We are going to Chicago to Dr. Uzma Siddiqui from the University of Chicago who will demonstrate an RFA procedure. Dr. Siddiqui, you're live on. Can you hear us? Hi. Good afternoon, everyone. Nice to be with you all, even if it's virtual. Moen, I thought my audio was broken because I heard you say you were wrong, so I never hear that. So in summary, this patient that I'm going to show you, I inherited from another colleague. They had a long segment barrett, supposedly C10, M10, and two years ago had an area of high-grade dysplasia that was resected at 29 centimeters. There was a perforation, they had an Ovesco placed, did well, and then more recently came back two years later, they had a stricture at the side of the Ovesco. We removed the Ovesco, but now our goal is to try to eradicate or ablate the residual barrett's esophagus. So we'll just show you the segment to start. We have a 190 scope, I have a distal attachment cap. Here we are at about 24 centimeters, and then we'll make our way down. We can comment on the mucosa. For the most part, it looks pretty regular. In this area, you see a tattoo and maybe a little bit of narrowing, but not much, and a little bit of scarring you can see at six o'clock. So this is where his prior resection was with the Ovesco placement that we removed. And then we'll go up, down, and probably the bottom tattoo is about, sorry, I can't hear you Reem. Why was it? Why was it placed? I have no idea. This was two years ago. So I think the referring doctor originally wanted to mark the location of the high grade dysplasia, which was just across from that. But that's the only thing I can surmise. But I agree in the esophagus, typically, we don't use tattoo. And then I think the bottom of the intestinal metaplasia is around 34 centimeters. So I do think C, probably C9, M10, there's a little bit of a tongue higher up. And then he has a hiatal hernia. So you know, I'm interested in hearing what the panel has to say. We have a long segment Barrett, he had a history of high grade dysplasia. I think there also was an area of low grade dysplasia in the past. Obviously, we want to eradicate the residual background Barrett at this point. And we have options with RFA, cryo, where obviously, if we're going to do it, we're going to do RFA. I didn't see anything too concerning under white light or NBI that I wanted to respect this time. Yeah, I think, Uzma, this is Prateek again, you know, that's the key, just as you're mentioning is, you know, you would want to do mucosal ablation with, you know, we'll see all the different techniques here with, you know, RFA, cryo and hybrid APC, you just want to make sure that you're not performing those therapies in the setting of something that needs to be resected. Correct, because obviously, the ablation effect does not go deep enough. So if you really have dysplasia or an early cancer, you want to resect it, A, to clear the lesion and B, to get accurate histopathology. Now, Prateek, I would say, I was just going to say it's hard to interpret the mucosal vascularity and pit patterns in the area where he has the scar tissue, and where the Ovesco was causing a stricture. Right. I mean, I don't know. So that's always going to be very, and we had that discussion, Uzma, on our imaging section or the diagnostic section, and that's always very difficult to, you know, differentiate. And as long as a biopsy has been obtained from that area sometime in the past and doesn't show any cancer, because again, you know, you're always concerned whether a stricture within a Barrett segment is cancerous or not. As long as that's been ruled out, I mean, I don't think your imaging, just as you're mentioning, will help. And if that's the scenario, you know, that's an area that you may, as you will probably do, is not overlap with the balloon so that you don't, you know, cause excessive overlapping burns there to lead to a bigger stricture in that area. Correct. Correct. And I was thinking, this has been biopsied, I think twice in the past, and it did not show any obvious dysplasia, it showed a lot of ulceration, but I was thinking, A, to do the balloon, because we have a long segment Barrett, so you can treat, you know, four centimeters at a time with the balloon ablation catheter, but perhaps just stopping short of the strictured, or this area, the scarred area, it's not really strictured right now, but maybe I don't want to exacerbate it and just do the proximal Barrett's above it. How much is the distal Barrett's below the stricture? Same question. I feel like they're still a little bit just below, a couple centimeters. Go back, where's the G-junction there, Uzma? Right here. Is that the G-junction? So I think it's right here, and then if you come up. I think the G-junction is lower, Uzma, lower. Keep going, Uzma. I think it's right here, sorry, 34. Yeah, so you probably can do the balloon below and then above. That's true too, and just hit the four below, that's true. And I think, again, when you're, I'm going to spray some mucumus now, when you're counseling your patients, you do mention stricturing, obviously the longer segment you treat, perhaps a higher risk for that, also chest pain, nausea. We usually give all of our patients a parafate and a viscous lidocaine solution. So how, so let's say we ablate below and above the stricture, and the stricture has Barrett's or the narrowed area has Barrett's, what do you do with it? You apply some APC maybe? Apply some what? I apologize. APC, I mean, Pratik. Oh, well, you