids. They've had several self limited food impactions, they vomited regurgitate frequently after eating meat, and they are being referred for evaluation and possible endoscopic therapy. They've had a barium study with a tablet that essentially looks like this, they notice, sort of a fixed narrowing kind of in the middle part of the esophagus, and a tablet gets hung up there and eventually dissolve and sort of past. I wanted to ask for maybe cable, you sort of alluded to earlier, when you want to get a barium study, can you kind of expand on you know what dilation, do you think a barium studies warranted and kind of what dilations you're like I don't really need to study. I, you know I get a barium. And I'm anticipating that the structure is complex and by complex I mean that it's either long like more than a couple centimeters, potentially multifocal post surgical or related to some type of other condition like radiation. So they tend to produce some nasty looking structures, and it sort of helps in pre planning counseling the patient, knowing what they should expect. In terms of number of endoscopies potential complications. I think it helps the team prepare for the procedure, what to have in the room, whether or not fluoroscopy is going to be necessary, whether you're going to use Savory versus Balloon. So it does, I think it sort of sets expectations and then makes the procedure itself much smoother. Yeah, I mean, that's kind of how I sort of look at it. I mean, I think with radiation, for me, that's one type of a stricture that I've grown to have a healthy appreciation for, and especially the complex nature of it. And so that can kind of guide sort of your strategy going forward. So here's the EGD, at about 25 centimeters, there's a stricture with smooth borders. There's no clear evidence of mass or malignancy, and a standard upper gastroscope does not pass through. So Cable, you kind of touched upon this sort of situation, do you use fluoro or no fluoro? For me, if it's the first time I'm dilating, if it's a complex stricture, if it's a long stricture, I can't get the scope through, I tend to use fluoro. But part of that is sort of guided by the fact that I have a fluoro room, and I know that that's not always accessible. Does the patient need to be intubated? I think if it's a very sort of challenging stricture, proximal airway issues, I probably would at least have it done with anesthesia as opposed to with sedation. And you sort of hit upon balloon or savoury dilation. I think if it's a long stricture, if it's a very proximal stricture, savoury, if it's a focal stricture, balloon. And then some of these advanced techniques, needle knife, tunneling, etc., these are sort of strategies that I sort of would reserve for more anastomotic type strictures. So this is kind of what I did. Again, couldn't get the scope through. You could argue that for this stricture, because you can see through it, you could probably pass a soft tip guide wire, and you probably would be okay. But again, because I have access to the room, that sort of changes it a little bit for me. But again, with radiation, I usually on the first dilation am very cautious, because I just never know how the tissue is going to respond. It is a little bit friable. So I'm going to fast forward a little bit here. And so for this one, I did pretty much just straight balloon dilation. And I may under dilate. I don't have that retroflection option. You can see a little bit of daylight on the first dilation. So we know that we're probably not getting that adequate response, but eventually we can start to go up a little bit more. And again, I'm super conservative with the first radiation stricture dilation. So to me, burning a balloon is not a big problem at all. You know that with some balloons, you can kind of pull it to the scope and torque so that you can sort of look through your balloon dilator. And this is a good time to get some feedback from your tech or nurse, how much pushback they're getting on the dilation. You certainly want a little bit of pushback. It means that you're getting a response. But an incredible amount of pushback means that maybe it's time to take a look. And again, I dilate until I get sort of a mucosal disruption. And in this situation, because I could dilate a little bit, I'll use that to taper so that I can advance my scope through and sort of complete the exam. Pass it over to Kable, who's got an interesting case. Thanks. So this is actually a full disclaimer. This is my colleague, Dr. John Penaros' case that I'm borrowing that I think has some good talking points. So this is a 63-year-old man who in his childhood had been exposed to some chemical and suffered on esophageal stricture, and I think was initially treated with endoscopic dilation. And then again, 20 years ago, but now he's having progressive dysphagia to solids. And so he underwent his first endoscopy with our group, and you can see in the bottom left that it revealed a benign appearing stenosis. This was at 32 centimeters from the incisors. The junction was at 39 centimeters, so somewhere in the mid to distal third of the esophagus. And eventually it was characterized as six millimeters in diameter by 20 millimeters in length, so relatively long. And it was not traversable, of course, with the diagnostic gastroscope, which you'll remember is 9.9 millimeters typically. It was dilated, as Kumar mentioned, with a soft tip catheter balloon to 15 millimeters. And you can see in the second picture that there's the beginning of a waist there, and then in the third picture that waist is completely ablated, and you can see the ischemic segment of stricture there. And in the final picture, you can see a nice rent just proximally. And so he was brought back about a month later. And if you look at that first picture, it almost looks like nothing happened. It didn't do anything for him. And so at that point, he was dilated again to 15 millimeters. And then this time, triamcinolone corticosteroid injection was performed. Joan, Kumar, can you