Hello, everyone, and welcome to the ASG IT&T Center. I am Prateek Sharma from Kansas City, and it's my pleasure to welcome all the participants today on our next edition of ASG Weekend Endoscopy Live from the IT&T Center, which is brought to you by Medtronic. Today's topic is endoscopy in patients with Barrett's esophagus. And before we start off with the program, I just wanted to go over and introduce our panelists as well as the live endoscopy procedure takers for today. So I'd like to start off by introducing Professor Irving Waxman. So Irving is professor of medicine and chief of gastroenterology at Rush University. And Irving, along with his team, has graciously opened up their endoscopy unit in Rush here in Chicago for us. So Irving, welcome to the program. And also, my sincere thanks to not just you, but your team of nurses, endoscopists, as well as the patients for agreeing to participate in this wonderful educational endeavor brought to you by the ASGE. Next again, in no specific order, we have Saouni. Saouni is assistant professor at Johns Hopkins. And she is one of our rising stars in endoscopy and is interested in all areas of therapeutic endoscopy, specifically related to precancerous and cancerous luminal lesions. So welcome to Saouni from Baltimore. Next is Cadman Leggett. Cadman is assistant professor at the Mayo Clinic in Rochester and is a member of our ASGAI task force. Besides that, Cadman has also an experienced researcher and is one of the leading researchers when it comes to imaging and diagnostic in Barrett's esophagus. And so it's very timely to have him on this program to share his expertise with us. So Cadman was supposed to be here at the IT&T Center in Chicago, but unfortunately, the weather had different plans for him. So Cadman, we are missing you here in Chicago, but great to see you online, and thanks for being with us. Next, the person who is farthest from us is Professor Luis Caro. And Luis is running the gastroenterology and the endoscopy division at GADET in Buenos Aires, Argentina, and has great interests and is a world's expert in both colon cancer as well as Barrett's esophagus. He's the secretary for SEAD, which is the Inter-American Digestive Endoscopy Association. And while we are on that topic, I just wanted to also recognize that specifically the roles of Cadman and Luis to open this up program today to folks in LATAM as well. So we are very grateful to have Luis join us. Finally, last not but least, is Prasad Iyer. Prasad, again, is a world-known expert in the field of Barrett's esophagus. He is a professor of medicine in Mayo, again, in Rochester, and has written several of our guidelines that we all follow in our daily practice. So again, for those of you joining us virtually, again, grab a cup of coffee and spend the next hour or so with us as we go around and talk about Barrett's endoscopy. So if Professor Waxman or Irving is ready, let's go ahead and go to Irving here at Rush University at his unit, and he will tell us about the first case and what he's planning on doing. Irving? Good morning, Prasad. Good morning, everybody who's viewing. First of all, I do want to thank my team that's working with us, Nathalie, Mered, assisting me, Don, Dr. Eric Sloan from anesthesia, and Dr. Ben Anestesia-Pedro from our IV and A.J. Singh, my colleague and production manager today. The case we're doing this morning, this gentleman I've known since 2014 was referred to me for long segment Barrett's, C10, M10, we've been surveilling him on their standard Seattle biopsy protocol since 2014, and last November, we did our last surveillance protocol as well as Watts, what area is sampling, and interestingly enough, at 35 centimeters, he showed an area of high-grade dysplasia, and Watts showed indefinite for dysplasia. So the interesting thing for me about this case is that you could actually not find a dysplastic area. In our experience, and we published this many years ago, it's a very, very few number of patients that have advanced pathology in the absence of a visible lesion or visible changes that cannot be identified, and the same thing has been published by Jax Bergman, where, again, it's unusual to have invisible dysplasia, but this patient had it. So he underwent a wide-field ablation modality in January, and he comes today here for follow-up and assessed response to ablation. So we're performing an endoscopy with high-definition white light, we're here at the EG Junction, you can still see foals in the EG Junction, and we're going to start slowly withdrawing the endoscope, looking for, A, a response to treatment, and B, to see if I can find anything that gives me a clue where the pathology is. So as I'm getting ready, I'm at 40 centimeters, you can already see that very low in the EG Junction, very low in the esophagus, there's no response to treatment at 6 o'clock. As I continue to pull back, you can see all these stiff areas that, again, did not respond to wide-field ablation. And I'm slowly, again, and methodically examining this mucosa, and I'm particularly interested in having the consonants of 35 centimeters, where the area of high-grade dysplasia that I could not identify was. So you can see here a very large segment of non-respondent virus, where exactly are 35 centimeters. So we're doing MBI, or digital chromoendoscopy, and also