I think we'll welcome Dr. Boshan to talk about the next topic. He's going to talk on the role of the principles of interventional IBD, the indications, the contraindications, precautions, and Boshan needs no introduction. He's an expert in interventional IBD, and it's perfect that he's giving a talk on the introduction of the perspectives of interventional IBD. Thank you, Uday, and thank you, ASGE, especially Reddy and Lyle, for your support. Actually, finally, I can see the interventional IBD involved to become a new sub-specialty. I really enjoyed the talk by Dr. Bernstein, Dr. Khanna, and Dr. Rath. Today, I try not to use some of the published data or evidence. I just used some of my personal experience and the lesson. Tomorrow, we also want to share some of my own personal lessons when you practice at the Cleveland Clinic for almost 20 years and now at Columbia University. Here is my disclosure. As we know, when we practice endoscopy, an important one, it is far most important is the principle. Then, by technique, an equipment, device, or supply is probably least important. The most important one is the principle. So how do we do prepare the therapeutic endoscopy in IBD? Now, there's a gap between the IBD specialist and between the therapeutic endoscopist. I think the therapeutic endoscopist is probably focused mainly on the ERCP esophageal disorder, and an IBD person focused on medical therapy, and an IBD surgeon focused on the surgical part. There's a gap, so we need more and more people interested in the therapeutic endoscopy in IBD. So, regarding how to prepare the therapeutic endoscopy in IBD, I listed here pre-procedural imaging, bowel preparation, anticoagulation, antibiotic use, and corticosteroid use, and the biological use of the biologics, and then what is set in the biopsy. Here is our consensus guideline, so that we recommended all the patients undergoing therapeutic endoscopy should have some form of cross-sectional imaging, either CT, MI. Occasionally, we use ultrasound to detect the inflammatory structure versus a fibrotic structure. PEG solution is preferred. Anticoagulation, we strictly follow the ASG guideline for the therapeutic endoscopy. Normally, we do not need antibiotics, except the people with the diverted colon or diverted ileal pouch with the stoma, and then corticosteroid, we highly recommend to try to avoid systemic steroid. If you have to use it, the dosage should be less than 10 to 20 mg a day. You can still use a biologic agent pre-, intra-, or post-operative post-procedure period. Second, try to do elective setting, try to avoid emergent therapeutic endoscopy. Sedation or a MAC, or even sometimes people with a high risk for aspiration, general anesthesia with intubation is recommended, and then we highly recommend CO2 insufflation. The biopsy for people with a structure, we recommend at least a biopsy on yearly, and then your biopsy at the index, the very first therapeutic endoscopy for structure. So here is, if you have a formal further reference, please refer to this consensus guideline from Global Interventional Inflammatory Biodiesel Group. So cross-sectional imaging is important. Sometimes you can see the structure, but near the structure, there could be a fistula nearby. So if you deliver the endoscopic therapy, it can be dangerous. So now, this is the slide that brought from Dr. Mao from Singapore University, and there's a tendency to use ultrasound, especially ultrasound elastography, to differentiate inflammatory structure versus fibrotic structure. It's not commercially available yet. Regarding the location, when you deliver the endoscopy, you're looking for the area which has a thick muscle there, such as the pylorus, such as the ileocecal valve, and the anorectal area. And when you power with the thin, especially small bowel, middle of the small bowel, duodenum, and the esophagus, the esophagus has no serosa, it can cause perforation. We should be very careful. Now, regarding the bowel prep, our fellow, Dr. Siegel, presented a case. We have over four months, the 100 consecutive therapeutic IBD endoscopy, we use a PEC solution. PEC solution, we use the MiloLAX, yeah, 250 gram, together with the 64 ounces of the Gatorade, and then the success, the good and excellent prep is about 94%, 95%, and the therapeutic procedure were completely 95%. We would, some of the patient, we may have, if we have a short, a short segment of the small bowel, or the large bowel left, or the colon, rectum, or the ileal pouch, people may use the Fleece Enema as an alternative, but recommended the patient should have oral solution with a PEC. Now, orientation is very important. Orientation, we normally put the patient in the left lateral position. You will know it's a quadrant. The quadrant, it's a left upper quadrant is posterior wall, right low quadrant is anterior wall, either it's in the distal bowel, in the colon and rectal area, or ileal pouch area. Now, here is an anterior wall, you can see the nearby organs, vagina, and the posterior wall actually isn't here, it's called a presacral sinus. So, keep the orientation is very important for the therapeutic endoscopy in IBD. Now, this is the way to do the orientation, right? This is the patient had a presacral