Well, I thank you and Shabana for this very kind invitation. It's a huge honor and a pleasure for me to be here, and I'll try to move my slides if they do move. Let's see. Oh, yes. So these are my disclosures. So I'll give you a bit of an overview. We'll look at the background and then dive into specific topics and then take home. And I know we're coming to the end of a very long day, so I'll try to be as rapid as possible. Okay, so the background. 2001, Kubrick, Space Odyssey, us, Small Ball Odyssey. Why? Because as you know, before that it was like a space exploration timeline with lots of failures and very unsatisfactory techniques like push, which just caused loops and you don't really get very far. 2001, birth of capsule, birth of double balloon. It was followed by the birth of your baby, Paul, spiral, etc. And others came along. But, you know, these two technologies have stood the test of time and have changed things. And this is the first prototype, the first publication by my second father, Professor Yamamoto. And essentially, it is a simple but genius idea. You just grip the bowel very gently with latex balloons, and you're able to manipulate the bowel and pull it behind you, placate it and go forward. And there's many variants in how you can do this, but it really, really is the bee's knees. Capsule has made tremendous advances, as you've heard, in the world of AI, etc. And also, we've had great advances in cross-section imaging. And these are not competing. These are complementary. As you heard Carol say, especially in young people, you have to think of cross-section imaging. Capsule is a really, really good scout because it's minimally invasive. Patients just swallow it and off you go. And it's a good scout to direct double balloon entroscopy. And this allows for direct evaluation. So, for example, if you see mesenteric ulcers on the mesenteric side, it's more likely to be Crohn's. If anything, it allows you to take biopsies, as indicated, and that may alter the course of management because if you find an lymphoma, then you're not going to really advise surgery in most instances, endotherapy, and marking for laparoscopy. And we are really excited because just at the end of last year, Fujifilm launched the EN840T, which is a magnificent instrument, which has tremendous advantages with the water jet channel that's separate from the therapeutic channel, which is 3.2. And also it's been interiorly designed differently to allow you to go that much deeper. So this is a phenomenal scope with tremendous optics as well. And in combination with this, they designed a new distal hood. And this is tremendously important to attach to it because number one, it's holds true to the original design. Professor Yamamoto always puts a hood and that's how we do it because that two millimetres away from the wall of the bowel gives you that much more prediction. And in double-blown entroscopy, prediction of the lumen is directly proportional to efficiency and effectiveness. After 24 years of experience, we've realised that this has been a game changer completely. And it's also very useful for failed colonoscopies. It's very safe even in the first decade of its use. And this is mirrored by our experience at World3 where we do up to nine double blooms a week. It doesn't take forever. It only takes about half an hour. The insertion depths are very respectable and even our panentroscopy rates when it is indicated because it's very unlikely to be indicated. And adverse events are almost unheard of, 0.4%. So really, really good. And it's also really useful. This thing made it, my case made it to the National Geographic and the height of COVID. World3 was a bastion falling apart in the face of the wave. And essentially, there was this chap who was suffering from small bowel bleeding in the context of being on ICU with severe COVID-19. And as if that were not enough, he was also refusing transfusion with a haemoglobin of 3.5 grams per deciliter or 35 grams per liter. And he was going to die. So we did a double bloom in this really, really arduous circumstance. We found the bleeding diverticulum treated him, and now he's got a haemoglobin that's higher than mine. So onto bleeding, which is the main indication as you've heard over the course of the day. So I won't go into much detail with this. The overt one is the one that needs urgency. The occult one may wait a bit and allow you. And of course, it still poses formidable challenges now with high transfusion requirements, decreased quality of life, increased costs and all the rest. So what do you do? You Americans with the American Society advocate a repeat. Apogee and endoscopy in Europe, we're a bit more conservative. And although we accept that this may increase the yield, it's all dependent on quality. And if you've got doubt about the problem, you need to repeat the scopes, because these are the things that can be missed. So it's all about quality. If you doubt the quality, yes, totally agree, repeat the test. And I need to stress this, as Carol said, overt in the young tumor until proven otherwise. There's no doubt about it. So cross-section imaging here gives you more juice than a capsule. Do it, do the capsule, but don't rely on a negative capsule because solitary lesions can be really easily missed. They did a study once about the ampulla of VATR and it was missed in a significant proportion, I think about 40%. And this is the remit of bleeding, cause of bleeding. But