we're applying close-focus magnification to better examine this area. I'm speaking in Spanish already, you can correct me on this any time. So this is the area of 35 centimeters, and you can appreciate, a little bit worried that the mucosa doesn't look perfectly regular, the mucosal epithelium doesn't look nice, and the classic elevated V-line. And here you are at 34 centimeters, where you see another patch, pretty extensive, with the mucosal peak pattern that's a little bit irregular, but no big alarm sounds. So, you know, it presents an issue for me in regards to how to manage this patient, because if you see this area that did not respond to ablation, it's what I call a lumpy virus esophagus. So you have basically a lump here, and I could do repeat ablation modalities, but I suspect this is very, very thick and will be non-responsive. So my options are in some ways limited. So in this particular case, I would, in my practice, would go to endoscopic mucosal resection for two reasons. This, what I'm calling a lumpy-bumpy mucosa, it's exactly at the area where the biopsy show high-grade dysplasia. And if you look at the picture that I just took at six o'clock, you can see that there is this linear mucosal peak pattern, but at six o'clock, you kind of lose it, and then it becomes irregular with an increased capillary pattern, which makes me wonder if that is actually our area of interest. So I would be much happier in this particular case if this area wasn't under the microscope with my pathologies, rather than invisibly treated. We're again using digital chromoendoscopy, especially in this area, now it's at six o'clock, where you can see that that nice peak pattern that you were seeing proximally tends to disappear in the center of this lumpy-bumpy mucosa. So, you know, speaking nonstop, I don't know, Prasad, do you have any observations or anybody feel free to say you're nuts? That's just normal violence? Or you agree with me? No, I think you are spot on in my mind, you know, this area of almost sort of very irregular and loss of the pit pattern is somewhat concerning. So, and I can also appreciate, at least from here, the sort of uneven and fleshy looking area, which may not be as responsive to ablation, given its thickness. I did have a question for you, Irving, there were a couple spots on the other side, so I would maybe say small erythematous spots, yeah, right there. What do you, what do you make of them? You know, that's the only problem of once you do ablation, there's going to be skip areas that after you do ablation, as you know, there is all these islands in between, and it's very difficult to tell hyperplastic changes versus skip barrets versus true neoplastic changes. So, obviously, it's, I know, I feel exactly like you, I mean, the question is, am I concerned? So, what would I do if I had all the time in the world, or how would I, how do I go about this in my practice? What I usually would do is I take a biopsy of the lesion proper, and then I would ablate it with APC, so I don't have to worry about it. And if the biopsy just comes back, barrets, reactive, etc., well, it's already treated. Obviously, I usually map my esophagus and my biopsies, for example, in this particular case, I would be saying island at the 85 centimeters, six o'clock, I would do a large capacity biopsy, and then I would ablate it with, I would ablate it with the APC. Now, Irving, I mean, you've nicely shown us also on the islands, Prasad, that you are referring to, those look pretty regular, right? I mean, you look at them, the island appears a little bit prominent. I think the reason for the prominence is because of the prior endoscopic treatment. Around it, there is a thick rim of neo squamous mucosa, and it appears as if it is raised, but really, I think it is, to me, it appears like non-displastic barret esophagus. Luis, any comments on that? No, it's okay. I agree with Dr. Pratik Sharma and Delaya. Questions for Irving? Irving, good morning. Buenos dias, Irving. How are you? Yes, in hour nine, you lose a little part in the mucous, like a node. I know it's a node, but it's an isla. Do you have any opinion about that part in the nine hour? It's a little isla? Yes. Please, yes. So, yeah, thank you, Luis. This is what Prasad was mentioning, and Pratik was talking about, which the mucosa looks very regular, and it may be an area where the ablation didn't work that well, or a skipped area, and what I would be doing, as I mentioned, is large capacity forceps, and then ablating it, making sure that I document in my endoscopy pathology report where it is located, just in case it comes back as something unusual. So I think you see this after a wide, deep process of ablation. Cadman, do you want to just give us a brief summary, perhaps in Spanish, about the main findings that Irving has shown us on this very high quality inspection? Can I ask a quick question first? Sure, absolutely. Yeah, I just wanted to make a comment and a quick question, just to emphasize something that Irving said about the importance of landmarks. So you mentioned the diaphragmatic hiatus, the gastroesophageal junction, and then the extent of the barrets, and that's what defines the PREG criteria, and that's what we use to measure the extent of the barrets. And my question to you is, you mentioned that this is somebody