talk about if you use steroid injections for these types of lesions and sort of where it falls into the algorithm for you guys, what type of stricture and when you would use it? Yeah, sure. I do use intralesional steroid sometimes in rare cases similar to this, but usually it would be a stricture that I dilated several times, probably a few more times before I would consider a steroid. And I think the reason why I don't use it straight off the bat is just that there's not great data. I believe the data is from small series showing maybe some increased interval between dilation, but we don't really have that much great data. The nurses hate doing steroid injections. I don't know if you guys have the same experience, but because this is very viscous, it's really hard to push through. And so I think at Vance, you guys have the larger bore needles, and sometimes I have to go steal those to make our nurses a little happier about me using intra-procedure steroid. But I reserve it generally for patients, and I don't have a strict rule, but in patients that I feel like I've tried several times to dilate and I've gotten nowhere, maybe on the third or fourth, maybe more sessions in. Yeah, I'm kind of the same way. I think the data, if I remember correctly, is on the mastomotic strictures. But having said that, when you have a stricture like this that's recoiling almost back to where you started prior to a dilation, I don't think it's unreasonable to try something new because, to be honest, it was a pretty aggressive dilation from the beginning. And to get this degree of recoil, the sort of theory behind it is to hope to get some remodeling after the dilation and disruption. So yeah, I mean, I think that for a stricture, we can sort of have a debate as to what counts as a refractory stricture. But I think that refractory stricture, meaning one that has been sort of aggressively dilated with an appropriate interval and still recoils, in my mind would be a decent candidate. But that's, again, not really data-driven. It's just you want to try something new. Thanks. I think my practice is similar. I usually would wait to try steroids until I've dilated it a few more times. But I think you're right, Kumar. In this case, the endoscopist was probably so impressed by the amount of recoil here and just moved down the algorithm. And so this time, they brought them back two weeks later. And on endoscopy number three, you can see that, always hard to tell from the photos, but it almost looks like there is no difference, once again, in the size of the stricture. And so at that point, he was dilated to 15 millimeters. You've got to be thinking about what your next step might be here. Thoughts? I'm sorry to interrupt. Is there any thought for Joan or Cable about, at this point, switching to Savory dilation instead of a balloon dilation, just to get that sheer force in addition to the radial force? Yeah, maybe. Yeah, I don't know, from a literature standpoint, if they've compared switching from one therapy to the other. But I think for something like this, it makes sense. And if you feel like you're not getting great apposition with the balloon, and it's clearly not helping, and for the additional longitudinal shear stress that you talked about. The only reason I would maybe bring it up is the length of the stricture. And certainly, these are long balloons. They're 5.5 to 8 centimeters in length. So they're going to traverse the stricture. But sometimes, it's not homogeneous, the stricture itself, in terms of its diameter. So you may get a lip or a rim that is in variable diameters. And so only for that reason alone. Again, not data-driven. But that may be one thought here, is to just switch over and try a Savory. Great. Can we advance the slide? So they brought them back two weeks later. So closer intervals. And endoscopy number four, as expected. There was no significant improvement in the stricture. And so actually, at this point, and we can talk about the definition of the textbook definition of a refractory stricture. But it was felt to at least clinically be refractory. And the decision was made to place a fully covered metal stent. What do you guys think about that? At what point do you choose to place a metal stent for, let's say, a non-anastomotic stricture? I think for me, it's sort of a game of attrition. I mean, you work on it, and work on it, and work on it. And you want to work on it until you've opened it up. And if you feel sort of you're really heading nowhere, the benefit of the stent is that you get persistent dilation in between your dilations, almost. And that sometimes gets you over the hump. That sometimes gets you over the hump. I think the trade-off is that oftentimes, these stents are not terribly tolerated. And so you risk sort of patients who are just miserable, but then they're also miserable because they can't eat. But I actually think in this circumstance, this is a good indication to try something new, whether it's an advanced maneuver. It's probably too long for a needle knife. It's probably too fibrotic for a tunnel approach. But I think a stent would be kind of, I think it'd be pretty reasonable. I'm not done. What do you think? So yeah, I would agree. In general, I am coming from the standpoint of not having fluoroscopy, and not placing a softra stent. So for me, it's kind of not part of my routine in terms of what I offer for softra strictures. Of the patients that I have seen with very stubborn strictures that ended up getting stents, we end up seeing some of the complications. They almost always migrate. And this is after stents are sutured down. And or they have severe pain, and we end up having to take them out. So I'm interested to see where this case goes. It's probably going to be successful. My own bias is that I kind of leave that to last case scenario after talking multidisciplinary discussions, and then referring to my advanced colleagues. I think the migration issue is interesting, because you're right. I mean, we oftentimes, I guess you'll probably tell us if