angioictasis or small intestine vascular lesions, as the Japanese like to call them, are much commoner causes as we get older. So investigation strategy, usually capsule first after top and tail, but again, cross-section imaging in the young and always consider straight to DBE, especially in the context of torrential bleeding, unless they really need a CT angio. If they're bad, they need a CT angio and then possibly an angiography. So missed lesions, please be vigilant. This case was a GIST. These are nasty vascular things, as you've heard, and they can only be present on the outside. So this one was only an ulcer and it was missed on capsule. So please be vigilant. And this is another case where things were missed on capsule. This patient was bleeding out every so often. He had a history of vascular surgery and bang, that's it, only on one frame and that's an aortoenteric fistula. So please, please, please be vigilant. I hope that missed lesions will be less common now with AI help, but still, still, still be very careful when reading capsules. Don't do it when you're tired. Don't do it when you're distracted and slow down your frame rate. Okay. Concordance is very high with the DBE. And in most cases, we are directed by findings over their investigations, because it is a bit invasive. So the small bowel imaging, this is the algorithm. So the overt is the route to rush down. Okay. If they're overtly bleeding, you can't waste any time within 48 hours, things need to be set up. The occult one is a bit more relaxed and you need to consider things. So case examples, you've heard small intestinal vascular lesions. So this is what you see on the capsule, red spots or red leashes of vessels and how to treat them safely. So this is argon plasma calculation. You need to use a non-contact APC with low flow of the argon, because otherwise you'll distend the bowel to the end of the world. And that's not very useful to go deep. And you have to treat all of them meticulously. My record is about 300, which I did recently in Mexico. And an example, this is a video from my mentor, Professor Yamamoto. So if you have pulsatile lesions, don't even bother dreaming about APC, just clip them. I don't favor bipolar because the small bowel is exceedingly thin and to go through the wall of the bowel is going to be easy. So if you have something that doesn't stop bleeding with a couple of shots of APC, just clip it. And this is the Yano Yamamoto classification, which as you've heard, guides you to treatment. Take home messages about treatment, non-contact, low power, low argon flow rate, consider a saline lift and clip pulsatile. And that's my case where I treated over 300 in Mexico. So longer term outcomes, yes, they re-bleed. Do I give up on these? Absolutely not. Because as we showed in our paper, which we published with JiChi now 10 years ago, my goodness, how time flies. And if you keep on treating them, you show that you are decreasing transfusion requirements and re-bleeding. And there is a case for a Druven medical therapy. These are associated factors with Sievels. There's a meter analysis now and somatostatin analogs are favored. So we go for lanreotide. Octreotide works a bit better than lanreotide, but it's a pain to administer every day. So lanreotide, you only give 120 milligrams as a depo every month. And we've got quite a few patients on this doing fine. And this is a recent paper we published on this very rare entity called blue rubber blebny. The syndrome horrible condition causes great disfiguration. These can happen anywhere in the lung, heart, wherever. And the systemic therapy, although they have some response to suralimus, can be difficult. And I've discovered serendipitously that, because before we had a conundrum as to what to do with these. Do we clip them? Do we inject them? What do we do? EMR them. And I realized that if you cold snare them, interestingly, you don't get a catastrophic bleed because that's a foamy thing that's full of a bit of clotted blood. And if you snare them off, cold snare them, you find the vessel at the base and you just clip it. And we've made a difference. When I go to Great Ormond Street, which is a world famous children's hospital, as you know, in London, we make a world of a difference to these where they conglomerate. So more bleeding cases, because I think bleeding is important. So this is the case of a juvenile diverticulum similar to the one that I showed you earlier. And there's always a clot in its base if it's culprit. And the trick here is not to not use a snare or anything else to remove that clot. Keep your weapon, which is going to be the clip inside the channel, remove it with the clip using it as a biopsy forceps. We usually try to inject a bit of adrenaline around it to be cautious and use your clip to remove the clot. And then you've got your tool or instrument or weapon of choice ready at hand. You throw the clot away and then you apply definitive therapy with one or several clips. There are things we can't really treat. This was a small bowel lymphandroma in a young chap who was bleeding intermittently. That's what you see on capsule and that's what we see on DBE. This needed surgery, so we marked it. And then this is looking the devil straight in the eyes, because in this case, the surgeons really, really were reluctant to go in even though we've we had cross-section imaging favoring this but not clinching the diagnosis per se and capsule favoring