leak from ileal pouch anal anastomosis. Posterior wall, it is in the 11 o'clock, 10 o'clock, and anterior wall is 5 to 4 o'clock. Now, this is after the therapy, we deliver the therapy with a sinusotomy and epithelialize the sinus. Here, again, it's very important, the patient actually, there are two holes here, one hole leading to the bowel lumen, other one is actually is vaginal fistula. So, we use the orientation, rectal orientation, posterior wall, and anterior wall, and use a guide wire. Over the guide wire, you can deliver the endoscopic therapy. Here, we do the electro-incision with the IT knife. So, this is the distal bowel lumen, and this is the fistula opening. Fistula opening here, and the lumen is here. So, the orientation is a key. Now, this look like an asthmatic structure, look benign. As a matter of fact, it is the cancer of the small bowel, the adenocarcinoma. In patients with a long history of the coronary disease, this is actually at the ileocolonic anastomosis. So, we recommend at the index colonoscopy, endoscopy for therapy, you at least need a biopsy, and then the biopsy yearly afterwards. So, all the structure, you at least at the time of the first intervention, you need a biopsy, and at least a biopsy once a year. Now, know the anatomy is a key. So, actually, there's the report from one of the outside hospital said, oh, there is a five to eight millimeter diameter structure in the distal bowel. Actually, that patient was three months prior to that, the bowel was completely normal. How come within three months, it developed a structure and developed the inflammation like this? As a matter of fact, it is the, we call a transverse staple line leak here. So, the previous endoscopist mentioned about a structure, or he thought the structure isn't here in the neo-terminal ileum. As a matter of fact, the hole isn't here. So, then we found that hole, the transverse staple line leak is a surgical leak. And then we put the, over the scope clip there. So, this is the patient, it's like, especially after surgery, we shouldn't familiar ourselves with post-surgical anatomy. Now, here is another guideline. It's an endoscopic evaluation of the surgically altered bowel in an IBD, and you're welcome to read that article in the previous detail. Now, indication. Over the years, I summarized the past literature, and then I now practice here at Columbia University. So, I summarize in the five areas currently in endoscopic therapy in IBD. Structure, fistula, and abscesses, basal removal, foreign body removal, and the treatment of the blocking luminal lesions, and FMT, fecal microbiota transplant. IBD, surgery-associated complication, and the colitis-associated neoplasia. So, here is a structure. The structure therapy, we use a balloon dilatation. Actually, Dr. Nina Kouho-Bruho from Mayo Clinic will later on give you a presentation on the endoscopic balloon dilatation. And then other treatment and modality, the structurotomy, structuroplasty, stenting. Example, we do the balloon dilatation, and typically the people with IBD, the goal of the endoscopic therapy, the balloon size is 18 to 20 millimeters. And then you may require several sessions to achieve that goal. So, greater dilatation is important. I think the thinner the structure responded to the balloon dilatation, the better. So, typically the people, if they have a structure more than four to five centimeters long, the balloon dilatation typically doesn't work well. Now, how about the electroincision? So, we give a formal name called endoscopic structurotomy and endoscopic structuroplasty. So, here is a description. So, this is the anastomosis structure, anastomotic structure, use a knife to treat, open the structure up. We call it structurotomy. So, this is probably in the future for the CPT code purpose in terms of terminology. Now, this one we call structuroplasty. Similar concept to the surgical structuroplasty. Basically, you open the structure and then you put a spacer in between. Like you open the door, now you put a door stopper to prevent the structure closing again. In the meantime, also prevent the bleeding and prevent of procedure-associated perforation. Now, how about its use? I think as compared with a balloon dilatation and a structurotomy, a structuroplasty, I think this is especially in the anorectal area as a structurotomy is more applicable and is safer because you cut the structure in the circumferential way and you have good control of your tip of the scope. You know how deep you go. And then most important one, just in case there's a bleeding, it's easy to control. You can just put a local compression with a tampon. Now, I anticipated this trend. So, all chronic disease structure, most of the people now, the gastroenterologists, IBD specialists, even some of the corrective surgeons feel comfortable with the balloon dilatation. But you can see the more and more people are comfortable to the endoscopic structurotomy or structuroplasty. And there's a tendency, maybe anorectal structure and anastomotic fibrotic structure, we may use more of the structurotomy rather than balloon dilatation. So, here's our data at your anorectal structure from Columbia. These were presented at the DDW. We have the 18 