I think before we proceed, I just have a quick question, the cast hood you talked about, is that specific for the double entroscope alone? Because we don't have that here. I don't have in our facility in the US, the use of a cast. Yeah, that cap is commercially available in Japan, but not outside of Japan yet. So if you are interested in, I will talk to the company to introduce you, and if that is introduced to the United States, that's wonderful. I think the Ovesco has one. I used once. Ovesco. Yeah, but that's not for the tip of the entroscope, the entroscope diameter is different, the Fuji one. I see. I like this mark, the calibrated, it's very, very smart things. Now my question for Dr. Yamamoto, so quite often, you know, I met the, I have 10 surgeons in my practice, Dr. Robbie Cameron is one of them. The surgeon loved to do strictureplasty. Now they got a multiple stricture, they do multiple strictureplasty. Now from the regular scope, my maximum of luck, I can pass three strictureplasty sites. But some of the strictureplasty deep in the jejunum, when you do the balloon entroscopy, when you go through this multiple strictureplasty site, do we have, do you have any difficulty there? First question. Second question, multiple surgery, people have a lot of the scar, like the bowel is so angulated. When you do the push, the enteroscopy, are you worried about for the drag that you're angulated about and the cost perforation? Yes, that is a very good question. Yes, after the surgical strictureplasty, the problem is that could cause adhesions. So the insertion of the entroscope could become very, very challenging. That is another reason why we want to avoid the surgical repair. With the endoscopic balloon dilation, we don't make any adhesion unless we make a perforation. So after the endoscopic balloon dilation and medical treatment, the insertion of the endoscope becomes easier. But after surgical repair, sometimes adhesion makes the insertion of the endoscope challenging and risky as well. I see. And the next question I have is the passage of a balloon to the endoscope. Sometimes I have difficulty in getting a 12 to 15 balloon through that because the balloon is bigger. To pass that balloon to the tip of the endoscope and dilate that stricture. Any techniques you use to pass the balloon through an angulated or twisted small ball? Yes. When I use a double endoscope, I inflate both the balloons and then jiggle the endoscope to make the shape as simple as possible. That is the first step. And then I use a little bit of olive oil to lubricate the inside of the channel. And I use the balloon up to 15 millimeters. And if you use the balloon up to 20 millimeters, that is too big. So up to 15 millimeters with olive oil, it can be inserted easily. Okay. Thank you. We have one question from the audience to Dr. Yamamoto. I think I was wondering if MRE is an option in your clinical practice rather than an endoscopy. Yes. What is the role of your MRE in your practice? Okay. After good control of the inflammation and balloon dilation is not necessary anymore, then the follow-up could be by MRE. And only when the inflammation without stricture and the adjustment of the treatment strategy could be based on the MRE findings. But once the significant strictures, which require dilation, then we perform laparoscopic endoscopy. One last question, Dr. Kiran. So we talked about surgical management of perforations. I mean, do you open up the abdomen if you need to go in, or is an option for laparoscopic approach for these patients for perforation? Yeah. I prefer a laparoscopic approach as long as that can be selected by the surgeon. We ask the colleague surgeons to perform laparoscopically as long as they agree. It's always feasible to do it laparoscopically. It really depends upon how sick the patient is, if they're unstable, or there's a lot of scar. If the patient's had a perforation, you just want to approach it quickly and efficiently. But a patient who has not had a previous surgery and who's not otherwise ill, I think laparoscopy would be the best approach. I agree. Yes. So the discussion between the endoscopist and the surgeon are very important. Without discussion, just send the patient to surgery, then they will open. Agree. So my question actually for Raju, is here. Raju? Yeah. Yeah. Dr. Raju. So if you have a perforation, when you use a through the scope clip, do you have a preference? You know there's some of the wider clip, but it's like 17 or 16, even like an R20. Or some of the clip is a stronger, but a shorter, like the co-clip is a little bit stronger. Do you have a preference? When you have a perforation, stronger? I think it's important to make sure that you're able to bring the edges together first, and then apply a clip that is probably going to retain there for the longest. In terms of which clip is better than others, we don't have a comparative