this ended up getting sutured or not. But it's almost like their motility is stronger. It compensates for the stricture. And it's like sometimes you're shocked that a big stent really just gets migrated through. Despite such a tight stricture. Great. So I guess what I'm hearing. So I think, and correct me if I'm wrong, the classic definition for refractory benign strictures is failure to sustain a 14 millimeter diameter after five sessions of dilation in two week intervals. I guess what I'm hearing is that we're not necessarily tied down to that definition before we would consider an advanced therapy like stenting, right? So here's the immediate post stent placement fluoroscopy image. This is esophageal stents come in different diameters. Most common are probably 18 millimeters and 23 millimeter diameter. And they come in various lanes. I think the most common are 10 to 15 centimeters long. This was a 18 millimeter diameter stent. And this one is actually a short stent of six centimeters length. And I think what they were going for here, and I think generally what is preferred is you want to have at least two centimeters of stent above and below the stricture, which in this case was two centimeters. So they're going sort of for a perfect fit. And I think they wanted to maintain this in the esophagus and not have it cross the GE junction for a couple of reasons. One is that that can predispose to reflux and cause pain. And as one of the reasons why it may not be tolerated. The other is, I think, anecdotally, and maybe it's based on some limited research, there's a lower chance of migration just because you have the GE junction below to at least somewhat protected from a distal migration. And so you can see here that the scissors, which was used for marking purposes, represent the center or the location of the stricture and about equal amounts of stent was placed above and below. And as Joan alluded to, it almost seems like these never go perfectly afterwards. And so two days later, if you can hit next, he came in with pain. And I apologize, this chest actually is very hard to see, but you can see the markers on the top and the bottom of the stent there in the middle of this chest and those bright white lines. And this chest actually suggests that the stent has approximated actually upstream above the stricture, which explains why he was symptomatic. And so if we could advance the slide into endoscopy number five, confirming that the stent had migrated. And mind you, this is without any fixation technique like Kumar had mentioned. And so both of them actually had called this well in advance. And the next step that was chosen was to dilate once again, and then interestingly placed a larger diameter, longer stent, hoping that that would provide some more anchoring without any additional techniques such as clipping or over the scope clip or endoscopic suturing. And you can see a very tight waist once again in the middle portion of the stent. This is a 23 millimeter, 10 centimeter long stent. And he had a follow-up endoscopy four weeks later. Fortunately, the stent was well tolerated during this time and it did not migrate. The stent was removed and you can see sort of the immediate post-stent result there, which usually looks good. And the importance of continuing PPI cannot be overemphasized because you want to reduce any further inflammatory injury. And this patient, surprisingly, has done really well at six months without any recurrent symptoms and has not required a repeat endoscopy. Thank you for that. Thank you for that. I have a quick question if you don't mind, followed by one question from the audience. You mentioned the stent was removed four weeks later. In general, how long do you tend to leave stents in place before they have to be removed? My upper limit is usually around six weeks. And that stems from the concern that there can be overgrowth of the tissue at the ends of the stent and cause another potential stricture or make removal more challenging. Kumar, Chong, do you guys do anything differently? Yeah, I mean, it's the same for me, about four weeks. I think my typical... I mean, it's shocking if they're able to tolerate four weeks. I mean, I would be ecstatic with one or two weeks sometimes. But yeah, I mean, seldom want to leave it longer than that. The longer, the better. I mean, I think that the more remodeling you get and the more likelihood of a durable response. But yeah, I mean, this is a great case. And I think some of the points you mentioned, Cable. I will say, though, that stents that don't cross the GEJ are probably a little bit more tolerated, which was really fortunate for this patient. I think once you cross the EGJ, then it's a tough battle. Any thoughts, Joan? That's pretty much the same as what our advanced folks do. But also, they have to be on a stent diet, and they don't like that. It's another limitation for leaving the stent in for long. That's right. I'm going to move to case number three, if that's OK. This is a 68-year-old with a history of laryngeal cancer who had chemo and radiation, underwent G-tube placement, completed therapy. One year out of therapy, did not have any evidence of disease based on last ENT evaluation. He has not taken any PO, and now that he's sort of cancer-free, wants to start eating and remove his G-tube eventually. And so I thought that I would show sort of a technique. I know for whatever reason, I feel like savory dilation sometimes is not, fellows don't get as much exposure to the technique. And there are, I guess, a couple of different techniques. And we've shown a couple of cases of balloons, and I think balloons are nice. They're easy to use. There's sort of a visual part to it. But savories are a little bit different. I think they're incredibly effective, as Joan mentioned, for EOE patients. But I think technique is sort of an important aspect of this. I'd like to show sort of just how I do a savory dilation. Just a couple of pearls. Number one, as you guys can see, I leave the lights on when I do a savory. And