that had whitefield ablation that did not respond to therapy. How do you define that? Is it by the appearance? You mentioned that it looks thick, or is it by how much residual barrets is left over? You know, again, that's a very good question. What's a non-responder? You know, I think this gentleman, as I said, had a 10 centimeter long segment, and I see less than 50% response, probably around 40% response. And I think you can go either way, which is a second round of treatment before you really declare him non-respondent, or you can say partial response. As you know, probably there's about 10 to 15% of patients that do not respond to ablation or terminal ablation. So I would at least want two treatments before I declare him non-respondent, but I'm not optimistic that it would work in this case, based on what I'm seeing, because I think it's probably 40, 50% of non-response. And I think this area that I'm showing you at 6 o'clock, what I define as the famous lumpy, bumpy mucosa, this is not going to respond, because it's too thick and too irregular for the ablated modalities to be able to destroy. And I think, Irving, that's a very good point you're raising here. I think one of the main reasons, either for referrals or one of the main reasons for lack of response that we see is when mucosa, which should be resected, is actually ablated, right? I mean, and you have invasive cancers happening because of that. You have residual barrets or residual neoplasia. So I think this is an excellent demonstration. So, Cadman and Luis, if I can have you just say a few words in Spanish to all our LATAM people, then we will. Irving, we will let you go and we will see you back in about 15, 10 minutes, 15 minutes to show us the resection. Luis, do you have any other comments? Yes, yes, barret, barret gland, es decir, glándulas enterradas, que quizá en la cicatrización post ablación, puede comprometer el futuro de este paciente. Gracias, gracias. Okay, Cadman and Luis, excellent. Thank you for that, for our Latin American colleagues. And while we are waiting for Vaxman to come back to us, Sauni, a question for you is, what's your preferred method for, you know, inspecting Barrett's esophagus? I mean, do you, just a few separate questions, which we'll go around the audience then is, do you use a cap always on the tip of the endoscope for your standard examination? Do you routinely spray dye, like either acetic acid or indigo carmine? Do you routinely use virtual chromoendoscopy, whatever scope you have at your unit? Can you walk us through your process? Yes, thank you, Dr. Sharma. So, I always use a cap, because it helps stabilize the wall. And that way you can have the on course view. And sometimes even the area at 12 o'clock, if we don't put the cap, you don't really see well. Or sometimes the wall comes close to the lens and you cannot see it. So I always put a cap when I examine patients with Barrett's. I usually have only a couple millimeters of the cap out, because if you have the cap out too much, the light dims and you don't see it very well. Before examination, I usually suction air and fluid in the stomach. That way we see more of the distal esophagus. If we have distended stomach, it will pull esophagus down and you don't really see part of what you want to see. And like Dr. Beckman showed us, slow, careful examination, both white light and NVI. And usually I use white light first to get the overall view and then NVI. I always use additional near focus to help visualize the vessels and the surface pattern. I usually use NVI mainly. It's very easy to use, just press the button. If you have other types of scopes, you can use that as well, like eye scan, eyes. I not typically use chromoendoscopy, although sometimes we use that. For example, patients that have esophageal varices and we don't want to biopsy, we use acetic acid and ethylene blue. But otherwise, I think good high quality white light and chromoendoscopy is usually efficient to examine the focal collisions. Excellent. Prasad, I mean, Sawani mentioned something in passing, which was a good inspection. Prasad, to you, what does a good inspection mean? Is there something that we should all be looking at very carefully? Are there some metrics? I mean, how would you define good inspection? How would you define like a high quality examination in Barrett's, which I think all of us should be practicing? Yeah, I think, Pratik, you're talking about maybe some metrics that we might be interested in following. In addition to everything that Sawani and Cadman just mentioned in terms of cleaning, defining the landmarks, taking your time, doing white light and narrowband imaging, I think if we follow the colonoscopy literature, there are a few things that have been proposed. One metric that has been looked at is something called the neoplasia detection rate, which is basically the proportion of patients with high-grade dysplasia and cancer that are detected during a first surveillance endoscopy, either per endoscopist or in a practice. That is something that has been discussed somewhere in the realm of four to five to 6% are some of the initial studies. A second important potential metric that has been discussed is Barrett's inspection time, again, leading to the same concept that if you look more and carefully, you are going to find more