We have some time set aside for questions, so I'm going to start off where we left off. And there is an interesting question in the chat which says, I know we've all been talking about high-definition endoscopy and high-resolution endoscopy. And there is a comment here that says, any outcomes known on 4K endoscopy? I'm not even aware of that. Yeah, so television monitors have come a long way. And I think we have gone beyond the conventional high-definition. And I know there is 4K, which is even higher resolution. I don't believe there are any studies out there on this technology, unfortunately. There is a question, which is more about endoscopic eradication therapy. And we could take that later. Let me just see. Yeah, so there is a question here. While using water to clear mucus at the G-junction, I see a lot of laryngeal spasm under propofol sedation. Are there any tricks that you use? So what I do is don't use large amounts at the same time. So spray and then suction right away. Spray, suction right away. So you're putting like, I put like, say, 10, 20 cc's at a time. And then go down to the stomach and suction it right away. And also having the head end elevated, probably about 40, 50 degrees or so, that would help too. And then telling the nurse anesthetist beforehand that this is what you're doing. You're going to spray the esophagus. So they're already there. They're suctioning the mouth too at the same time. Very good. Another question, nodularity slash single nodule seen on Barrett's on NBI. Biopsy versus direct EMR. I think it's a very important question. So I would suggest a direct EMR. Because even though usually, visible lesions have higher rates of dysplasia than not. So when you see a nodule on Barrett's, my suggestion would be to refer to an expert center for EMR if it could not be done directly right away. However, biopsy is OK to do too. There is a concern, a theoretic concern, if it would lead to more fibrosis. And it would make an EMR more difficult. I have not noticed that. What do you say, Prasad? Yeah, I think it really depends on the expertise that you have, right? Not everyone in the community would have the expertise for an EMR. I think the more important thing in my mind is to A, identify as you showed. Take a careful look. Look carefully. See, is there any area? And sample it whichever way you're most comfortable with. I think a single biopsy should be OK. It should not make the subsequent EMR more challenging. It's sort of analogous to the colon polyp paradigm that we also talk about. But if you can take a good single or maybe at the most two targeted biopsies, put it in a separate bottle and see what it comes back as. Now, if it's extremely evident sometimes and you think this needs resection, then you should feel free and very comfortable referring to an expert center with resection expertise. We could take this question. So the question, I'm just going to read this. It says, so why not EET for dysplastic BE? And if successful, repair CRURA plus LES. GERD is a chronic disease and the problem with disrupted anti-reflux barrier will still exist. What do you think of the protective value of nisenfundaplitation and links in regression of IM? So I think there are two questions here. One is after endoscopic therapy, should you fix the hernia and do a fundaplication? And the second is, does that also lead to regression of IM in those without endoscopic therapy, in those with barracks? So the second question is much easier to answer. What is the, there is the surgical literature talking about regression of IM with doing nisenfundaplication or so. And then the medical literature where PPIs are compared to nisenfundaplication, they're very minimal regression notices. So I would never suggest a patient to have a fundaplication or a links procedure for possible regression of IM. As far as what we know, and when we are looking at the natural history or so, regression of IM is not, it's an uncommon, it's a rarity. And it may be possible if there is like a very short segment or so, because intestinal metaplegia is patchy. So regression of IM for a long segment barriers is almost unheard of. I would not put any weight on treating with the PPIs or nisenfundaplication for regression of the IM. So that is one. And then in those studies, which are showing about the regression, we are not clear about what were chosen as, who were diagnosed as the patients with barrett's esophagus or so. So there may be somebody with a one centimeter segment of intestinal metaplegia or less than one centimeter segment of intestinal metaplegia. So that is one thing. And then the second question, so you do the endoscopic therapy and if it is successful, why don't you do a fundoplication? So I'm going to contract it this way. If it is already successful, why do you need a fundoplication? Fundoplication is always an option for a patient with severe GERD, irrespective of dysplastic barrett's or not. So if it is eradicated already, so it is gone. Now you're talking about the severe GERD. So it is always an option for a patient. So if they want to go ahead with fundoplication, no qualms in suggesting that. But also they have to understand it is not a permanent fix. And then it can, fundoplications do fail over a period of years. And then there have been that study with speculars, about 60% of the patients ending up back on PPIs 10 years after fundoplication. Although not all those patients has any objective evidence of GERD or so. So fundoplication is for a durable management of GERD, but it is not like a permanent fix for GERD. So that is one issue. And second thing is, from a patient's point of view, if they already had eradication of the barrett's and if their GERD is well controlled with PPIs, why would they want to go through fundoplication? Unless they want to not to take PPI therapy or so. And as I have mentioned before, if the patient is not responding to the endoscopic therapy, I would think there is ongoing reflux going on and probably refer them to fundoplication at that point of time. No, I think those are excellent points, Prashanthi. I think once you have ablation successfully completed, then the argument goes back to the original issue of, what is a better way of controlling reflux? Is it meds or surgery? And I think both are equivalent options. It's so patient dependent. And I think over time, the volume of fundoplication has, I think, sort of gone down and plateaued. Yeah, I think the person who's asking the question is saying EET is not chronic fix either. Correct. Absolutely. So endoscopic eradication therapy is not fixing reflux. It is only fixing the dysplastic barrets and causing remission of intestinal metaplasia. But we still have these two avenues to control reflux. You either have medical therapy or you have surgical therapy. And I think that the argument remains the same. There are pros and cons on either side. And as we have shown, I think most of the studies that have followed patients after complete remission of intestinal metaplasia, the risk of recurrence is finite. But it's not extremely high. In fact, dysplastic and cancer recurrences are even lower. It's probably around 1% to 2% a year. So I don't know if the jury is out in terms of, are you better off taking medications or are you better off having surgery? For all the reasons that you just discussed. And ultimately, it comes to the patient's choice. If they want to decide to go with a fundoplication or not. And then one thing to remember is these are the patients with severe GERD and then they may have weak esophageal motility too, which would limit the options of doing a Nissen fundoplication or so. So something to think about. Yeah. And I just had a patient, she was not responding and I was thinking about fundoplication. Now, when I did a manometry, this patient has a absent peristalsis, completely absent peristalsis. So the options at this point in her are either a toupee fundoplication or doing a gastric bypass with a short limb. So there is not much of malabsorption. So those two are the possibilities in that patient. So it is not an easy answer. Yeah. Yeah. Okay. So I think we are at a point where we are ready for a break. So how about maybe we come back at two o'clock, 15 minute break. Yeah. Sounds good. There seems to be a question. Are you basing on biopsies follow up or what? Biopsies. Yeah, obviously. Yeah.

4K endoscopy

mucus clearing techniques

Barrett's esophagus

direct EMR

follow-up