Next, we move to our state-of-the-art lecture, Raw Endoscopy and the Management of Inflammatory Bowel Disease, which is a relatively new and hot topic, and Bo Shen is going to present. Thank you. Thank you. Thank you, Peter. Thank you, Asma. And thank you, James, for having me. This is a difficult topic. Actually, interventional IBD, actually, we will practice in this section, I, myself, has been labeled by my mentor, say that you are technically not so great. So if you are technically very great, you do the ESD, EMR, ERCP, the IBD interventionist, we are the, we call the leftover. So here's my disclosure. So these are slides we use a lot. So you have a three to five-year window period to medical therapy for any IBD. The first three to five years, inflammatory form of the IBD, this is in the setting of the Crohn's disease. Now after three and five years, majority of them, 75%, 85% of the patients develop some form of complications, so fistula, stricture, abscesses, then you need a surgery. After surgery, you will restart the cycle. Now endoscopy, actually, here, play the bridging role. Our goal is try to let the people avoid surgery or at least reduce the number of the, total number of the surgery, lifelong. This area is evolving quickly. So from 1990s, everybody feel comfortable to do the balloon dilatation, later on, ESD, EMR for dysplastic lesions associated with the IBD. Now for the last 10 years, we also invested some of the efforts to do the surgical complications, IBD surgery complications, an asthmatic leak, chronic acute leak, and then later on, so the area that evolve very fast. So we try to standardize the care, so we have a group called Interventional IBD, the Global Interventional IBD Group. So as a special interest group in the ASGE, the Interventional IBD. So we published a theory guideline, this is one of the five, and the first guideline in terms of how do we endoscopically treat the stricture in chronic disease. So I summarize this list, it's going longer and longer. So the five category, if you can apply it endoscopy for the diagnosis and management of the IBD. First, of course, the stricture, second one is the fistula and abscesses, third one is any intraluminal lesions, that including the fecal microbiota transplant. Number four, and your surgeons will love you, because the colon is a difficult organ. Actually I told my chief, surgical chief, Dr. Craig Smith, I said, if you do the cabbage, if your scale of the difficult, zero to 10, if you do the cabbage, about a six. If you do the IBD surgery, difficult, would be seven to eight, why? Because colon lack of the blood flow, so either you got a stricture, get a leak, then acute and chronic leaks. So as an endoscopist, and we can play some role here, the last one is called colitis associated neoplasia. We know the technology, technique is there, but it's what's the oncology outcome still debatable. Here, my last slide, yeah, regarding the stricture. So here we do some classification, if you are interested, read our article actually published in the GIE, and then Lancet, the basic line, if you have a straight stricture, shorter than four to five centimeters, you can give it a try. Now if your patient had already stricture, had a pre-stenotic dilatation, the balloon dilatation with the stricture typically not as good. But we have other tool, including stricturotomy, endoscopic stricturoplasty. So there's a lot of study. If you have like read literature on the imaging, including bio-ultrasound, always every investigator said they can tell it's an inflammatory stricture versus a fibrotic stricture. But in reality, actually, it's not very reliable. As endoscopist, what do we do when you see the stricture like this? Use barb's forceps, or use the tip of the balloon, knock around. If it has an easy kind of bleeding, probably it's an inflammatory stricture. If it is hard, it is a fibrotic stricture. But of course, when you do the first time the stricture therapy in IBD, you always, always biopsy. Why? Because a cancer can happen. So now regarding what's definition for the stricture, actually, radiologists and endoscopists are different. Radiologists said you need a pre-stenotic dilatation in order to define that stricture. But as endoscopists, the way that we have a guideline said, what's a stricture? Stricture means if you pass the pediatric colonoscope, you found the resistance, or you cannot pass through it. Then we call it a stricture. So that's why the definition of the radiographic definition and endoscopic definition is different. The radiologists need a pre-stenotic dilatation above the stricture, right? All the endoscopic definition is just, if you found a stricture, you're harder to pass through it, or pass through it with a resistance. We call it a stricture. Now sometimes when we do this stricture, we ideally, we do the retrograde fashion. You pass the scope through the stricture, and then insufflate the balloon. We call it retrograde dilatation. Typically I do the performed endoscopy, I do not need a fluoro. So I use a thin scope, pass the stricture