cases. Actually, the survival curve is pretty good. So, we can treat the structure. Surgery-free survival here. Okay. Now, how about a stenting? So, very nice article by Dr. Larus and she will present the endoscopic stenting for the treatment of the Crohn's disease tomorrow. Stay tuned. It's the final nail in the coffin because according to their study, the endoscopic stenting is not as good and as safer as endoscopic balloon dilatation. So, stay tuned for tomorrow's lecture. Occasionally, in the rare occasion, probably stent still has some rule. For example, this patient has ulcerated a short structure at the ileocolonic anastomosis. Every time we do the balloon dilatation or electroincision, he has a bleeding. So, what happened? We put the axial stent there. Axial stent, this is the perfect fit for the patient with the short structure, especially anastomotic structure. Now, fistula and abscesses, another application. So, often the fistula associated with the structure. In that case, the patient had a tight, structured ileocecal valve with a proximal small valve dilatation and a developed fistula. Then, you can do the fistulotomy through the endoscopy with a knife and put the spaces there to open the structure trap up and actually serve as a two-purpose. One is a fistulotomy. In the meantime, that cuts the ileocecal valve structure. So, the fistulotomy with a fistulotomy. For the fistula, shorter than three centimeters, then less than two centimeters thick, you can give it a try. So, here we use endoscopy or at the endoscopy suite, we use a needle knife for the drained abscess to incision and drainage. Sometimes we can find the fistula track. We introduce the fistula track with a jagged wire and then followed by a CTAR. So, here's a picture like this. This patient had a short vaginal fistula. It's a vaginal fistula opening. You put a jagged wire through the jagged wire. This is this side of the vagina and then you over the jagged wire, you can introduce the CTAR. You can do it in the endoscopy suite. Now, next one is a basal foreign body and blocking lumen lesions and FMT. So, as we know, occasionally you can see the trapped capsule, especially in people with the coronary disease. You can do the antigrade or retrograde endoscopy to fish the trapped capsule out. Sometimes you have a basal, especially in the area of the structure. So, that's a patient who had partial small bowel obstruction symptoms or large bowel obstruction symptoms. You can either use a balloon or use a knife to open the structure up and then take the basal out, use a roth net, the endoscopic net. Now, sometimes the people have this anastomotic ulcer and the bleeding and then you can see the middle of the ulcer bleeding, there's a dislodged staple. Our experience, you remove that this dislodged staple may help the healing that ulcer and decrease the risk of the bleeding. Now, here is a circumferential polyp, inflammatory polyp, block the colon lumen, lumen of the colon, the patient that presented with a partial bowel obstruction symptoms. This inflammatory polyp with white cap and you know what, you can just use a snare to take it out, either cold snare or hot snare. Now, here is a stool transplant. You can put the stool through the endoscopy and then use a tampon to template the whole stool there for half an hour and one hour. How about IBD surgery associated complications? We can do the clipping, sinusotomy, fistulotomy, and the bleeding control. Here is a common practice surgery for IBD, for colon disease. You have a ileocolonic resection with a side-to-side anastomosis, and the anastomotic side can have the structure and can also have the transverse staple line leak. And then so the streptoplasty side can easily get the leak too. And so the people with the stoma can have the structure and can have the leak. Now, regarding the yeah, this leak, regarding the colon, also the collagen surgery, J pouch is a standard practice. The J pouch is a man-made organ, actually. There's a lot of the, not a lot, that quite often the J pouch surgery associated with a surgical leak, the estimated three to five percent. The common place of the leak is called the tip of the J, middle pouch body, and the presacral area, and the distal pouch, and then the vaginal area. So the common things is number two, number one, tip of the J leak, and the presacral sinus. So treatment of the fistula and sinus is different. So here's the bowel lumen, here's the skin, right? Here's the fistula tract. You do whatever you can, even temporarily close the primary orifice of the fistula tract. And then if this is the part of the skin, you can try to open other things up. So now for the people with a sinus, so there's a sinus, there's a bowel lumen, there's a sinus at the opening here. What do you need to do? It is try to open the sinus up with a knife, and put a clip there to the both side. Now this is the stomach closure side, there's a small hole. You can close the way that either with a, through the scope clip, or you can use over the scope of clip. The fresher, the better. If the surgical leak only, say, less than one month or three months, the tissue is fresh, and then the result in the scopicotherapy, the better. Now this is the endoscopic sinusotomy. So