The floor is open for questions now. So one question is, is it feasible to do band EMR with variational bander if EMR snare kit is not available? Yeah, you know, I think technically it is doable. The only thing is that you will not be able to pass your snare alongside the device through the biopsy cable. Because if you were to use the Wilson Cook device or the Boston Scientific device for band ligation and EMR, then you can pass the hexagonal snare right alongside your equipment through the biopsy channel and resect, so you band, resect, band, resect. But if you were to only use a banding kit, you would have to do it one at a time. You would not be able to pass the snare alongside your banding device because it's not hollow. I hope that makes sense. So you would have to put a band, you would have to band, band, band, and then you would have to remove the bander, you would have to come back, and then you'd have to snare, snare, snare. So it becomes a bit challenging. But if you were to do only one, then perhaps you could do it, but you would waste five bands. In that instance, I typically use the Olympus snare kit for an EMR. I hope what I'm saying makes sense. APC for band EMR resection margins, is it necessary? Yeah, fantastic question. I think in the colon, it's been shown, I think there have been randomized studies which have shown that if you APC the margins, you're less likely to have recurrence. So I come back to that original argument I made about what is different between band EMR or piecemeal resection in Barrett's versus piecemeal resection, say in squamous cell cancer in Japan. So in Barrett's, remember, we may do piecemeal band resection, but we always ablate. So I don't think there is a big reason for us to treat the margins of the band EMR sites with APC, because in two or three months when everything heals, we're going to come in ablate overall. I've already touched the, if by some reason I leave a ridge in between my band EMR sites, then I try to take care of it with an EMR, but not the margins. That's just my practice. I don't know. Prashanthi, what do you do? I do not do APC because we are going to do RFA anyway for whatever is remaining. Exactly. Exactly. Another question here, majority of obese patients do have asymptomatic Barrett's. So why do obese patients plan for sleeve gastrectomy? Why do they not have simultaneous anti-reflux surgery? Are you waiting for the reflux symptoms, esophagitis or Barrett's to develop postoperatively? Why? We know very well that obesity is a risk factor for Barrett's esophagus. Yeah, maybe a bit out of scope for this meeting, but I am not a bariatric expert, but the little that I know, I know that many of these, particularly sleeve gastrectomy, I think is a procedure that leads to a lot of reflux postop. And I know that investigators have reported high rates of reflux, even Barrett's after some of these and perhaps the need for anti-reflux surgery. I'm sorry, I'm not too much into that field to answer that question, but I know it's been studied. So what we do here in our center, the practice is before the bariatric surgery in patients routinely do have, especially if they have GERD symptoms or so, they do have a pH study done, Bravo monitoring. If they have abnormal pH study, they usually go for gastric bypass or so. They don't do a sleeve gastrectomy. So that is one thing. And then as far as sleeve gastrectomy, along with simultaneous anti-reflux surgery, the thing is in some patients, there is worsening of the reflux. In some patients there is improvement of the reflux because they lose weight, there is decrease in intra-abdominal pressure and a part of the stomach is removed. So there is less parietal cell mass. So that is there. So there are both pluses and minuses to the sleeve gastrectomy. I think there were some case studies where they were doing like a simultaneous sleeve gastrectomy with anti-reflux surgery with much better rates of GERD postoperatively. So what was an anti-reflux procedure, Prashanthi? If it is not done before, if the sleeve is not done beforehand, so they do the case studies were about fundoplication simultaneously. So before they do the sleeve gastrectomy, they do the fundoplication and sleeve gastrectomy during one operative procedure. Okay, got it. Not afterwards. Any other questions? Thank you all for attending. There's, I'm sorry, there's one that just showed up. It says any particular hands-on courses for barracks management for gastroenterologists who are not working in major cities are far away from major centers. I know of several, I know the ASGE actually has an ablation masterclass, if I'm not mistaken. There is also an EMR masterclass. You can look up the ASGE website. At the risk of promoting our course, we have a male esophageal course in December in Phoenix, first weekend. And we actually have an ASGE hands-on course there, where we, you can get some hands-on experience on ablation and resection. So there are several of these courses around. ASGE has at least two. So I hope I answered that question. I'm not sure if there were, is she okay with me telling this or not? Cleveland Clinic, we have a course, a hands-on course in, on April 1st, on different ablation techniques, the EMR, as well as the, yeah, they should be, PH, yeah, they shouldn't be hard to find. Yeah. So Prashanthi, thank you so much. And again, to the ASGE staff, Marilyn and Lyle and Reddy, thank you for all your help. And I think this was, this was a great session. And I really appreciate the partnership with, with, with, with the ASGE staff. Thank you so much. Thank you. And Prashanthi and also all the attendees hanging in there and spending most of their Saturday with us. If there are no questions, we will, we will adjourn. Okay. Thank you all. Yeah. Have a great weekend. Thank you. Bye. Bye-bye.

EMR

endoscopic mucosal resection

Barrett's esophagus

band EMR

APC