data, to be honest with you. There's one study from Chris Thompson's group, which looked at retention. All we need is five to seven days for most of the wound healing to start happening. That's what we need. It's probably better to start not in the center, but start at one edge, and a little bit away from the edge, so that you can bring the edges up. And that allows you to apply the clips much more easily. That's something that is probably better to do. The only problem with the clips is, if the wound edges are sloping down, then you can't really apply a clip nicely when the wound edges are sloped down. Otherwise, for most of the wounds that are around at right angles like this, you should be able to close the defects. This is based on the animal work that we have done. We were not able to close the defects that have sloping edges. And those are the ones that we used a suturing device. At that time, almost 15 years ago, when we used a suturing device, it was like a T-Tac that we applied. Now, with the ThruDiscope suturing device that is available now, you may be able to get away from that. I think the excitement is to have ThruDiscope suture. If you apply one suture at one side, and then you drag the edge to go to the other side, you should be able to close any size defect. I'm just making a guess, but looking at how the systems work. Okay, so that will lead to the next question, because you're so modest about IBD, the things that you are not taking care of the IBD patient. But there's similarity, because you are taking probably a lot of care of the patient with radiation. Now, radiation structure, radiation injury, it's probably harder if we have a perforation. What's your tricks if you have to do the endoscopic therapy, even remove the part that radiated the bowel, and it has a perforation, or the bleeding? What's the trick for control the bleeding? What's the trick for close the defect, radiation bowel? I want to share with you, when I'm dealing with radiation injury to the bowel, I call my surgeon to help me out. Okay, so you don't even try something. Yeah, the thing is, one thing is we have to keep in mind is, you know, I want to share two thoughts, two thoughts on that. When I see patients who have had radiotherapy for uterine cancer, right? That's probably the commonest reason why I'm doing a colonoscopy for screening. Somebody had uterine cancer, hysterectomy, radiation. That colon has been fried by the radiation. And that colon is at a higher risk for perforation. And that's the colon where even what I think is what we feel like the regular resistance, I'm uncomfortable pushing beyond a particular resistance, if I find that it is harder. And in those cases, I may even start with a slim colonoscope instead of a pediatric colonoscope, so that the slim colonoscope is much more, I think, flexible, almost like a noodle and easier to go in, right? In terms of resection in a fibrotic or radiotherapy treated area, the tissue is not, it doesn't respond, right? You know, if you want to close a defect, it's much easier to have a colon that has never been treated, where you can bring the tissue together. When it is fibrotic, it's very hard to do that. And it's probably true in a few cases where I've taken care with IBD and polyp with intense submucosal fibrosis. They are very hard to cut, and they're very hard to close. Wow. So I learned my lesson too. Yeah. So what do you think? I want to hear what you do and what Hiro does in those cases when there is a lot of fibrosis and submucosal fibrosis. Dr. Hiro, Dr. Yamamoto? Okay. I totally agree with Raju. The radiation and the radiated intestine is very fragile, and we can't completely close or treat endoscopically. I also ask the surgeon to help me. Yeah, I would like to make one point that we have not covered is, unlike in the regular colon that has not been affected by inflammatory bowel disease or Crohn's disease, and when you're doing an EMR, maybe in some cases in the right colon, you will see some submucosal fat, but for the most part, you will see connective tissue staying blue by your indigo color. By your indigo carmine or methylene blue. But when you see somebody with IBD and you're resecting a polyp that has been affected, the segment has been affected by IBD. What I've observed is, it's more common, it's probably more frequent that when you resect, you will see a lot more submucosal fat. And we always have learned that, hey, if you see fat, you should worry about the perforation. But I've seen more fat in patients with IBD resections. And I wanted to see whether that's the thought process, because otherwise, you know, when you see fat, we always worry, hey, did I go too deep? So actually, this is a great talk. That's what lead me to present the case. I need your guys' help. Okay, I need your help. Thank you.

endoscopy procedures

surgical repair

MRE

perforation management

fibrosis treatment