that's because there are hash marks on the wire that are very difficult to see, I've noticed at nighttime. I'm sorry, when the lights are dim. The thing is, your assistant is holding the wire at the mouth the entire time. So there's never a moment where they're distracted and not holding the wire. Because when the wire slips back, that's really when you're prone to sort of having issues. So we pass the dilator over the wire. You can see that he holds it the entire time until we're sort of ready to go. I'm sort of used to doing the dilation by myself and not having somebody else hold the other end of the wire. So I pinch the back end of the wire to myself. And I just advance the dilator so that I know that the wire didn't move. And then obviously, we do our exchange to leave the wire in the same place. You can see the assistant is ready to grab the wire the second it comes out. We all do a check to make sure that the wire hasn't moved. We note how many hash marks we have. That's probably the biggest area where you're prone to lose wire, is on that second dilation, not the first dilation. So having a relook and a check and making sure everybody's on the same page before you pass your second dilator is sort of critically important. And again, sort of the same thing. We'll lube up the dilator. And I'll pinch it, and we will advance it. And the assistant will let go only when we're ready to pass the dilator. And the reason for this, if I can advance this, is when you pass a guide wire into the stomach, you can sort of notice there's a sort of a turn or an angle, a twist at the EGJ. And your guide wire, your stiff guide wire, allows your dilator to negotiate that turn. If your guide wire comes back inadvertently, either you don't pick it up, it's dark, you don't notice the hash marks are now two instead of five, when you pass that dilator, it's going to just follow the trajectory. And that is the most common side of a perforation, about two centimeters proximal to the EGJ related to a savory dilation. I don't know, Joan or Cable, do you have any comments on technique? Do you do it differently? Guide wire, and I'm talking about non-fluoroscopic dilation. I do it remarkably similarly. But it's interesting though that I don't think I've seen too many people, my colleagues doing dilation because we do how we were trained. I have heard from the fellows that some people will pass the dilators behind their backs. And so I think that there are many different, and I'm talking about esophageal specialists, to kind of straighten out. I don't know, I don't get it, but how you dilate is how I do mine. Cable, what about you? Yeah. I'm sorry, go ahead, Joan. I'm sorry, go ahead. I was just going to say that we do have our techs, well, they're trained to hold on to the dilator on the other end, which I wasn't used to. But they do that for all of the faculty across the board. Cable, what about you? I actually did the exact same way, even though I didn't train at the same program. So it must be a good technique. The one thing that you should be aware of is that this savory wire has markings on it. And so easy enough to just double check that the marking has not moved before the next savory passage. And if there's concern that it has moved back significantly, then you can always replace it endoscopically for fear of what Kumar really nicely showed in these pictures. Yeah. I mean, I think that it's a great point, what Cable just said. You have to replace it endoscopically. I think if the wire comes back and you push it in, that's certainly where you can sort of run into trouble because you can just curl the wire into the esophagus as opposed to having it inside of the stomach. It's an easy thing to do is just push it in, get your marks at four or whatever. But the safest thing is always restart entirely, get your scope down, advance the wire down, and confirm sort of each time. One question from the Q&A regarding savory dilation. Do you use silicon or any other product on the wire prior to initiating? I don't. But I think one point this brings up though is that the wires that at least we use, they're reused and they're process wash reused. And sometimes, and the way that the integrity of the wire is, for them to put it back into the bags, they have to be wrapped and they're wrapped around itself several times. So it's not infrequently that I open up a dilator, the nurse does, and I find a kink, right? Just from the processing. And that is problematic because when you're passing the guide wire over, you're feeling resistance. And that's a problem when you feel resistance and you don't know if it's from the guide wire or if it's from dilating a stricture. So I will routinely, and I'm kind of notorious for this, we'll throw out our guide wires that should be retired. And every once in a while, I think I do run a little, I try to smooth out the kink a little bit as I'm holding the guide wire. And whether it's with a little bit of lube or not, but I don't routinely do anything on the guide wire to help it pass. Typically, I don't have to. I think that's actually a really good question and a good comment about the kinking of the wire. We've switched over about a couple of years ago to disposable wires. I think for that exact reason, I think there's a handful of manufacturers that are making disposable wires. When they get reprocessed, if they get kinked, again, your dilator will be a little bit sticky going across it. And also the way you reprocess the dilators, you can get some stickiness and some damage on the inside of the wire port of the dilator that can make it a little bit tough to pass. And again, this is all tactile. So if you get that tactile feedback, I would say the same issue occurs. They make some of these masks that have holes inside of them. I think anesthesia or sometimes nursing likes them, but they cause a lot of friction at the point of entry when you put the dilator through the mouth. So I actually don't like those masks when I'm doing a savory dilator. What about you, Cable? Are you spraying