dysplasia and visible lesions. Manuscripts from your group, and I think more recently from the United Kingdom, have suggested perhaps a minute per centimeter, again, emphasizing the importance of careful inspection and spending adequate time. Luis, is the practice in Argentina and in South America any different than what we have been discussing? And again, feel free to make a few comments in English and a few comments in Spanish for our UNILATAM members. Okay. Thank you, Professor. In Argentina, we use every time. First for taking quality endoscopy is time, time, time. Time and see really very slowly. And then in every procedure, we use acetic acid and then MVA in my practice. This is very, very important for us, but I need to put emphasis in the take your time, like I call on, say, the professor. It's very important for look every area. And if you have some, obviously, in every time, but if you have some doubt, you can use no virtual life indicator. You can use blue or blue. But yes, all day, we use acetic acid in our procedure. Okay. To all our virtual participants, if you have any questions for our experts, please go to the Q&A box down at the bottom of your Zoom link and you can send us your questions. Irving, are you ready for us? Can we come back to you? I'm very ready for you. Okay, perfect. So let's go back now to the endoscopy unit at Rush University where Irving Waxman, who, you know, demonstrated very elegantly for us the diagnostics in Barrett's is now ready for a resection of an area of abnormality that was shown by both white light as well as with virtual chromoendoscopy. So Irving, over to you. Tell us what you have done in the meantime. What's this cap which is sticking and what's your plan now? Welcome back. So as we were discussing, one of the things that I'm thinking about is how am I going to address all the abnormalities that are still remaining here? And yes, we were talking about who is considered a failure of ablation or can you just reablate these areas before you consider a failure? And the whole issue is like, yes, you could reablate, but what I was mentioning is that this lumpy, bumpy area is not going to respond to ablation. So my plan is going to be to do endoscopic mucosal resection. And you can see in the proximal edge of the Barrett's, you've lost a mucosal pattern and there seems by MBI to be increased capillary pattern. It happens to be at 35 centimeters where the high grade displacement was detected. I don't think it's going to respond to ablation. So we're actually going to do endoscopic mucosal resection. As you know, many years ago, we published in the Red Journal our experience with about 140 patients that we completed endoscopic mucosal resection with very, very good results. I don't think it's necessary here, but I need to remove these because just standard ablation is not going to work. And I am worried about it. So what are you going to, Irving, are you going to inject or do, what's your next steps here? So I have the cap designed by Professor Inouye, which is basically a cap with a slit, a hard cap oblique with a slit around seven o'clock, which is going to basically be the scaffold for a snare, a special snare designed for this kid. The first part I'm going to do is I'm going to inject the lesion that was in the lab. And I'm just injecting with saline. Let's inject. And you can see, excuse me. Irving, do you use any blue dye in the saline or are you happy just with saline? Excuse me, I'm sorry. I'm very comfortable with saline. In the esophagus, I'm very comfortable with saline. And basically, because it's so different that I feel very comfortable, you can tell what's abnormal and what's normal. So we routinely use saline in our unit. But one point that is worthwhile mentioning is when you're injecting, you want to see a vertical leap of the target. If you don't see a vertical leap, meaning into the lumen, you obviously have to worry that you're injecting too deep or that there's invasive disease. In this particular case, you see a very nice vertical leap. I'm very comfortable with what I'm seeing. And now comes probably the tricky part of this kid is mounting the snare. And what you want... You want the tip of the snare to be anchored in that slit in the calf. So once the snare is out of the position, you're going to go to your lesion, apply some suction. Close. Close the snare. And you saw how much time it took for the resection to happen. So in my mind at that point, I became an athletic, taking the reinterpreter role, because it took a lot of energy. And what it's telling me is that the mucosa is very, very thick, which is the explanation of why it's not responding to ablation. You can see here the area of the resection. And you can actually appreciate how big the virus is and why it did not immediately was able to be removed. So Irving, one of the things that... Do you ever mark the area that you want to resect? Or because here the lesion is sort of like visible quite clearly endoscopically. Is that the reason you decided not to mark anything? I decided not to mark anything, because I want to remove everything. OK. So I don't need to... I don't... It's not going to be an issue for me because nothing is going to stay. Right. So, but if you're going to be doing this ablation, one important point that I really want to think about is