there's a sinus here, this pouch body here, basically you cut the wall between the sinus and the pouch body, and incorporate the sinus into the pouch body, and then this way basically you convert the sinus into the diverticulum. The similar things you can also apply when the people have the colorectal anastomosis, or coloanal anastomosis has a leak, presacral leak, you can use the same approach. Now how about the bleeding? When you have fresh anastomosis, or old anastomosis, when you have the bleeding, you can inject epinephrine, you can do APC, you can do the even local sugar injections, but my experience is the mechanical way always work the better. So we put a lot of the clip there, and then this, the anastomotic bleeding, we do the clip too. This is a fresh post-operative bleeding, this old post-operative anastomotic site bleeding. Try the clips. Now how about the last one, it's called a colitis-associated neoplasia. We can do the polypectomy in the mucosal, in the endoscopic mucosal section, endoscopic submucosal dissection. So be careful actually when you do the, remove the dysplastic lesion in the colon, because the fibrosis, submucosal fibrosis is very common in people with the IBD. Now you can do the ESD in an MRR, this slide is courtesy from Dr. Emery Gorgan from Cleveland Clinic. You can do the, technically you can do it. Now, according to syndical guideline, it was basically all the endoscopy, sort of like all the dysplastic lesions virtually endoscopically visible, and they're almost removable. True, or maybe not true. Actually this patient had a small, the long-term ulcerative colitis. You can have this ulcerative area, look like the colitis. You know what, we did a biopsy, found out the adenocarcinoma. Okay, so now some of the adenocarcinoma actually buried underneath of the sort of normal looking mucosa on the endoscopy. So can you imagine if you do the EMR, you only remove the partial, a piece of the bowel on the top, you leave this cancer there, it can be like a buried bone there. So be careful. So actually, don't forget that we always have a surgeon available. If the lesion is very close to anus, actually this is the other slide I borrowed from Dr. Ravi Karan, my partner at Columbia University. And I spent time with him in the OR, and he showed me how to do this surgically. You can do the mucosectomy, even like the excision of the lesion, far more deeper than our endoscopies, the EMR and the ESD. So don't forget our surgeons are available too. Precautions. When you do the therapeutic endoscopy, so very careful about the steroid use. You try to avoid any concurrent steroid use. Like this case, when you do the gentle balloon dilatation, ended with like the visible perforation, but we have a backup plan, you put a clip there. Now, lots of the patient, because of the IBD, they already lost a large segment of the bowel. So the bowel is, the volume is small, and then prolong the procedure, you can cause ileus. And then in the procedure room, or in the recovery room, you can put a decompression tube, and then 30 minutes, 10 minutes recovery, the decompression tube will help to get some air out. Of course, again, emphasize you should use the CO2. Now, if the people have the bleeding, for example, they will remove the inflammatory polyp at the cuff area, the distal bowel, and they have the bleeding, you can use a tampon there to make sure in your endoscopy suite, you have the tampon available. Now, I really just want our audience, when you treated any lesions in the diverted bowel, this patient had a stoma, and with a diverted large bowel, and very friable. Those patients, in my practice, I would rather give you some antibiotic prophylaxis if you deliver any therapy. Now, this is the same thing, the patient has a long-term diverted bowel, there's a mucus in the rumen, there's inflammatory polyp, and occasionally it causes bleeding. So, we remove that polyp, you know what, there's already perforation there. So, normally we say, okay, people have the diverted bowel, you have the perforation, and then in most cases, we just observe with antibiotics, because the patient already had a stoma here. But you should be very careful, don't stay there too long, pump too much air, and if you deliver the therapy, just be gentle, and then quick in and out. So, here is my last slide, endoscopic management of the IBD. Our goal is to deliver the therapy more definitive than in medical therapy, but less invasive than surgery. We try to defer, or at least in some of the patients, avoid the surgery. We need to understand indication and contradiction. Bowel prep is important, and the image, pre-procedural imaging, and the medication is important, especially the steroid. We should know the anatomy, especially post-operative anatomy, orientation of the scope, and the disease location. Try to do elective surgery, not emergent surgery. We always have an exit strategy available, just in case there's bleeding, there's perforation, you have a rescue plan that includes surgical backup. Watch out for any endoscopic therapy for diverted bowel.

Interventional Inflammatory Bowel Disease

Therapeutic Endoscopy

Pre-procedural Imaging

Bowel Preparation

Consensus Guidelines

IBD Surgery-associated Complications