is but not clinching diagnosis per se and we reluctantly went down and literally looked the devil in the eyes and as you can see around the corner no that's not going to be a spot of food that's the Dacron graft facing us thankfully it didn't explode in our faces. Viruses can be treated I don't like treating these if there is a patent portal vein or splenic vein only if there is obscure sorry occlusion of the portal vein or splenic vein because cyanacrylate glue can migrate into these and cause a bigger problem and we've published on this and essentially this is what you see it's usually at the anastomosis in patients with previous HPV cancer surgery and this is a case in point it's the viruses here at the hepatical jejunostom you can see the whale sign you can see the varix bleeding and we inject the varix and the most rewarding thing is when you see glue coming out of the bleeding point as you inject that culprit varix it's not really a good idea to inject the place where it's actually bleeding and so we inject the varix and then see the glue come out of the bleeding points very slowly it's a mix of lepidol and cyanacrylate we inject slowly so that we don't send the glue elsewhere because it can embolize and it's very satisfying when you treat these because these are patients who have been bouncing in and out of hospital for a long time and you can give them a lot of respite and you can see the glue coming out of the area there that where it bled very nice. Meckles you've heard and this is an ectopic stomach which usually lives at the side of a meckles you can't do much about these just tattoo them and you know send them to the surgeon's way so some mistakes to avoid not referring not doing repeat endoscopies have indicated overlooking GI radiology delaying timing is key there's nothing more important than timing here poor investigation strategy so follow that algorithm and also do that double balloon properly because if you don't go deep enough or if you think that you've gone deep enough and you haven't then you're going to rely on a false negative and the patient will suffer and it's all published here. Inflammation and strictures so you've heard all about inflammation today an ulcer is an ulcer is an ulcer the small bowel has a very limited vocabulary it will either get red it will either get ulcerated or it will do something within those parameters but it doesn't give you a diagnosis so this could be anything this is not a diagnosis of Crohn's and many a time this is what you see this could be drug-related it could be inflammatory from non-steroidals and the deeper they are the more mesenteric side they are the more likely it is to be Crohn's but you'll only get that if you go down with a double balloon scope or corroborate and you have to be very careful because otherwise you'll end up with a retained capsule even though we many a time use the patency capsule and it's important that we really really rule out the strictures so if there are strictures and we can avoid surgery by going down for them and treating them with with double balloon and the main rules for this is short and why short why under five it's very simple the balloon is not that long and building a longer balloon will not cause it to work very well because it will buckle so if you have a long stricture and you try to dilate it the results are going to be poor and plus you may risk a perforation in the middle of the stricture because of differential pressures within the stricture fibrotic because if you've got a very inflamed one it may increase the risk of perfs and also straight not tight angulation again to make it safer and these are the types of strictures we like dilating and we don't really go for radiology radiologically induced strictures like deep x-ray therapy because they're not because they're gone okay and this is the sort of stricture we go for not inflamed and also straight so the one on the left not the one on the right this is our algorithm which was published in the european society guidelines a couple of years ago before you do it have an mdt discuss have options with the patient because there is a small risk of a perforation and how you do it use a clear through the scope balloon preferably under scleroscopic guidance albeit it's not absolutely necessary and don't go to the moon while doing it you know be gentle get the patient back if need be and that's us doing this is a non-steroidal stricture but this was a crohn's one and i'll try to play the video yes this is there's always a bit of ulceration this is not really an inflammatory stricture it's more of a fibrotic with some inflammation and then we get in front of it i'm not sure whether this was the one with the retained capsule but the trick is to visualize to have a straight scope to get directly in front of it and then once you're there you actually start inflating keeping the balloon in the middle of the stricture aiming the scope through the balloon to see through it so that you will have a degree of safety and that white rim is what you want to see okay i'm moving forward i'll skip this because it's a retained capsule like this one so fibrotic rule five centimeters and the cost hood is useful this was another beautiful toy developed by our dear friends in jiji medical university it measures the diameter of the stricture and allows you to dilate many strictures if you put it at the end of your double balloon scope most procedure important to be