could try, I mean, a hybrid APC, you could try cryo, maybe a spray technique would be a little bit easier to get into a scarred area where it may be harder to have an ablation, an RFA catheter, get good tissue apposition. So I would probably opt for one of those in that one spot. So for the 360 Express Halo system, we're going to put a guide wire down, and then we're going to exchange off our endoscope. Now Pratik, do you like to take biopsies at the time you're doing ablation? No, I like to stay away from that. I mean, the bleeding that you get from it can interfere with the coagulant that you may get with the device. So it's been reported you can do it, but I prefer not to do it, have just a very clean mucosa, just like you have. So Uzma, I think if you have like three centimeters below the stricture, then obviously you can have the balloon below the stricture and do it. But if it's less than that, you can also use a focal device or some other method to ablate below the stricture. Sometimes, especially if you have a hiatal hernia, though, it can be hard, I think, with the RFA catheters, sometimes to get good tissue apposition in that distal area. Can we get the room view to see how you guys are placing the device? Can we put the room view big? Okay. Oh, okay. Can you see it? Okay, perfect. Can you step to the side? Okay. So we put the catheter on top of the wire. There's a four centimeter electrode here, and there are also centimeter markings on the catheter. This is more so once you start your ablation process, you know, okay, I'm going to move four centimeters down for the next ablation. And then as we... Once we start the ablation process, you know, okay, I'm going to move four centimeters down for the next ablation. advance the catheter down, then we're going to put the scope next to it and do our ablation under endoscopic view. You can put a little bit of lube on the floppy tip of the catheter, but try to avoid putting lube on the actual electrodes. And then my assistant Milena, who's pretty experienced with this, is going to give me a little bit of tension on the wire, and then we're going to pass it down. Now the good thing with the express system is that you do not need a sizing balloon like you needed with the old system where you had to put a balloon down, a catheter down and size the esophagus, which was very time consuming. Now you can just pass this catheter down and it automatically sizes for you. And then what you want to do, you want to start at least one or two centimeters above the top of the Barrett's to make sure that you're hitting that top segment. When you're moving this catheter in and out of the esophagus, you want to make sure it doesn't unravel. So anytime you're moving it around, you like to rotate a little bit clockwise. So I think we're good. And we're definitely above the top of the Barrett's right now. And then we'll position our scope right behind the catheter and then we're ready to go. And then you can't see my feet, but there's a gray and a blue button pedal and you're going to hit the gray to start to inflate a little bit of suction. And then you can hear it going off and then you'll hear a beep. This is set at 10 joules with this catheter, you know, with the focal ablation catheters, when there's dysplasia, you often use 12 joules. So now I'm looking at my markers at the mouth and I want to go about four centimeters down. And push everything together, keep this a little bit closer. OK, and then we will try to hit again. And the process is you're going to ablate everything once and then you're going to come out with the scope and the catheter and then you're going to clean the collagen off and then ablate one more time. And it was getting a little bit close. Would you do any focal ablation at the same time to areas that you missed with the with the balloon? I don't usually because I know I'm going to bring him back in three months. And you know, at that point, I'll see what's residual. I don't know if the panel does anything different. Yep, that's what we do. I would do the same, you know. Yeah. So now. I guess you ablated the structure. I know. That's what I was just thinking because I was trying to avoid it, but now it happened. Maybe and maybe. Well, now I feel like we'll just finish it. Now we'll just finish it. I was just gonna say I wanted to look to see. But now I'm definitely making sure my ablation probe is below the structure and I may I probably will not hit it twice. And then we'll go from there. So now we're going to I'm going to pull out the scope first and then we will pull out the catheter. We're going to disconnect it from the generator. And then again, you don't want the electrodes to unravel off the catheter. And then we're just going to kind of turn clockwise as we pull it out. You can. Yeah, you can take a look. Yep. You can pull everything. All right. Sometimes if you're in a hurry and you try to just pull it out, the electrodes can definitely become unraveled. And then you can use your cap just to kind of clean off the coagulum and then we'll go back for a second round. And then I'll bring him back in three months. And most all my patients, all the Barrett's patients I see in clinic and I let them know, you know, this is going to be a long journey. Now you can see here at the bottom, we didn't get really good effect. Actually, I did stop short of the structure. It looked like we were in it, but we were just above it. We can probably go back and ablate a little bit more distally. So when you bring