please, please, please don't do skip resections. Because if you do skip resections, meaning you get this area here and then you turn to a different area, then you get fibrosis in the middle. And then when you want to come back and do further therapy, it's not going to work. It's not going to leave, etc. So you want to eliminate an entire segment at the same time. You don't want to do skip. I, unfortunately, for patients referred to me with multifocal high grade or intramucosal that have been manipulated somewhere else with skip mucosectomies, have had to send to surgery because it's just impossible to remove the intervening... Excuse me. The intervening virus mucosa between the mucosectomy site. Hi, I have a quick question. Yeah, go ahead, Prasad. I see there are different philosophies of injection versus no injection. I'm just curious what the panel thinks about adding epinephrine to the injection solution. Let's hear from... I don't think Irving's obviously not using that and he's using just simple saline in this situation. So I think, Prasad, I mean, yeah, so the concept of using epinephrine or a few drops of that is that some people think it reduces bleeding, whereas others are not convinced about that. At least my practice is not to use any epinephrine at all and just go with simple saline in that situation. But Irving, have you used epinephrine, a few drops ever, or have you stuck with just saline? You know, I'm a simple man. I mean, to me, the simpler you do this, the easier it's going to be. I actually wanted to bleed now rather than cause immediate vasoconstriction and then, when they're on their way home, start bleeding in the car. So I'd rather have the patient bleed when I'm doing this so I can do hemostasis rather than they have to come back later. But, I mean, it's different philosophies, right? I mean, that's me. I just, you know, I don't like to come in at night. So, Irving, what are you doing here? I'm sorry? I'm sorry? What are you doing here and why? So I see very big vessels in the center of the mucosectomy. And that's exactly the advantage of not having used epinephrine, is that I can see what I, I mean, would be concerned that could potentially bleed. So I want to make sure that this is outlayed, that this is electrocoagulated, so I don't have to worry about it later. Irving, are you using a coag grasper or what device are you using? I'm going cheap, Prasad. I'm just using a bipolar problem. Okay. Okay. So I think let's go to Saouni and ask a question. And I know, Samo, we'll get to your questions in a little bit, but just talking about this resection. Saouni, would you do this versus, you know, band EMR? So again, one of the, what Irving's very nicely demonstrated, as you can see, excellent specimens, but using the CAP technique. Saouni, do you use this in your practice or do you use band EMR in your practice? Yes, I normally use band, multi-band EMR. Like we're all familiar with how to put band for viruses, so it's really, like, not really difficult to learn how to use. I think either one is fine, but they are reported that using this CAP-assisted EMR might have a higher risk of perforation. I think it depends on the training, how frequent you do it. The other difference is that because if you use CAP-assisted EMR, you get really a lot of tissue. So it's better to inject, whereas for band-assisted EMR, you can inject, you don't have to. So that will be what I do difference. And the other thing is I would also, I prefer to mark, because when I start cutting, it's difficult to see where, what left at the margin or the cautery artifact at the margin. Okay, so Irving, back to you. So Irving, can you tell us what is your, is it just a personal preference using the CAP EMR? You know, I like it because I think I get more tissue. I think sometimes the bands may be thick. And honestly, Prateek, I think you use whatever you get used to. Excellent point, I think, Irving. I think so for the audience, I mean, the answer is that do what you feel comfortable doing and that you think you have expertise in. And I think both of those very similar results and do it. But those of you of us who do EMR, you can see a couple of like points here that Irving has nicely demonstrated. And more importantly, whatever technique you use, always go to the edge of your first resection and then suction and mucosa so that you're not, you know, leaving any fibrous bands behind. Now, for Prasad, you'll send this specimen to your pathologist. Now, one of the questions from Sammo is that the pathologist will, you know, slice these into 10 millimeter sections or however they do it. Are you concerned about the sections which have not been sliced? There's a question in the Q&A about losing some valuable information. Yeah, no, I think that's a very relevant, excellent question. So typically, the pathologists will do, at least at our institution, will do something we describe as bread loafing, where they are not just bisecting the specimen, but they are actually taking multiple sections. And I believe they actually take even thinner sections, if at all they see any kind of invasive cancer or they are suspecting any kind of invasive cancer. So their reads are in some ways tailored to the pathology that they are actually seeing. So, it's theoretically possible that if there is a very, very small