Dr. Shen, do you have any questions for anybody at this point? So the question for Susie, right, as I, so how do you, when you do the pouch, the endoscopy and the pregnancy, do you unhook the air insufflation? I typically do. I just don't want any air there. I mean, you need some air, but it's, you know, it's CO2, it'll get easily absorbed. And you just want to minimize how much you're putting in. You can use water to insufflate and that, you know, how much time do you really need to spend in that neoterminal ileum? It's really the pouch and you can use water to inflate it. So you're thinking of water is safer than air. Thank you. So one last question to wrap it up, I think both for Tanya and Marietta. So what do you think is the future, I mean, the role of FDRD in IBD patients in the future? I mean, FDRD, non-IBD patients, a lot of studies are going on. And do you do FDRD as an option for endoscopic resection in IBD dysplasia? I actually, I'm lucky enough that I am at an institution where, so Nina Coelho, who is on faculty for this, I just send all my patients to her for endoscopy because I want the best outcome for the patient. And it takes, as you guys know, and you've, you know, discussed today that it takes extra training and time and expertise. And so I don't do it. So I leave it up to my colleagues to make those decisions about the right technique. This is such an evolving topic and you can really save patients from surgeries if you know what you're doing and do it correctly. So I leave it to the true experts. What about you, Marietta and Tania? In my experience, no, I don't. I think still, you know, also the new guidelines of ECHO then will come soon about malignancies and there is IBD. We stress still the concept of the en bloc resection rather than piecemeal. And, you know, about your biopsies, there is now the new guidelines of the European Society of Gastrointestinal Endoscopy, which is the part, the lower GI part. We will not recommend to take biopsies surrounding, because as you say, there is no evidence. Of course, this is something some study can be explored, but consider patients with dysplasia and I live also with Tania, they have a very bad colon and most of them, maybe they don't control inflammation very well. So I think we should consider with caution. I don't know if it's better ESD rather than full thickness resection, but I don't do in my experience. I try to do en bloc and also EMR, of course, try to, if there is no EMR, try to, if it's indicated for ESD. I mean, I feel like only like 30% of patients have a normal colon when they do a resection. Most of them have active inflammation around the area, very subtle. So resection is very, very hard in this patient, you don't get a perfect colon in these patients. So Tania, what is your experience and I'd like to get your input. Yeah, great. I think it's a good question. I think the FDRD one, I do it rarely even indicated in normal colons because I think there are some lesions that are good for it, but those are few. I think for IBD, it's a tricky one because as everyone's sort of alluding to, these colons are a little different. They have that inflammation and scarring. I often find FDRD was a first, like touted to, oh, it'll be good for non-lifting, but that's exactly what it's not that great for because you can't get the area into the cap. So I think that the idea of taking that area in a focal way is, I'm not very comfortable with it. So I don't see the, I'm not excited to start exploring FDRD for IBD patients, in my opinion. I think that was your specific question, right? That's correct. Yeah. The question to wrap it up would be the role of resection in general in IBD patients, because I would say we want a perfectly normal colon and quiescent disease when you want to do a resection, but we really see in practice, only I see 30 to 40% have a normal colon. Most of them have actually active inflammation with the lesion. So what do you do in those patients? Well, I mean, I think it depends on the degree of active inflammation. So I think it's hard to get anyone in complete quiescence, right? I think you can get, if you're having a moderate to severe inflammation and you've optimized and maximized medical therapy, then it's a discussion of surgery for other reasons too, right? So that's kind of, I have a few patients I send back, come to me, referred for a lesion. It's so noisy in there. There's so much inflammation. And I say, you know what? Like, let's take a step back. Let's like try to upstage your medical therapy, or try a different one laterally, whatever, and then come back. And their colons, some patients are refractory, but others, it really changes. It changes the whole scene of what you're working at. And some of the lesions don't look as bad, right? When you see them again, I don't know. So I think I definitely have a handful of patients I've sent to try to get their medical management better before I remove the lesion, before automatically saying this is unrespectable and let's send you to surgery. So this is the reason why we need to stress the multidisciplinary approach. And I think this is crucial. And I agree with Tonya. I think patients needs to be treated first. And now we have, you know, different kinds of drugs, especially for, you know, for both ulcerative colitis and Crohn's disease. Unless, of course, you have a typical patient who has failed all the treatment and still is inflamed and he has, you know, dysplasia, then you need to differentiate between if he's low grade or high grade. We will change, you know, your approach. In this case, I think, you know, the best therapeutic option is surgery because patients anyway will not respond, is not responding to therapy. But if you have another scenario where you have a lesion, then the patient's active and has a opportunity, an option to heal or to be treated differently, I will. And I agree lesion change because when the patient is remission change.

endoscopic procedures

inflammatory bowel disease

dysplasia

minimizing air insufflation

medical therapy