vigilant for pain i always give them clear fluids mostly for about eight hours now and have a low threshold to scan in case of pain because the small bowel doesn't forgive and even a tiny perforation would usually result in an operation and don't think you're out of the woods if you've dilated strictures they will maintain a degree of narrowness so you should really optimize medical therapy and treat small intestine bacterial overgrowth if need be and re-dilate as necessary they're efficacious the meter analysis from bettenworth et al show that a even long-term effectiveness is very high and you can avoid surgery especially if you keep repeating it okay so take-home messages for this carefully selected patients may be repeated it avoids surgery and kicks the can down the road for an indefinite time if you repeat it okay and it's very safe less than five percent risk of perforation moving on to polyps polyps in the small bowel many a time equals poids jeggers or possibly sporadic although they're rare you've heard about poids jeggers thankfully it's rare the instance is about one in a hundred thousand to one in two hundred thousand and they cause problems apart from the tumors are pressure causing lots of cancers elsewhere in the small bowel they intersuscept obstruct and cause anemia and if they intersuscept then as kids usually they're about eight years old when they start doing it and they've had the first laparotomy that's going to make a double balloon difficult because again with adhesions it's going to be a harder enteroscopy that's the intersusception and that's on scan so we try to avoid getting these adhesions we try to avoid going in for an operation and an intraoperative enteroscopy and by using the surveillance strategy from two to three years i prefer cross-section imaging to capsule again because it can miss surgery lesions and a small bowel mri can actually give you a better location if we do this we actually change their thing and why did i cross off polypectomy and put endotherapy the malignant risk in these lesions is exceedingly small but they're vascular and can bleed during the procedure and they can pull muscular spropria from the small bowel into the polyp and if you cut even close to the head you can make a hole in the bucket duralyzer so no not a good idea this is the hole and thankfully we had the laparoscope ready there so so uh again genius of gigi uh professor yamamoto came up with the ligation uh ischemic polypectomy technique so the polyp is chunky and big we put an endo loop okay or poly loop a detachable plastic snare and just let the body deal with it through ischemic polypectomy and the risk of malignancy is almost negligible in these polyps the hematomas and if you've got a smaller polyp um you can actually apply um what we call the cross clip technique which also strangulates the blood supply of the lesion and i'll skip that and this is the crossed clip technique which uses two clips at 90 degrees to each other use a long distal attachment to move the clip to the 90 degree otherwise they land in the same way and you cross off its blood supply so again and take home messages for this part and preemptive strategy transforms at least this part of the pgs horrible journey ischemic endotherapy is safer and always discuss and have backup tumors okay so tumors we can't do much about unfortunately because of the fact that you know they usually need a resection but taking biopsies is useful this is not an adenocarcinoma this was lymphoma even though it looks destructive and ugly and it was managed with chemo radiotherapy another lymphoma here and so we can make the diagnoses through biopsies this was a trapwood carcinoma disease there was a bit of thickening on the cross-section imaging and this is us going retrograde and it's very useful for us to market and get biopsies and this was the result again i've showed you this and we can mark these for laparoscopic resection if it's indicated i think the surgeon would have had to be blind to miss that but you know i felt good many years ago doing this tattoo next to this lesion small little things as you've heard carol say so you know these are the neuroendocrine tumors they always hunt in packs the solitary ones are the jests these you need to biopsy to get a good understanding of it can make a difference and it's good to mark the extent because even if they metastasize removing the primary source from the small bowel can make a world of a difference to the patient okay so these are neuroendocrine tumors and the gist don't biopsy a gist i've had a bad experience a long time ago with big bleeding afterwards just tattoo and send to the surgeons so in summary overall and i think i've managed to still run ahead of time and despite the monstrosity of this size of the talk everything is complementary here the whole idea is to get the diagnosis a proper diagnosis for the patient and to treat them in a minimally invasive way double balloon is guided by other findings of less invasive modalities such as capsule and radiological therapy is safe and effective with adequate training so you know get training properly with double balloon set up the scope and the room properly it shouldn't be a boring procedure it shouldn't be a lengthy procedure and it's exceedingly rewarding when you find and treat okay and double balloon is safe it is effective and this is why it is here to stay thank you

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