So we have a few questions from the audience. So for Dr. Yang, besides endoflip, do you routinely, in patients with gastroparesis, do you do dilation or place a stent to help identify patients most likely to respond? The short answer is no. We still are trying to figure out what are the best pre-procedural prognosticators, and I don't think we have great data on any of this. There's been some data suggesting, well, maybe some patients that may respond to stenting may subsequently respond to G-POM, but again, remember, this is an extra procedure. There's cost involved, and these stents do migrate. And as I demonstrated on the slides, in clinical practice, a lot of these patients are getting injections with Botox, but previous well-designed randomized studies have not shown an effect with Botox injection. These patients are prone to having a placebo effect as well. So in my practice, I generally just assess the patient, see if they've gone through the medical therapy, dietary medications, that they're not on narcotics, certain prognosticators such as nausea being the main symptom rather than abdominal pain, not significant psychiatric comorbidities. These are the type of things that I screen for before deciding on the G-POM. Excellent. And for Dr. Rex, what are the most important steps you take to prevent post-polypectomy syndrome during these large EMR-type procedures? Preventing post-polypectomy syndrome, I have to tell you, I don't see it very much anymore. And I would say, you know, good lift is important. I haven't seen it at all underwater, but for conventional EMR, probably good lift. I think we've sort of moved out of the era of significant delayed complications because you can inspect the entire base of the defect and you've got it stained, you know, with contrast. And contrast stains the submucosa blue and you shouldn't see, you know, muscle in there. So if you don't see muscle, you're not going to have delay. I haven't seen a delayed perforation in over a decade. I mean, I have some immediate perforations, but not a delayed perforation. So and I guess there's going to be the occasional post-polypectomy syndrome, but I don't know anything else beyond that to do. Any other thoughts that anybody has? I just don't, I don't see, I honestly don't see very much anymore. It has been kind of a thing of the past and I don't know whether it's our technique or the electrosurgical generators have gotten better. We have certainly gotten away from hot biopsy type of techniques, which we used to use those in the past. So I hardly see it. I think how you demonstrate on your videos about sticking to perhaps a smaller type of snare may help. When you have a larger type of snare, you're entrapping significantly amount more tissue. So when you're trying to transect through a larger amount of tissue, there's going to be higher increased resistance, lower current density. But this heat is going somewhere. Just because there's increased resistance, it's not cutting that fast, that thermal energy is dissipating into the base. And so choosing smaller snares, like a lot of the speakers have said, may improve that. I think that's a good point, Dennis, and I often say to people, you know, to restrict yourself, especially in the right colon, to 15 to 20 millimeter snares. I will say sometimes when you have a big granular lesion and it's just really lifting up like crazy, that you have to use a 20 or 25 millimeter snare to have some reasonable amount of efficiency. And also the bulkier it is, you know, to get over those pieces that have more bulk to them, you sometimes need a bigger snare. But trending towards smaller, I think it's a very good point. A question to Sofia. Any experience with combined teeth with laparoscopic surgery? Because the main limitation of teeth is hiatal hernia. I think it's called C-teeth or combined teeth. Yes. As Dr. Sharma said, he had a baby with STIR. The combined teeth is another baby. It's just a baby with a surgeon's anus, which is a bit of an oxymoron, but it seems to be working very well for us. We do, we have some experience with it. It does require, conceptually, it solves the main problem, right? You fix the cruel defect, surgeons do that, and then we fix the angle of his, and it's a beautiful baby. At the end of it, it does require a little bit of coordination with the surgeons, but that could be achieved, and I think that is the future. Thank you. And a question for Neil. How do you decide in your mind when to do STIR versus a full thickness resection? Because now with suturing in the upper GI tract, we can close a full thickness resection fairly easy. What's your algorithm? So the question was around full thickness resection. So I think it's different if you're above or below the peritoneal reflection. I make a lot of decisions based on that. If I'm below the peritoneal reflection, as Doug pointed out earlier, it's no longer is there a semi-coastal invasion alone making the decision, right? And so in our center, just this past six months, we've gotten away from TAMIS, and they just will go straight to ESD or full thickness freehand resection for us, and that's a big deal for us. We had six colorectal surgeons on production. For me to take years to convince them of that, I think we're able to do just everything freehand below the peritoneal reflection. You'd be surprised if you spent time with your colorectal surgeons when they were doing TAMIS, trans-animal resections, they could get away with a lot because they're below the peritoneal reflection. When we're above the peritoneal reflection, it changes, and so the gist I showed you there, I would never take one of those patients, and I think this is a really important point, I would never take any of those patients and decide on ESD or STIR without going in front of a multidisciplinary tumor board. Every patient goes in front of a multidisciplinary tumor board. I did not choose to take that patient for a STIR. Actually, Max Schmidt, who's the assistant professor of surgery at IU, thought that would be the best thing potentially for the patient, so I think that's one deciding factor. And then the other big thing is, for something like a gist, it's encapsulated, so I mentioned if you rupture the gist, you're going to be in trouble. So if you use an Ovesco full thickness resection device, and you can't get it all the way into the device, it's very fixed, and you cut halfway through that lesion, now you've taken that lesion and made a stage four lesion. I like being freehand and having control of that environment, so that's why I choose that. Very, very small lesions that happen to fit in that Ovesco device, again, we have to work under oncologic principles. NCCN guidelines would say very small gists, perhaps very small carcinoids, don't necessarily need to get resected, and so then again, we'll put it in front of a multidisciplinary tumor board, talk to the patient, some patients absolutely want it out, you know, and that's a different scenario, but we tell them it's not because you need it oncologically out, if you choose to have it out, then we think about size in particular. Thank you. Well, it seems that everything comes to an end, and I want to thank you all of our faculties on behalf of myself and my co-directors, actually we hit the easy button, because the best way to do a course that is easy for us is to choose great faculty and leave it up to them to do the hard work, so thank you very much, guys, for supporting this.

medical procedures

gastroparesis

post-polypectomy syndrome

EMR procedures

hiatal hernia