the patient back in three months, do you biopsy first just to see what's happening or do you immediately just ablate? I tend to biopsy them. I know Pateek said he wouldn't, but I usually, I don't like them to go so long without getting another tissue diagnosis, at least as much as we can sample and make sure there's no recurrence of inflammation. So Reem, it really doesn't change what you would do. No. Right. So because, so I tend not to biopsy until all of the Barrett's is gone. Now to Uzma's point, if you were to see something abnormal at your three month endoscopy. So let's just say that the stricture appeared more prominent or there was a new visible lesion, which wasn't there before, then definitely I'd do it. But if everything else remains the same, you know, you could biopsy it, but it doesn't change what I do. Uzma, there was a question about the type of cap you're using. This is just a regular, which one do we use, DERIS cap, distal attachment cap. Yeah. Thanks. So I think for this one, again, I can just stay above the stricture, repeat ablation, and then I can go back and I can try to do the distal part, either with a focal catheter because of the hernia situation, or we can do a balloon ablation again. Yeah, Uzma, I like the idea of the focal catheter, just because as you showed nicely that the G-junction is quite wide open and you may need good apposition of the tissue. I'm interested to hear while we're waiting, I mean, these are patients with Barrett's 10 centimeters long standing, have any of you found that because of COVID you're seeing more high-grade dysplasia or intramucosal cancers with patients sort of missing their surveillance protocols? I couldn't say that personally, but I mean, as you know, there's literature from the colonoscopy side, right, about having, because the incidence is much higher, that's a much easier sort of a cancer to track that way. There are some data just emerging about just esophageal and upper GI cancer in general, and the trends seem to be the same, which is that there seems to be a little bit of a blip during the COVID time. It's interesting you bring that up, Reem, because I just had a patient recently that did have high-grade dysplasia about two years ago and never followed up, and now he does have invasive cancer, so I'm sure there is something to that. All right, so then we'll just start over again. I'm just going to work the area proximal to the stricture for right now, and then I think for the distal part I'll do a focal ablation, which I don't know if you have time to show, I could do that too if you wanted to just see the catheter at the bottom. No, it's okay, just do what you need to do, Usman, and at the end you can show us the final images, you know, once we come to the Q&A session. Perfect. Prateek, for RFA in the distal esophagus, do you include a little bit of cardio? Yeah, so I mean, you should include about five to ten millimeters of the upper Z-line, so approximately, as well as the same distance distally into the gastrocardia. The issue becomes that the majority of these patients have big hiatus hernias, you know, and as Usman's demonstrating, you know, the G-junction area becomes quite difficult, so I've switched to that in all the patients, irrespective of whether I use a balloon or a focal device, I will touch up at the end with a focal device, and I'll go in a 360-degree fashion, you know, above and below the G-junction, and I'll do that, and that also seems to reduce recurrences in the area of the G-junction, because the majority of the recurrences happen there, and that reduces it. Yeah, I, Prateek, myself, I end up, if I have two three-centimeter Barrett's, you know, and we know there is hiatus hernia, I end up just using the focal device, even when it's three or four centimeters, you know, it's easy to use, and I think it can be quick, and we can get the gastrocardia with that. I think also with the Halo Ultra 90, you have a little bit longer paddle, so even if you have three, four centimeters, I agree, I prefer to just treat that area with the focal catheter. The balloon just allows for too much, too much mucosal, there's not enough apposition there. Go ahead, Dream. No, I was just going to say that she demonstrated it really nicely with the suction, you really need to suction when you, when you inflate the balloon. That's true, yeah. To make sure that you get that. Uzma, before we move to Mimi, can you tell us your typical discharge instructions to the patients? So, usually, again, not necessarily data-driven, but we tell them clear liquids for 24 hours, and full liquids for a day, and then advance as tolerated after that. They're already, I like them to be on BID, PPI, at least a month prior to me, you know, doing my initial exam with biopsies, if the patient's already known, but they always have to be on twice a day PPI, and then we do give them Terafate as well for seven days, and then that we tell them take no matter what, and then a PRN viscous lidocaine solution mixed with Maalox. So that's our protocol, and then we'll bring them back in three months. Okay. Dream, Prateek, any final words before we move on? Really nice demonstration. Oh, good. Nice job, Uzma. Thanks for sharing this, and then if you do the focal, we'll come at the end just to look at the entire ablation being done, okay? Thank you. Thanks, Uzma. Great work. Great. Thank you, guys. Frankit, back to you.

video

Dr. Uzma Siddiqui

University of Chicago

RFA procedure

Barrett's esophagus

high-grade dysplasia