There's my endoscopic stents. So, to be very open and very frank, where do you place stents in your practice? Do you place stents at all in your practice at this time? And if it is yes, where do you place them at this point? Yes, I want to thank you very much, first of all, for your comments. In my practice, and now with the results of our clinical trial, we use first endoscopic validations. And then, if endoscopic validation doesn't work, usually we try to perform two sessions of endoscopic validations. Then we try to put a stent, but usually it happens in a very few patients, because as you can see in the clinical trial, endoscopic validations had a very high percentage of success rate, near of 80%. And also, if you look at the specific results of the clinical trial, in ileocolonic anastomotic stenosis, that were very short, endoscopic validations had 100% of success. Then, this is something that also surprised me, that you say that you, in your clinical practice, don't use endoscopic validation in these cases. And this surprised me, and also I ask you this question, why? Because I think that in ileocolonic anastomotic, endoscopic validation has also a good success rate. Okay, and if you put a stent, what kind of stents do you place, Carmen? Fully covered metal stent, for the moment. In the video that I show of partially covered metal stent, I only used one time, and I realized that it was very difficult, in seven days, to remove it. And I wanted to try to put this stent, because I know that there was literature about this stent, that says that it was a good stent, and they didn't mention anything about how difficult it was to remove it. And this was the reason that I wanted to prove this stent, and I realized that in seven days it was very difficult to remove it. And then I preferred a fully covered metal stent, the stent from Taiwan. Okay, all right. I think regarding your question, endoscopic validation and stricture artemia are equally effective in anastomotic strictures. I think it's not like I don't like endoscopic validation. Stricture artemia is very effective for anastomotic strictures. If it's a short stricture, very fibrotic stricture, I feel like stricture artemia works better compared to balloon dilation, because the risk of recurrence is lower, I feel like. When you cut it and then put the clips there, the spacer, the risk of recurrence appears to be lower. No need for repeat procedures compared to endoscopic balloon dilation. But again, both are equally effective, and I think there's no role for stenting in a patient with anastomotic stricture, I think. I think most of the times, one of these techniques will take care of the stricture, most of the times. And I feel like you don't put a stent in a primary stricture, a de novo stricture in the colon or small intestine. Do you put stents at all in those patients? Yes, yes, yes. I think that primary stenosis is usually longer, and then this is the question. For me, it's the fact that the stent has better outcomes than in anastomotic stenosis. I think that the length of the stenosis is critical in how the stents can have a good success in this case. And for me, yes, in cases of longer stenosis or primary stenosis, I think more to put a stent than to perform endoscopic balloon dilation. Okay, but those patients may probably need surgery rather than stenting, right, in those situations when there is a primary long stricture? Yes, this we have to demonstrate. In fact, I am preparing a study, a clinical trial, to compare the treatment of endoscopy, the treatment in primary stenosis, of surgery versus endoscopic treatment. In endoscopic treatment, we perform first endoscopic balloon dilation, and then if endoscopic balloon dilation doesn't work, we put a stent. But we are now trying to begin this study. It's not easy, because you have to do a lot of things before to carry out a study of these characteristics. But I think that this question that you said to me, we can see in a clinical trial. And this also is a question for you, for Dr. Navanizan, and Dr. Shen, that why you don't perform a clinical trial to compare endoscopic balloon dilation and stricturotomy? Because I think that with this, we can have the answer if we have to perform first structurotomy and not endoscopic balloon dilation. Yes, you're right, Carmen, absolutely. Dr. Shen, I think for you, I think the question from the audience is why do you use dextrose? What is the mechanism of dextrose to control bleeding? Yeah, it is the hyperosmolality. Hyperosmolality is the main reason. Actually, I believe that our Japanese colleagues sometimes use 3% of the saline for control of the bleeding, the same mechanism. But it's very effective for oozing type of the bleeding, but not for pulsatile bleeding, oozing type of the bleeding. So, make sure the glucose is all available and the clip is available. I hardly use the cauterization for control of the bleeding, or I hardly use epinephrine for control of the bleeding. Because epinephrine can cause ulcer. You already created ulcer. So, with a structurotomy or a structuroplasty. Actually, just go back to the structurotomy. Structuroplasty, there's a question for that. Actually, I described probably structurotomy similar to you open a door. Structuroplasty is you open the door and put the door stopper on top of that, so they keep the things open. Also, not only for the terminology perspective, but also important in the future for the standardization of the clinical care, even like a CPT code in the future. Yes. So, the