We have a number of questions, but I'm going to just start it off. You mentioned that it's particularly effective, in your experience, for anal strictures. Do you have any concerns about when you're doing a stricturotomy, potentially damaging the anal sphincter, or how do you avoid that? So actually, you know, with the thermal therapy, we don't see that. With the dilatation, with the self-dilators, there is a higher chance of us causing any perforation or damage or trauma to the nerves. With the thermal therapies, we are not cutting deep enough to damage the nerves. We are only cutting to the scar tissue level. The scar tissue, technically, is a dead tissue, right? So you're just cutting the scar tissue out. So we have not reported, so far, a single case in anal stricturotomy of patient having loss of bowel function or having any kind of nerve damage for which they developed incontinence. And what number are we talking about there, in terms of? So in my experience, I have done about seven. Dr. Shen has done more than me at Cleveland Clinic. They have published their experience. And then I think Dr. Nevin Nathan from Orlando Gastro published his experience in IBD Journal, as well. I don't know the exact total number. Obviously, it's small still, but so far, we have not seen that. Okay, wonderful. So case reports. Thank you. Yes. So tell me, when you're addressing these strictures, tell me about your approach to balloon sizing. So does it depend on sort of where you start, and how aggressively can you push the envelope in a single session? Right. So my balloon size depends on two factors. First is, what type of scope am I using? So if I am, let's say, in a patient with J-pouch, there's a pouch-inless stricture, and I can't get my EGD scope through, EGD scope diameter is roughly 9.8 millimeters, so you know you have to start at least at 10 millimeter or higher to dilate the patient's stricture. If the EGD scope is getting through, then you know at least the stricture is up to 10 millimeter size, so you can start dilation at 12, 13.5, 15. How high do I go with the balloon dilatation? That is a question a little bit difficult to answer. It's more of a field factor over the years you develop. Because once, technically, the scope has passed through, you have achieved the outcome that you want to achieve. But I almost go up to the size maximum I can. That is defined by how nicely I see the mucosa expanding during the balloon dilatation, and obviously relying on my tech to tell me how much resistance they are feeling. Sometimes I've even taken the gun from them myself to feel it myself as to how difficult it is to maintain the pressure. But depending on what scope you use. So similarly, if it's a PEDS colonoscope, you will start dilating from that number, and if it's an adult colonoscope, then you adjust the number accordingly. But it is the scope that I'm using, how the stricture looks, that decides what balloon size I'll use. That's wonderful. Thank you. And we have a question for Dr. Shergill if she's on the line. Yes. I'm here. Okay. Wonderful. So this is a question from the audience. Is chromoendoscopy required if using high-definition white light endoscopy in an optimized situation, that is, in a patient with remission, BVPS9, no pseudopolyps, et cetera, et cetera, and not doing non-targeted biopsies? My impression of the SINIC trial was that the main benefit was chromo only increased yield significantly in non-HD. Yeah. So this is the ongoing debate. I think we are pretty clear that chromoendoscopy should be used when you're using standard definition scopes. And the question is, with high-definition scopes, are we getting enough of a, in a clear enough view to be able to detect what's often these very subtle lesions? In my personal interpretation of the data, in the absence of the SINIC-2, I would say the standard is still chromoendoscopy, although there may be specific endoscopists who, after having done many of these procedures, can become high detectors with high-definition endoscopy alone. But I would say that for the average endoscopist performing IBD endoscopy, chromoendoscopy is still the standard, even with high-definition scopes. Amandeep, as somebody who has not taken care of an IBD patient for probably 15 years, I'm certainly not qualified to be even sitting on this stage. But for those of us who are endoscopists primarily and don't do a lot of IBD, when you were discussing the criteria for when dysplasia would trigger surgical resection, just, and again, pardon my ignorance, but when you say surgery, does dysplasia anywhere trigger basically a total proctocolectomy, or is there some nuance in how to approach that? Yeah, there's definitely a lot of nuance that's getting developed. I think for most, it depends on the extent and the severity of disease and the extent of dysplasia, whether or not it was, oftentimes if it's invisible so that it was detected in multiple areas of the colon, but just on these random biopsies or these non-targeted biopsies that were taken to maximize dysplasia detection, I think that patient would easily be considered for a total colectomy. But we're moving into the area where patients may have otherwise very good disease control in order to preserve quality of life, whether or not a segmental colectomy can be considered, especially maybe for our Crohn's patients that only have a segment of colon