through, see the other side of the bowel, and then I put a guide wire there, and I put a regular scope through it. Then you can do the dilatation or stricturotomy. This is the tool we always use for the balloon. Typically we use a CRE balloon, either wire-guided or non-wire-guided. Wire-guided is 5.5 centimetres, non-wire-guided is 8 centimetres. Now what's the outcome in the future, if you're in the documentation? How do you measure your success? Measure success immediately, or technical success. That means if you have an intraversable stricture, after your treatment, you can pass the scope through it, with and without resistance, your success. Or if the patient had stricture to begin with, but you can pass through it with the resistance, but after treatment you can pass freely without resistance, then called immediate success. Now what's the long-term outcome? Long-term outcome is very objective actually. We said one year surgery-free survival. One year surgery-free survival. Secondary outcome, of course, we measure the side effect, like the perforation, bleeding, ileus, and also called re-intervention-free survival. So if you're interested in the publications, I think there's two, at least the primary end point should be mentioned. Now this is what we call the technical success. After you treat, you can pass the scope through it. Now this is always here that people ask the question, what's the stricture I should treat with endoscopy or direct center for surgery? What size balloon we use? Or what's the duration of the balloon insufflation? Or should we inject a steroid? They are not. So actually the consensus guideline, we have 30 world's leading experts, get some of the guidelines for this. Balloon size, the target is 18 to 20. You may need several sessions to achieve that goal. But the size is different than you dilate the people with the esophageal structure. It's a little bit smaller. The 13, 14, you're happy. But IBD structure, your target is 18, 19, 20. And then what's the duration of the balloon insufflation? Actually they are all over place. Can be three seconds, can be 30 seconds. So the panel cannot reach agreement. So in my practice, I insufflate the balloon, I collapse the balloon immediately. So this is my personal. Regarding the concurrent steroid injection, no data showed the injection helped the IBD structure. So this we don't recommend it. Now there's a code related to CPG code, right? We give the name of the structurotomy. That means you cut the structure open. This is that you can use an IT knife, needle knife. You can the ERCP called an endocut, either II or Q in the air beam machine. Now another term, so we use balloon dilatation. Here is a, to go back to the balloon dilatation, we have the treatment for surgical structure versus a primary structure. So there is a delay associated in the right. And an asthmatic structure in the left. You will see this is actually the endoscopy balloon dilatation work the better in an asthmatic structure than primary structure. Actually you can see the two curve separate more. We use a surgical reintervention free survival here. So go back to the slides. Now also the balloon dilatation showed that the cost effective. As you know, incremental cost effectiveness ratio, right? So the magic number is 100,000. So this is more than 100,000 balloon dilatation is cost effective. Now this go back to the knife therapy. Sometimes we use the therapy with a needle knife, IT knife. And then you put the clip there. The clip there mainly served as the spacer. So like you force the door open, right? You put the door stopper. Because those structure otherwise easy to close it again. This is particularly useful in the people with the anasthmatic structure, either ileocolonic, particularly as a side to side anasthmosis. When you cut the structure, put the clip there, that's that you can avoid the surgery actually. Then also put the clip there to prevent the perforation and bleeding. Actually this one we call the endoscopic structural plastic. Now when you send your bill, send your CPT code, whatever, you can use it in the future to use this term. Endoscopic structurotomy and endoscopic structural plastic. So regarding the structure, actually very confusing. This is our new classification. Structure, that means the bowel lumen blockage. It's essentially feel like the garden hose. If you have inside, there's a rock inside the garden hose, we call it intrinsic. If you have something, some type of banded up garden hose, we call it extrinsic. But also have the intraluminal, intramural, extraluminal, right? So this is actually this. My daughter laughed at me about the first computer drawing. And just give the concept. It's the kindergarten level. So this is the structure. You see the intraluminal here, like the inflammatory polyps. And intramural, which is the fibrosis, hyperplasia. And extraluminal can be compressed by adhesions, by the fat, by the lymph nodes, et cetera. Now this is the side. If we have the intraluminal structure, left side is the predominantly is the inflammatory