anything on your guide wire? No, I do. I think our interventional techs are conditioned to just wet everything. So they just use water and then it's just lube around the dilator itself. And then to Joan's point, our savory dilators are also reprocessed and sometimes they don't come back in the case that they were sent in or they don't get replaced in the case right away. And so they have sort of abnormal, non-physiologic bends in them and things. And I will maybe just try to move on to the next dilator, a next size dilator at that point. I don't try to conform those or use those in any way. You don't want any unnatural resistance being introduced into your dilation. All right, I'm going to, oh, a couple of comments on proximal radiations pictures. I think both Cable and Joan sort of mentioned these points, slow and steady, frequent dilations. I think a lot of times patients get sent over for refractory radiation strictures and they're getting dilated once every two months. And for me, at least for radiation strictures, sometimes it's a Q weekly event and certainly be prepared for recoil. You can consider self-dilation. I haven't had a patient do this. I know there's literature available about self-dilation. I think it takes certainly a motivated patient for that. I don't know, Joan or Cable, do you have any self-dilation patients? We have quite a few actually. Usually these are, yeah, the esophagectomy, cancer esophagectomy, thoracic surgery patients. Our thoracic surgeons are actually routinely, they train patients in their clinics to do self-dilation. And so I inherit a lot of patients from there, but it can be time-saving and it takes them 15 minutes on a Sunday. Sometimes it's self-dilation, sometimes it's partner helping with the dilation. It's just, it becomes so routine and it helps them not have to go in every, sometimes monthly for dilation. So some of these selected patients really do like it. I've been trying to get a couple of patients to adopt this, but they're just resistant or maybe I'm not doing a good enough job of selling it. It helps. And the other thing that I think is that our center isn't experienced in teaching this. Where I trained at Mayo Clinic in Rochester, there was one or two esophagologists that routinely taught this. They did it with the help of radiology and they actually took them down and demonstrated that they could pass this successfully and reinforce that it was being done correctly, et cetera. And so I think that would be helpful. I don't think it's terribly difficult and I know there's a lot of resources out there, I'm sure. I think ASGE even has a video on how this can be taught and done correctly if somebody is willing to show this to their patients. And then lastly, don't forget that if you really can't advance anterograde, if they have a G-tube, you can use it. So use your G-tube to try to get sort of retrograde access and then you can start sort of working on them. There's a question about our radiation strictures on whether you would consider endoscopic incisional therapy, such as needle knife for management of these strictures. Cable, any thought? Yeah, my experience with radiation strictures is that they're typically longer. And so incision therapy works, I think, best for short focal strictures, like anastomotic strictures, especially. I think that's where the most data is. And so those are patients that I typically reserve that technique for. What about you, Kimon? Yeah, I think the esophagectomy patient who has a truly refractory stricture, I think that's a good candidate. I think prior to a stent in that circumstance would be a good situation. But radiation, again, the tissues are not normal. They're far more friable. They're refractory, which is why people think about these things, but I think it would have to be really a focal stricture to even think about that. All right, so I'm gonna present kind of a fun case from earlier this year and see what our expert panelists kind of think. So this is a 70-year-old who's had progressive dysphagia to solids with some regurgitation. He had a barium swallow that shows proximal esophageal stricture with holdup of the tablet. You can see the endoscopy here. This is probably around 20 centimeters. You can see sort of ulceration, some exudate. There's a stricture also related to this. And there's also some sort of abnormal mucosa kind of proximally to this area of stricture. So this is a patient who was referred over after they had a regular endoscopy. And so obviously this is an inlet patch and a stricture related to an inlet patch. And so I'm kind of curious what the panelists think about medical management and sort of overall management. Would you give PPIs alone? Would you give PPIs and dilate? And if you had to dilate, would it be a Savory or a Bloom? It's an interesting case. It's a biopsy. Kumar, it's during the diagnostic EGD. There were biopsies. I can tell you there's no malignancy, but it did confirm that this was an inlet patch. I think there's rare cases of malignancy in the setting of gastric tissue and inlet patches, but thankfully it's not that rare. To the point about the inlet patch, I would probably modify his diet and start with PPI alone and play it relatively conservatively. And if that didn't work, then I would dilate with a Savory just because of the proximal nature. You said 23 centimeters, so probably relatively close to the UES. It'd be, I think, challenging for me to get a balloon and hold it there and be absolutely sure that I'm bridging the structure. Yeah, same. The first thing I wanted to do was to biopsy it as well. It just looked like there's a little mucosal irregularity there. And actually before I started, I thought maybe this was Barrett's coming all the way up. And I've seen that before where I couldn't, we couldn't find the Z line and then just to realize that the Z line was all the way up in the U.S. So after biopsy, if there's no malignancy, I wouldn't be opposed to dilating it. This is a patient with dysphagia to solids. I would treat with PPI and probably