involved. And so this really does require multidisciplinary discussion in order to optimize both the surgical outcomes as well as the patient outcomes. So that's an involving area. And I'd be interested to hear what Gursimran's approach is at his institute as well. Yes, so I think a similar approach we have. So if a patient has more than one or two areas of low-grade dysplasia, we definitely offer them surgery right now because any area more than one area of low-grade dysplasia means that there is two or three areas that you might have missed. So it becomes very difficult in that scenario to defend saying that we can do this endoscopic resection. If there is high-grade dysplasia, then obviously they are going for a surgery. In patients with ulcerative colitis, a total proctocolectomy, in Crohn's disease now we are considering segmental resections because our techniques of follow-up and surveying these patients is getting better. So I think it depends, A, on what the primary underlying diagnosis for IBD is, Crohn's versus UC. And if they have more than one area of low-grade dysplasia, we are still referring them to our surgical colleagues to have that discussion with them. Now, some patients are refusing. In those cases, you know, we are offering them endotherapy with very close follow-up, but guidelines still say that more than one area of low-grade, they should be referred to surgery. You know, so as you mentioned in your talk, you are uniquely positioned to be able to do these high-level sort of endoscopic interventions in patients with IBD, and so there's a little interest from the audience about, well, you know, not everybody's comfortable with a needle knife in that context, but is there anything else that perhaps doesn't feel as dangerous? And actually, to your point, you know, once somebody becomes facile with a needle knife, it actually is less dangerous than balloon dilation because, you know, you can use your best judgment in balloon dilation, but ultimately, you're inflating the balloon and hoping for the best. And if your judgment is off or if there's something about that patient or stricture characteristics that, you know, sort of put you in a bad position, then there's nothing you can do about that, whereas with the needle knife, you have a lot more control and sort of a lot more impact, a lot more ability to sort of impact the outcome. But having said that, there's some interest around, you know, if one doesn't have needle knife availability or doesn't have the expertise necessarily, is there any role for a hot biopsy forceps to sort of remodel the stricture or even just picking away at it with a cold forceps? And then as a follow-up to that, you know, what kind of training could people who are interested who don't do this for a living, you know, are there any options to expand their skill set? Yes. So I think very good question regarding the hot biopsy forceps. So if you refer to the image in the slides that showed three types of stricture, the web-shaped stricture, the web-like strictures is somewhere where you can, might attempt using a hot biopsy forceps to disrupt the stricture. Those are two, three millimeter big strictures. They are not very fibrotic, they're web-shaped. Other than that, I don't think so using forceps to disrupt a stricture will help in this case. So if the strictureotomy technique is not available, then I would just say, you know, do balloon dilatation and, you know, kind of go from there on. But using cold forceps to disrupt a stricture that's two, three centimeter long or hot biopsy probably will not work in those cases. And quite honestly, I've never done it, so I'm not very sure that if it can be even attempted in those long strictures. So I would say either we refer a patient to an academic center where this procedure is being offered and then, you know, or just attempt a balloon dilatation. In regards to the training opportunities, actually I'm very thankful to ASG, not that they called me for the talk, but ASG kind of recognized this, you know, emerging pattern of the gap in the endoscopic training in IBD and they actually helped us establish a special interest group. So all ASG members can join that special interest group, it's called Interventional IBD. That initially was headed by Dr. Boshan and now currently I'm the chair of that for next couple of years. So via that special interest group, we actually started an educational series. All those lectures are on GILeap recorded as well, in which we actually discussed all these techniques in a web-based platform, sharing various different tips and tricks of how to do these techniques. Ultimately, I think the training for these procedures is just like training for any of the other procedures, meaning you will have to see a lot of cases, you have to probably go to a center where these are being done to observe some cases, and then once you feel comfortable you have to move on to the animal model training. Hopefully in future we'll also have a hands-on training sessions with the, you know, pig models. Once you have achieved that, then when you're ready to start these procedures, having a proctor helping you in first two, three cases is the way to go about them. So then, I think understanding the procedural aspects of knives in these patients or cutting, a very significant part also goes in understanding the IBD disease and its mechanisms. For