cells. Inflammation. You can see there's a lot of cells. Right side is the fibrosis and neuronic hyperplasia, even neurofibro hyperplasia. This is fibrotic, just know the nature. Now sometimes this extrinsic structure, for example, you can see that sometimes see this stoma side get pinched, especially by the mesh there. And then you can use the balloon dilatation there. Balloon dilatation. So extrinsic structure, sometimes you can still use endoscopic therapy. But sometimes you will see that when we use a lot of the biologic agent nowadays, and you will find either in the ulcerative colitis and Crohn's disease, you can find this type of structure with the normal leukemia and mucosa. But you can't pass the pediatric chronic scope through it. What causes it? Actually, there are multiple causes, maybe. Long-term use of biologic agent, maybe extrinsic compression, we call it constrictive structure, or intramural structure with the normal mucosa. And then those structure actually look like the fibrotic, right? Very careful for the balloon dilatation. This tissue is very fragile. Actually, I at least perforated a couple of the patients. So just now, how do we treat that? Actually, I use a needle knife or IT knife with a structural artery. It's safer than balloon dilatation. Now regarding the stenting. Stenting is very good for the colon cancer. But for IBD, actually, you should not use it, actually. So this is a randomized controlled trial. So the beautiful study done in Spain. Actually, the upper curve showed the balloon dilatation. Lower curve showed the stent. Actually, even balloon dilatation better than stent. Plus, the stent had the issue of the stent migration. I think unless somebody designed a new stent, the stent for IBD, we put aside. Many years ago, people also tried a biologically degradable stent for IBD. Didn't work. Now this is a summary of the pro and cons of the endoscopic therapy. Typically, if you can do the needle knife, IT knife, structural artery, probably you choose that. However, because when you do the cutting, there's always an issue of the ulcer you create. People can have a delayed bleeding. Used to be we have the delayed bleeding happen at 5% to 10%. Now, with a different setting, you may cut down to 5%. But you decrease the chance to have the procedure-associated perforation. So you decrease it about 50% less, the perforation rate, than the balloon dilatation. I will talk about the stent. Stent, in very rare occasion, you put a stent there. Very rare. If you want to put a stent in an IBD patient, please don't leave the stent there for more than a week. So regarding the fistula and the abscess, actually, there's occasion you can use a fistulotomy. For example, this is a very common condition in people with a chronic IBD. Iliochronic chronic disease, actually, the stricture at the iliopsoas valve. Now, after stricture, very long time, the stricture, they cause a fistula. Fistula from the terminal ilion to the cecum. Now, this is perfect for you to cut. Actually, you can cut that fistula track. In the meantime, also serve the strictureotomy. Basically, it lets things open. And the inflammation above that is greatly improved. So this is your perfect patient to do endoscopic fistulotomy. Now, sometimes you are having to be the endoscopy suite. The patient had a perianal fistula. You know what? You have a tool in your hand, right? Just put some betadine, 5% or 2% lidocaine, inject locally. You can use a needle knife to cut. Actually, it's better than surgical. Use a scalpel. Because when you use a needle knife, actually, it is at the cauterized the same time. And then the patient may or may not need definitive therapy with like a siton placement or not. But since you have access there, you happen to be the endoscopy suite. It's very convenient for you. Now, this is actually sometimes we do. Because in Crohn's disease, there's abscess in the perianal area. Behind it is a fistula. You can actually place the siton through. You use the guide wire. Here, we put a siton, use the guide wire, introduce this around the skin side, and then use the barb. It's a forcep to grab the tip of the guide wire through inside of the rectum. And it introduced the siton. Now, how about a bezoar, fallen body, blocking luminal lesions, and FMT? Of course, if you have the Crohn's disease, you have the trapped capsule. You can take it out. If these people have the stricture, above the stricture, some bezoars, you cut the stricture, take the bezoar out. And sometimes, you have these things, either like anastomosis area has a dislodged staple cause of bleeding. You take it out. By the way, if you treat IBD, bleeding. Try not to use any cauterized things, OK? No heat probe, no bicab, whatever. You will do either clip, or in my practice, I spread sugar, 50% of the sugar. So IBD patient, ulcer, bleeding, they don't like heat. Now, sometimes the stricture is very hard. When you treat the stricture, above the stricture, bowel wall mucosa is floppy, especially at the anastomosis side, because you know the bowel tone of the small bowel and the