with dilation. Yeah, and that's exactly what I did. It was PPIs and dilation, but let's see here. I think this is the first endoscopy that I did. And yeah, re-biopsied, dilated. And you can see there's sort of inlet patch tissue, there's exudate kind of adjacent to it. And so, there are reports of sort of acid producing inlet patches. And so that's kind of how I approached it. And so I actually offered RFA treatment to the inlet patch in addition to dilation. So this is the through the scope RFA dilation device. I don't have great data on it, aside from saying that it probably wasn't gonna harm anything. And if we could in some way sort of ablate that acid production, because I actually don't know what the bioavailability of PPIs is on the sort of ectopic gastric tissue. And so I just, I don't know, Joan, if you have any insight on that or? I think the data is quite controversial. One thing that I don't know if you thought about was, do you think the ulceration there could have been from pill esophagitis or even food sticking and causing irritation there versus acid related? Yeah, no, I think that that's probably definitely a reasonable point. The fact that there was like mucosal hypertrophy, just even more proximal than the stricture, it sort of led me into that direction. So we ended up ablating him and then we ended up dilating him. And then his follow-up, oh, here's the dilation. And maybe it may have been a little bit more distal than that cable, but the balloon, I normally would agree that I would do up a savory dilation more proximally. But in this circumstance, I thought I could get a good handle on it because it was a pretty focal stricture. And then on follow-up endoscopy, the ectopic tissue just wasn't there. And he's been doing well ever since. Now, I certainly can't say, oh, there was a little bit left, but for the most part, that inlet patch was gone. I think this was, I ended up doing a second RFA just on that little pocket, but the inlet patch kind of extended almost circumferentially just distal to his UES. So again, this is an anecdote, but I think just kind of a fun case that shows sort of a little bit of a different type of a stricture and sort of how I approached it. It's very interesting. Majority of my patients with inlet patch either have no symptoms, right? Or if they do, it's very nonspecific, whether it related to inlet patch or not, I don't know, it's usually like globus. And so I usually don't offer any treatment. And I think the concern is that the RFA itself can cause stricture. Then you're, you know, and you're going to end up dealing with the complications of the treatment. So this is really interesting. Nice result, Kamar. All right. I had another case. We talked a lot about refractory strictures. And so this is not that different from Cable's case, but this is kind of an interesting etiology, but this was a 55 year old with substance use disorder, had severe withdrawal associated with nausea and vomiting eight months ago, admitted and now in recovery doing well, but has developed progressive dysphagia to solids and even some liquids, had multiple food impactions requiring regurgitation, underwent an EGD outside and was known to have a very tight stricture at the EGJ, dilated to eight, symptoms improved for a week, but recurred, underwent two additional dilations spaced by four weeks to similar diameters, again, to no relief. And so Cable, I guess, to the points that you made about a refractory stricture, he's been dilated about three times and is kind of still at the sort of same spot. This is the endoscopy and this is right at his EGJ. He has sort of this exudate ulceration, this sort of hypertrophied mucosa. I can tell you it's been biopsied several times without malignancy, also with cross-sectional imaging that doesn't show any malignancy. And so it appears to be a benign stricture in his distal esophagus. Any thoughts like how you guys would sort of approach this? Is the patient still having nausea, vomiting? I think, you know, if that's kind of the root of the cause of the stricture, I would control that first before trying to manage the consequence. So he actually had that in the setting of his withdrawal symptoms, had this almost what sounded like it could have been a forehog. He was managed entirely outside. But since then, he does not have any nausea or vomiting, but just dysphagia. And he's now on a PPI? He's on a, yes, he's on PPI. He actually ended up getting a G-tube placed. Because... Getting PPI through the G-tube. So I can tell you kind of how I approached it. The general sense is, I assumed he had some sort of ischemic injury related to severe retching and vomiting, and maybe concomitant acid reflux. It didn't have the flavor of that typical straightforward peptic stricture. Those almost always respond to PPI and dilation. And this seemed to be truly refractory to that. And we really probed him for caustic ingestions, et cetera. There was no history. And so this was his endoscopy. You can see sort of that modeled appearance of his esophagus. And as you get sort of to the... I'll fast forward this a little bit. As you get to his distal esophagus, you can see that sort of exudate, the ulceration, mucosal changes. What do you guys think? I'm always curious about your strategy in the context of a ulcer. Joan or Cable, do you dilate if there's an ulcer or... I don't like saying ulcerated or even severe esophagitis and dilate. Sometimes I do, but it's two reasons, right? One is that it's increased risk of bleeding, perforation potentially, and less effective if it's a... Dilations are meant to be for fibrotic structures and not inflammation. And so I sometimes will have patients come back after BID-PPI before I do aggressive dilation. Yeah, same here. One thing though with this, I wonder if you considered, maybe you already have, but if it's so tight and it's inflamed and you wanna give PPI, how are you giving the PPI? Are the pills getting through or is it through G-tube? Through G-tube, yeah. I think through this. Yeah, he ended up