example, we talked about perforation in IBD patients and how we cannot close them. So I think having a knowledge of both those things is helpful. In regards to resources, I think the best step forward will be to join the special interest group under ASGE, and we will continue to share our knowledge, you know, in coming years also via either in-person or web-based conferences. Wonderful. Thank you very much, and we appreciate the shout-out for the SIGs. So if you'd like any information about that, if you just want to check with the ASGE desk outside the front door, they'll be able to give you some more information or they can come up at the end of the session. We have a question for Dr. Shergill from the audience. We now have AI moving into all different aspects of our life. What do you think is the role for AI in IBD, and do you think that this will change dysplasia surveillance in the future? Yeah, certainly AI is disrupting the way we approach endoscopy and what endoscopy can both detect and sort of leading from there. I think that there have been studies that have used AI to determine endoscopic disease activity. There have been studies of AI for colitis-associated neoplasia. I'm not thinking of anything off the top of my head, but I'm sure that those studies are being done. And so certainly, you know, the hard part with these IBD-associated neoplastic lesions is they often can be very subtle, and especially if the disease is not in remission, that inflammation can sometimes mask underlying lesions. So I think that as the technology is developed and becomes more sophisticated, it may supplant the dye-based chromoendoscopy, and that's certainly something that I think many people would look forward to. I think that, you know, being at a center, especially with fellows, we do it on every single case because I think, again, this is the standard, but it's also important to teach our fellows how to do this very easy technique sort of moving forward. I also happen to be at a center with Drs. Kaltenbach, Satickno, and McQuaid, who headed up the CENIC consensus guidelines, and so our center may be biased. I know, again, that as, you know, people want to believe that high-definition white light endoscopy, and with the adjunct of AI, maybe it can achieve the same outcomes as chromoendoscopy. But as we think about, you know, even in our regular colonoscopies, every 1% increase in ADR leading to a decrease in interval cancers, I think that every lesion that we find in IBD matters now, and until we have data that tells us otherwise, any of these tools and techniques that can help us maximize data displacement detection are going to be important to utilize and implement. We have a follow-up question for you on that. Is there any role for fecal DNA testing for dysplasia and surveillance in IBD? I am not aware of that data. So we are close to the time of adjournment. Couple of rapid-fire questions for you around stricture dilation. So are there any sort of, you know, you talked about the characteristics of strictures that predict failure to respond and need for surgery. Are there any characteristics that predict a higher likelihood of perforation? So the strictures that perforate are not very well understood why they perforate in IBD patients. It's not always the inflammation. As I mentioned, the size of the balloon is not a predictor of the perforation. But in my personal experience, if you go in and you do not have a pre-procedure imaging, and if you see there is a lot of inflammation, and you will see that with ulceration and edema, those strictures I would definitely avoid dilating, because once there is inflammation and the inflammation is transmuted, like in Crohn's disease patients, those stricture, in my opinion, can perforate very easily. On the other hand, the fibrotic strictures that have been there for a while, they, I think, tend to perforate less because they have scarred down enough for us to attempt the balloon dilatation. And lastly, you touched briefly on intralesional steroid or Kenalog injection, and you said there really wasn't a role for it. Is that because there are no data to support its use, or because there are preliminary data to suggest that it's just not effective in this context? So yes, so we actually looked at that, even in our guideline paper that we published, the one that I cited here. So there was one study that came out that said it was effective, and subsequently another RCT came out that said it is not effective. We personally have used this, you know, numerous number of times, and we don't think so there is any effect of steroids helping in, intralesional steroids helping in IBD patients. And the study that came out subsequently that showed no help, it actually showed slight worsening of the stricture. So the consensus from the global IBD group was to recommend against using intralesional steroids in patients while directing the strictures. Wonderful. Well, I just want to thank you all for, first we thank all the speakers, and also thank you all for coming and spending time with us. I know there's a couple more people who want questions, but please come up, feel free to ask if there's any outstanding questions, and again, thank you for joining us, and we hope you enjoy the rest of the evening.

endoscopic procedures

anal strictures

inflammatory bowel disease

thermal therapies

dysplasia surveillance