focus of, let's say, submucosal invasion, you're missing that. And I think there was a paper from the Dutch group recently that was suspecting it, but we haven't seen that a whole lot in our practice. So, Prasad, I think excellent points. I think the issue is it depends as to what they see. So if they see only low-grade dysplasia, I don't think you're going to be worried about missing anything else. So I think it's a theoretical concern. And if there is cancer, they go in with multiple more sections and go back and do it. So I think it's done very well. Louis, to you and to Irving, can you, both of you have a little bit of discussion here, maybe about ESD? There's a question from Madhav, is that rather than piecemeal resection here, would this patient, should they undergo ESD? So any comments from either Louis, you, or from Irving? My questions to Irving. The first is how to calibrate the ERBE for the audience? And second, how is your plan for surveillance in this patient? How is the next endoscopy, upper endoscopy? Well, we're using the ERBE's endococcule at an effect of three, and the four squads of 235 watts, which is, I mean, we use the same thing for colonoscopy, for polypectomy, to tell you the truth. In regards to follow-up, it's going to be depending on the path, open and loose. If I go the high-grade, this patient would be very happy. I may even give him six months rest. And Irving, the second question is, when are you going to bring this patient back? Sorry. If I go to this stage, I would bring him in six months. If I didn't, I would bring him in three months to continue with the ablation. Okay, so I think Irving's gone over the, Louis, excellent question about the settings on that. And, you know, also what you're seeing, a little bit different differences in practices. For example, I would not routinely touch up the blood vessels, you know, in this situation. Prasad, you also, along with Cadman, perhaps I'll talk to Cadman, who also along the Mayo Clinic with Ken Wang and Prasad, you have the highest experience in the US on resections. Cadman, do you routinely touch up these blood vessels with these, you know, coagulation? So our practice is to use a mix of saline with methylene blue and epinephrine. So there's definitely that component where there is less bleeding. You know, I get the debate about, you know, if there is bleeding, it's better to identify it right there and then treat it. But we usually don't encounter, you know, bleeding after that approach. If I do see active bleeding, then obviously I do act upon it, and I do try and cauterize those blood vessels. If there is a prominent blood vessel, I'll tend to just gently cauterize it. A quiet grasper, sometimes the tip of a snare would do. So that's my practice. Dr. Iyer? Sawney, how about you? You also, Sawney, does large field resections in the colon as well. So we typically do encounter these superficial blood vessels. Would you routinely do something about it, or just let them be? If I can see the blind end of the blood vessels, for example, when you cut through it, you see a stop at the surface. I usually treat that. In the esophagus, the muscle is much thicker than in the colon. So if we do careful ablation with soft coagulation, it should not cause severe post-coagulation syndrome. Large blood vessels, I normally treat. Small blood vessels, and I don't see blind end, I don't treat. I think this is always deeper and unlikely to cause delayed bleeding. I think, Pratik, it sort of almost depends on what kind of technique you're using. With ESD, when we are dissecting a bit deeper in the submucosa, and you tend to cut through some larger vessels, I'm more inclined to treat them. Usually with a coagulant. With EMR, I don't typically do this unless I'm seeing something large that I'm concerned about bleeding. Can I ask? Yeah, Luis, please. The follow-up I ask to Irvine, as the resection is extensive, you use epinephrine and spray or something? Epinephrine or corticoid? So Irvine, because you've done such a widespread resection, are you going to spray anything on the post-resection side? Right. So one of the things that we learned from our series, from doing complete eradication or complete mycosectomy, is that if you're going circumferential, the stricture rate is around 30% to 35% and will require dilation. Usually when you do wide field, but it is not circumferential, your stricture rate is a bit smaller. But here we are approximately, I don't know, 180. So I am going to inject the steroids at the edges of the resection site, and we've had good results in regards to stricture prevention. The other thing that we do routinely, depending on the extent of the resection, if it's a large ESD, et cetera, we will probably read the patients in seven days for prophylactic dilation and put them on a protocol of prophylactic dilations. And that I actually learned from Professor Inouye in regards to very large ESD of squamous cell carcinomas. So that's what I've been doing. Now, I think you asked about ESD. To me, ESD is something I'm going to use if I see a lesion that I am concerned that already has invasive cancer. Why is that? Because when I'm doing wide field EMR like this, I mean, I'm going to get all the mucosa, so getting margins don't matter, because everything is coming out. And you're still going to get death