getting a liquid formulation and he ended up getting it through the G-tube. So what we ended up doing is, again, I still was somewhat concerned about malignancy, even though the proximal part has been biopsied. I did an EUS. This is a situation where we used his G-tube. Here we just did a, put a balloon and kind of mapped it out. Fast forward a little bit for the sake of time. Ah, here we go. So we sort of stuck a pediatric gastroscope through his G-tube. And it's always interesting to do an endoscopy through a G-tube because we're a little turned around. And so once we kind of figured out where we were going, we took a look at his EGJ from retrograde and he's got a hernia right here. And to be honest, for the most part, it looked pretty benign. Some of that heme is from the wire guided, the wire passage previously. And I did take biopsies of this area that ended up being completely benign, but it was still ulcerated. And this sort of ulceration, just again, Joan, for the same reasons that you mentioned, it's a little concerned about just going aggressive and dilation. And so this was a patient similar to yours, Cable, that I reluctantly offered a stent. Prior to this, I had actually dilated him myself with a balloon very, very cautiously and was a little bit worried about the response afterwards. I had him on the fluoro table and there was no leak, but I just knew that by upsizing him, it probably wasn't gonna get the response that I was looking for. And so ended up placing a fully covered stent. I did end up overstitching it. Remarkably, he was able to tolerate it for only about two weeks. And after that, the stricture was far more manageable, but I would say that that wasn't the end of the story for him. I think that gave me the confidence to dilate him up a little bit more, knowing that he tolerated a stent that was 18 millimeters in diameter. So I was able to go to 12 to 15, and then I ended up using steroids. And that's really what ended up getting him to be in a little bit more stable place. So I still dilate him, but I'm able to take him to about 15 millimeters without significant recoil sort of in between. Would you guys have done anything differently? Or I don't know, I'm not presenting this as like a big win. I'm just curious what you guys would do, because I don't know what to do for this case. I don't think so, Kumar. I think you were able to achieve what you did in remarkably few endoscopic sessions. I will say that maybe because he chose to stent a little bit earlier. Otherwise, yeah, you could aggressively bring him back once or twice weekly, go up incrementally to 15 or 16.5 millimeters. And then my guess is that he'll probably just come back down. And that's if you didn't have a complication in between. Can you talk about, Kumar, your steroid injection technique? For example, are you a four-quadrant person before or after dilation, et cetera? Yeah, I am not a four-quadrant person. I put all 40 milligrams directly into the disruption. So I inject after I dilate, when I get that disruption to expose the submucosa, I inject directly in there. And again, all anecdotes and just my personal style. And I just want to get that steroid in the submucosa in hopes that I'll get remodeling. I tend to do it the other way, but not based on any data. I've noticed a few times where if I try to inject after I've caused a disruption, sometimes it just leaks out. And then I'm all out of steroid. And I don't know how much actually went in. I mean, your nurse is pretty upset when you're asking for a second vial. Right. Tell them to add it to the tab. And then I guess theoretically, if you inject into submucosa and then dilate, I don't know if there's better dispersion of the steroid. But again, I think it's all- That's interesting. I do a combination of what you guys do. I do it after and I do four-quadrant. I mean, I try to do adjacent to the disruption, but for the reason that it usually just leaks, I do around and I just end up doing a four-quadrant. The one instance where I feel strongly about doing it after dilation is if it's maybe a little bit of a longer structure and you can't get to the distal part with the needle confidently after you open it up much easier that way. All right. I'm gonna wrap up with one more case because I don't think it's appropriate to talk about dilations and all these success stories without showing some complications. So this was a case, this is a 38-year-old who had some developmental issues, had a fundoplication and was referred for esophageal stricture. So the fundoplication was actually redone and the patient had a G-tube, was primarily eating through G-tube, but was coughing and regurgitating and those symptoms became more symptomatic. So I ended up not being able to get through from above and so went through the G-tube from below, was able to get a wire, did some savory dilations only to about maybe eight millimeters. And so brought them back for a dilation. This was done under fluoro, a wire was passed, the dilator was put over the wire and this is a eight to 10 dilation. And so I'm just curious how you guys would sort of approach this situation. That's frightening. What do you think? I actually did this with a third-year fellow, so. Do you think was that from the air that you're putting in? Well- I've actually never seen this. So there's CO2, there is tenting of the wall. So I believe it could be barotrauma. But I don't know. I mean, I guess that's my best guess though. I've never seen barotrauma in the esophagus result in a split. I mean, I've had disruptions, even perforations at the site of the dilation, but not proximal. So now we have somebody with a pretty tight stricture and then a proximal perforation. So what do you think? Have you biopsied the esophagus previously to know that there's not like a, you know, like implant is or something, a dermatological condition? I actually didn't. I didn't biopsy the mucosa, only because the problem seemed to be exclusively at the EGJ where that contemplation was redone. Wow. So this case was actually