large bowel, or small bowel and the rectum is different. So you treat the stricture, and all of a sudden, small bowel mucosa blocked again. You know what? You can put the banding kit, banding, esophageal banding, the banding, the prolapse. Now, this is the larger prolapse. So sometimes it cause the symptoms, cause the bleeding, cause obstruction. And then this, the otherwise, would be disease under control with the biologic agent, right? You have the endoscopy, you have the snare, use a hot cord snare. Then you take this part out, and of course, you can do the stool transplant here. Now, last one, it would be the surgery complications. This is anastomotic bleeding. You know that ischemia bleeding is very common. So you put the clip there and spray some sugar. See? Now, this common area, the surgical leak, you can see this is called transversal staple line leak. This anastomotic leak, and then there's a leak at the stoma side. This is chronic disease structure. Right? Okay. Now, this is the ulcerative colitis. With a pouch surgery, the leak all over place. Common place of the leak is number two. We call it tip of the J leak. And then other one is a vaginal fistula leak, and then presacral leak. And if you happen to be the bigger cancer practice, the colon cancer practice, you know what? Your oncologist, your colorectal surgeon will love you because you know what? Nowadays, a lot of rectal cancer, they do the low anterior resection. Then they do the radiation. Of course, the presacral sinus happen. Very hard to treat. And at the endoscopy, you can treat it. So typically, we treat a surgical leak. If you want to put a clip there, make sure the tissue is fresh. So just immediately within 30 days of the surgery, you put the leak, you put the clip there, helpful. But if it become the chronic, you rather than clip, actually drain it. It's different. So this one is a fresh leak, just small. You can put it through the scope clip. Now, this is like a tiny rectal vaginal fistula due to the leak. Then you can put it over the scope clip. And this tip of the J-leak, small, you can put it through the scope clip. If they're big, you can over the scope the clip. Now, this is called sinusotomy. I think the technique is much simpler than ESD, EMR. Basically, there is a sinus chronic abscess cavity. And this is either rectum or iliopause. Now, there's a wall between them. Basically, you cut that wall, and you convert it into the sinus, into the diverticulum. The sinus become the part of your bowel. So success rate actually higher than surgery. So this is a pre-sacral. Because when you do the endoscopy, by the way, it's a very important orientation. You put the patient in the left lateral position. And if you put the scope in the 45 degree, and then left, left corner, it is posterior wall. Right low quadrant is anterior wall. Anterior wall, don't touch it. Because there are sacs of nerve there. There's vaginal wall there. So right low quadrant, don't touch it. Left upper quadrant is your zone to practice. This one, you do the sinusotomy. And after several months, you can get healed. Now, this is we compare the surgery with the surgery totally redo with the endoscopic sinusotomy. You can see the advantage of endoscopic therapy. Then you can see the complication rate. Surgical side is the right side and the endoscopic left side. Now, last one would be still controversial. You can do the polypectomy for colitis-associated neoplasia. You can do the EMR for colitis-associated neoplasia. Technically, you can do the ESD for colitis-associated neoplasia. But however, IBD is totally different in the game. Look at the ulcerative colitis patient like this. You have the inflamed mucosa. You know what? How much fibrosis you have. Then if you do the ESD, EMR, a lot of the bleeding. And then are you sure you can able to cut? Say good example. If this patient, if you do the EMR, you know what? The cancer already underneath. Now, if you have the distal rectal region, remember, you always have the surgeon on board. Actually, you can bring the patient to the OOR. If the distal rectal region, they can do the much deeper cut than we do in the ESD. So there's a lot of room to improvement. All the literature here, majority of the case report, case theory, only a few of the case control study. There's no randomized control trial. I can foresee the area evolve very fast. We really need to further define what's the nature of the structure? What's the anal rectal structure? Is it different? What's the relationship with anal rectal structure of the fistula? What's the AI use in the dysplasia screening? And then we need to develop a new stent. You need a new scope. We need to do the stem cell therapy. And then we need to further define oncology outcome, the ESD, EMR, in colitis-associated neoplasia. When it still has a room to how do you go to damage control, especially the bleeding from the endoscopic cutting. Thank you very much. Thank you.

raw endoscopy

inflammatory bowel disease

interventional IBD

stricture therapy

endoscopic treatment

surgical complications