on pathology, and nothing here looks like cancer. So doing a very, very big ESD for high-grade dysplasia doesn't make any sense. Now, if I have a visible lesion that I think could potentially harbor cancer, that's a completely different beast. So that, I would prefer to do ESD. So Irving, can you just thank you for telling us the settings you're using for the endocard that you're using for your resection. How about the setting for your electrocautery probe? Oh, my electrocautery probe. Yeah, if you can just look that, and there's a question from the audience about that. Yes. I'm using 30 watts with an effect of 3. OK, thank you. And there's also a question from the audience about the use of APC. And why are you burning some of those edges, Irving? The reason I burn the edge is there was a little bit of Barrett's lining in the edge. And rather than do a very big resection and cover already treated Barrett's, I'm increasing the circumference. I mean, for a 2-millimeter edge, it's easier for me to operate it with APC than to do a very big resection. And that is the reason. The other way, so another take-home message what you've heard from Irving is once you do widespread resection, like what he has done, is almost reaching 50% of the circumference, there's a high likelihood of stricture. So Cadman, do you ever use budesonide? There is some evidence to suggest that if you give PO budesonide after the resection, continue it for two to four weeks, it reduces strictures. What's your practice in Rochester, Cadman? I haven't tried budesonide, but I do trimicinolone injections at the margins. And you have to be in the mucosal margin so that the trimicinolone stays within that space. And then if the patient develops dysphagia, then bring them back for dilation, independent, obviously, of the barotendotherapy. Because one issue is that if somebody has a stricture, that may limit your ability to do further barotendotherapy. OK. Thank you, Cadman. Prasad, there's a question, again, from Samo about use of biomarkers. And now they're commercially available. Panel of biomarkers which are available that are being marketed about using for, not in this case, but in deciding progression to neoplasia. What's your practice, Prasad? Are there either one biomarker, like P53, or this panel of markers which are available that you routinely use in your practice? I mean, Prasad's, of course, one of our world-famous experts in biomarker and has done a number of studies. So Prasad, your comments? Yeah, thank you. This is an evolving area. I think the one that has perhaps gained the most attention recently is P53. There have been several, several retrospective studies and, more recently, a prospective study as well. The challenge with P53 remains in terms of the standardization of the technique by which it is assessed and the still considerable variation in the assessment of whether it is overexpressed, underexpressed, or lost. And I think that has prevented it from getting into guidelines. Sometimes our pathologists will use it as an adjunct, but we are not using P53 just yet for those reasons in at least predicting progression. The other panel of markers you're talking about is a combination of several markers, including P53. In a recent study that we published, we found that it was very specific in the sense that if you get a high-risk score, it is likely to be not a false positive. It is likely to be a true positive. But it is only modestly sensitive. So we are still exploring its use, but we have not started using it routinely. But I could imagine a panel like this could be helpful, say, in a younger patient with long, long segment barrets, maybe 10 centimeters. You're not seeing dysplasia. Maybe they have a family history. And you're really on the cusp of what should you do. Should you be more aggressive? And I could see something like this being used, maybe indefinite dysplasia, which is not going away. Those kind of things, I think, are certainly something to consider. OK. And do the guidelines comment anything on this, Prasad? Let me just say. Yeah, sure. Please go ahead. Irving, I see you're injecting steroids at the border. Well, I want to just the point that Carmen was making. When you're injecting, you don't want to see. You see the blanching of the submucosa. And that's the effect that you know that the serum is going into the edge of the submucosa. So you want to see that blanching effect. That was the point I was trying to make. I just want to keep moving. So I'm sorry. Let's go back to the biomarker. No, no, no. Irving, I think just to summarize, I think what you've nicely shown in the second part of your demonstration is, again, after recognizing the area which was not appropriately responding, because just as you mentioned, the mucosa just didn't appear flat. It just didn't appear right. And I think you've done a great job with piecemeal resection, but again, getting rid of all the margins and not leaving any bands behind, which I think is the true sign of a master endoscopist. So we thank you for that. And of course, showing us what to do with some of these islands at the edges and to prevent the strictures. So Irving, we let you go and continue. It sounds like you're still going to be treating a few of the edges and probably injecting more steroids. So I just wanted to recognize you and