several years ago and it was before I did POEM. And now looking at it, I probably could have just kind of approximated it. As with all complications, you know, number one, make sure your patient is stable. The patient was stable. Was there any crepitus? There was no crepitus and respiratory status was okay. So I think the one issue is if you just clip that perforation, you still have a distal obstruction. And so you're prone to get a chronic leak out of that. So similar to an incomplete myotomy with POEM, if you don't complete the myotomy and you have a mucosal injury, you're going to get a leak out of it. So my approach was actually to stent this so that I cover or divert the leak, but also treat the stricture so that there's no distal obstruction. Cable, what do you think? Over-stitch? Put your hand there. I, you know, I think the over-stitch, you have an opportunity here because, you know, it's happening in real time to actually do a primary repair, which is nice. But like you said, I think easier said than done. Over-stitch, if you have the skillset or if the skillset is available, I think would be nice here. I would probably still, for the reasons you mentioned, leave a stent behind. Just like you said, just to relieve the, or at least turn the pressure gradient into your favor and maybe leave an NG tube as well. I think the wrong thing to do is to just bail on this type of a case. I mean, I think you have to do something. Leaving an open area like that with a stricture, I think at minimum, clip it and leave an NG tube in, and then you transfer to a colleague who can help and do something else more definitive. But I just brought this up because things are going to happen. When you do dilations, hopefully you don't have a situation like this, but it's very important that at this time you try to address it in real time because the clock's ticking the second you have a perforation. Eric or Singh, any final questions? We have a couple of minutes before we're done. There's one question in the chat about if the defect was closed with clips, can an esophageal stent be deployed over it? Yeah, I mean, I think the answer is yes. You do get a little bit of pressure against that mucosal wall. You could also, if you were really slick, just put the stent just below, but I think covering it in a time like this, you're not going to leave it indefinitely. You're just going to leave it to kind of take care of the situation. I think it probably is okay. I don't know, Cave, what do you think? Would you worry that the stent was pushing in on the clips? I've had one instance in which a clip was used to mark a stricture before placing a stent, and I saw the clip be pushed out. And I think if you were to try to close this, you're probably looking at at least five or six clips. And so I don't know. I think I'm just a little gun shy from that experience. So I think the point is well taken, but I don't know if it actually makes a difference. Probably not, like you said. So I see somebody in the chat saying that, could this be EOE? And I think this is kind of historically the bad rep of EOE, the crepe paper esophagus, spontaneous rupture. I don't see this in EOE. EOE patients will tend to have longer rents and have symptoms, but barotrauma, this is very rare. And it doesn't tell me necessarily EOE. The semicosta didn't seem so fibrotic as it does in EOE. It seemed far more fragile, I think, but again, it wasn't biopsy. There's one general question about how do you measure or guess the diameter of the stricture? Maybe when you can't retroflex and see it from the stomach. That's a really good question. I think you try to size it up against the regular scope, knowing that the size of your scope, so similarly is about one centimeter or just below. So if I feel a little bit of resistance as I pass or I can sometimes see a distal stricture and it kind of sort of pops through without causing trauma, I know it's maybe at the size of my scope or maybe just below, especially if the scopes ends up causing a little bit of trauma. So you can size it up that way. Sometimes I actually use my dilator to size it up, right? So when I say I'm not afraid to go back to look, I'm passing, I underestimate it, and then I'll go in after passing two, three sizes to look, and then I can sometimes see where I'm just starting to cause some mucosal trauma, and then I start from there as kind of my ground zero and dilate up. Yeah, I mean, I think that's the right strategy. Same thing, I do the same thing. Under dilate, your scope will be a guide, whether it's about a centimeter for a standard gastroscope, six millimeters for a pediatric or ultra-thin gastroscope. So there's your general marking. All right, well, I think that's, we're sort of at the end of the half hour. I want to thank our faculty moderators, Dr. Joan Chen, Dr. Cable Visrodia, as well as our fellows who have been combing through all these questions, Dr. Eric Przybyszewski and Dr. Singley. I also want to thank the ASG for giving us this opportunity and all of our participants. 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. Registration is open, and many of these programs are complementary to our ASG training members. Visit the ASG website to register. The next ASG Endo Hangout session will take place on Thursday, July 7th at 7 p.m. Central Time under Wellness and GI Fellowship and Beyond. 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 are 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 the website and make sure to sign up. In closing, thank you again to our panelists and moderators for this excellent presentation, and thank you to our audience for making the session interactive. We hope this information has been useful to you, and with that, I will conclude our presentation. Have a good night. Thank you, everyone.

esophageal strictures

management

barium studies

fluoroscopy

savory dilation

balloon dilation

steroid injections

fully covered metal stents

esophageal stent placement

dilations

radiofrequency ablation

self-dilation

complications