next question to the audience is I think a couple of questions. I think Simon can answer one of those, but I think the first question is, what is the role of EUS? Is that EUS better than MRI for mapping perineal fistulae? And then I think once you put a seton in, will the tract ever close? So, Simran, that's for you. Sure. So, I think in regards to seton, once you place the seton, the principal aim is to continuous drainage. The tract usually will not close with seton placement, but it will prevent pus and abscess formation and reduce inflammation in that area. So, once a seton is placed, it should remain in place. I don't think so the tract's closed, especially if it's an IBD fistula. Sometimes in cryptoglandular fistulas, you can see the closure happening just with adequate abscess drainage or incision and drainage. In regards to EUS versus MRI, now EUS always has been very fascinating, and one of our partners from the global IBD group, Dr. Schwartz, has worked a lot in this regard of utilizing EUS for fistulas, for not just localization and for disease management. However, I still feel, at least in my practice, I find MRI pelvis, a well-done MRI pelvis to be superior to EUS, because sometimes if you have a lot of inflammation or if you have complex fistulas, sometimes, at least I personally, find it difficult to map just with the EUS, the surrounding anatomy to the fistula. So, in my practice, if I'm suspecting a fistula, we have a very good protocol here that we use for the fistulas, and MRI pelvis, for me, stands out in that regard. Yeah, I don't think MRIs can beat EUS. EUS, I think, except for Schwartz, in most studies and most centers actually use MRI for routine following patients, and usually we don't remove the seaton. I think Dr. Schwartz' practice has actually removed seaton based on EUS appearance, but sometimes patients have seatons for years together because it never closed otherwise. So, I think it's different from what we do. Schwartz is not available right now to answer those questions, but I think we can always communicate by email later on. I have a comment. Actually, we could operate it dependent. Like the experience with Dr. Schwartz, probably his review, if he experienced one, probably EUS is better than MRI. In my experience, last time I had a patient from Canada, from one of the local tertiary care centers, sent it to me for the incontinence. I ordered it. MRI was missed. Actually, my endoscopy also missed. You know what? So, the transrectal, transanal ultrasound, the rigid correctal surgery use, rigid in the clinic, that a gentleman, Dr. Schroeder, there, the transrectal ultrasound that detected the defect there. So, that's why it's all operated dependent. Everybody needed a little bit of training on that, you know. So, that's a good one. And then, yes. So, the people ask the question, is that, does D50 work for post-protectomy oozing? Yes. Especially protectomy for inflammatory polyps work very well. Work very well. So, yeah. And then, the other question is oozing. Do we have any question? I think we all addressed it, right? Yeah. I think we can probably go to the next session, unless there are more questions. Oh, don't forget the next session. Okay? I have a question for all of you. Okay? Now, we know. I have a question for you. One moment. When you were talking about the perforation, did you mention anything about the stents? I think that no, no? About to put a stent in a perforation. What do you think about that? Yes, I did use the covered stent to treat the ileostomy site. When I did the blunt dilatation perforation, I put the stent at the cover of the ileostomy site perforation. But for the other part of the perforation stent, I have not used it. So, this is a good option. And then, actually, leading to the other question, one of the audience mentioned about using vacuum to treat the perforation. Actually, vacuum therapy has been extensively used by chiropractor surgery. Now, only a few institutions use it. Endoscopically, introduce the vacuum sponge to the area. But if you're very close to the anus, for example, if you have the perforation in the anorectal area from the endoscopy, you may ask your surgeon to help you do the examination on an anesthesia, put a vacuum sponge there, especially acute perforation. Very good. My next session, I have a presentation for endoscopic management of the surgical leak. Dr. Shen, just a quick comment on the stent post-perforation. Hi, Karmai, how are you? I think if you have a micro-perforation, then I think you can place a stent and hope for healing to happen. In IBD patients, I'm talking about. Non-IBD is a different concept. But in IBD patients, if you have a frank perforation, then I just want the audience to understand a stent is just a way of you getting patients an hour or two until they can get the OR ready and the surgeons can take them. Because there will not be a primary healing on its own just with the stent placement because of the nature of the inflammation. So if you have a perforation, you have promptly recognized it. And if patient is stable, I would not waste too much time in the belly at that time to put a stent across the perforation. I would send them to the OR. But if you need some time and patient is relatively stable, you want to attempt a stent just to temporize it. I think that is feasible because primary closure of a perforation in IBD patients almost never happens on its own. For more information visit www.ISGlobal.org

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