your team, again, on a Saturday on behalf of everyone to come in for this ASG weekend endoscopy live. We still have a few minutes. If you're done, feel free to join us on the panel. If not, I see you still have some work to do. So thanks again, Irving. No problem. And just to make the point, I mean, this looks easy, but it looks easy because you have a very well-trained team. All of these things, it's the team that makes you look great. I'm just a plumber. I'm a tissue purveyor. All of these guys are the ones that do the work. Thanks, everybody. And I'll see you hopefully on the Zoom in a little bit. OK, thank you. Nice. OK, so good job to Irving on that. And Louis, you also have had a lot longstanding interest in biomarkers. And I know that you sometimes do use it in your practice. What's your patient population you use it for? Yes, not in all patients. But we use B53. And a question, sorry. What happened with how is the present in the fish in the study in the Mayo Clinic years ago? What is today for fish? What is the position? Yeah. Pratik, OK for me to answer? Yeah, yeah, yeah, please. So fish was something that was promising. I think we published a fair number of papers. And Abbott was the company which was actually making those probes for us. And I think one of the challenges with fish is that it is very labor intensive. It still requires manual interpretation of gains and losses. And because of that, the volume was really not picking up a whole lot. And I think in a fast paced practice you need quick techniques. So maybe more quantitative techniques as opposed to qualitative techniques. And I think that was a major hurdle in it sort of becoming widely used. So we are not using it a whole lot, unfortunately, anymore. Thank you. Thank you very much. Let me have you answer one of those questions on the Q&A is what's your approach, Kadman, to patients who have large hiatus hernias, a long Barrett's? Do you routinely send them for a hernia repair? Yeah. Or you follow them? What's your approach? I saw that question, and I was afraid that it was coming my way. But it's a little bit of a point of debate, right? I mean, in my practice, I don't recommend necessarily everybody with a Barrett's segment or long segment Barrett's to undergo a fundoplication. If the patient is not responding to, say, a high acid suppressive therapy, twice daily, PPI therapy, my practice is usually then follow that up with a pH impedance study, try to understand why they're not responding. Some of these folks have PPI hypermetabolizers. And if at the end of the day, we conclude that we are unable to adequately control reflux, then we would consider the patient for a fundoplication. The challenge sometimes with a fundoplication is that it distorts the anatomy, especially at the gastroesophageal junction. It may make examination at that junction a little bit harder. OK, no, well said, I mean, Cadman, and I completely agree with that. Sauni, one last comment from you on resection. I mean, as people are trying to get introduced to it, either in the early years of their training or want to sort of learn it, what are some of the tips or suggestions that you may have for people to either incorporate that in their practice or get better at it? For resection, before we start doing resection, I always tell the fellows you need to learn how to recognize, delineate the lesion. That's most important because if you cannot do that, then you will not know whether you should resect and where to resect, so cognitive part. So in terms of learning the techniques, during the fellowship, you may have a couple of faculties that perform these procedures. You might want to spend some time with them, learn, like come to the weekend course by ASGE like this, to learn the little tips, like using the CAV, EMR, how to do it, and we point out the important tips during the procedure, like don't leave the edge, maybe consider marking, et cetera. So this is for EMR. I think observe a lot of procedures and see how you can improve them. Like I would say when I first started, I have a lot of bleeding, not like severe bleeding, but oozing, oozing from resection. But I learned with time to cut, to apply coagulation slower, cut slower, and that helped. So you also need to look at what is the benchmark for your procedure. Do you have more recurrent than what report in the literature, and you need to come back to look at your outcome. How can you improve that? OK, thank you very much. So it's 10 o'clock in Chicago, and this is a full hour of weekend endoscopy live at the IT&T Center brought to you by Medtronic. And I'd like to close up the program. And again, my sincere thanks to all our experts for joining us on a Saturday morning. So Cadman, Prasad, Savani, Lewis, and of course Irving, thank you very much for joining us. And of course, to all our attendees joining us over a cup of coffee. And we'll see you back again on a Saturday, again with another episode of ASG Weekend Endoscopy Live. So signing off from the IT&T Center, I'm Prateek Sharma. On behalf of the ASG, have a good rest of the weekend. Thank you very much. Bye. Thank you for inviting me. Thank you.

endoscopy procedure

Barrett's esophagus

gastroenterologists

diagnosis

treatment

chromoendoscopy

magnification

biomarkers

endoscopic mucosal resection

healthcare professionals