Next, we will be going to London, University College London Hospital, to Dr. Rehan Haidry, who will be demonstrating some imaging of Barrett's esophagus and neoplasia. How are you doing? Can you hear me okay? Yes. So listen, Moin, Pratik, Vani, good afternoon from a sunny London. It's a real pleasure to be part of this fantastic course, so thanks for having us. I've got my consultant colleague here, Vinay Sehgal, who's going to be my wingman, and the fantastic team at UCH. So guys, let's just talk a little bit about the case very quickly. This is a gentleman in his early 80s who's been referred to me for assessment of an endoscopic lesion arising in a segment of Barrett's. We're going to be showcasing you quite a lot of technology over the next 20 minutes. What I'm using here is the Pentax Highline series. This is a magnification scope, the EG2990, because, I mean, I feel a bit dizzy after listening to that last presentation. There was so much going on there. So we're going to go back to basics, and because I'm a significantly better endoscopist than Professor Bhandari, I don't need artificial intelligence. So we're just going to go back to boring, boring white light endoscopy, a bit of chromoscopy, and then actually we'll also show off with a bit of AI at the end. But actually, a lot of the guys who are probably watching this, Pratik and Vani and Moin, just want to know what are the basics, because actually, even though AI is here to stay, we need to go back just to doing the basics, which is washing, looking, using the switches on your endoscope, and then we'll throw in a bit of the fancy stuff. So this is the first time I'm seeing this Barrett segment. So guys, I'm just going to just talk through a few basics here. And a lot of what I say to the guys is garbage in, garbage out. So if you're looking at garbage, you're going to make a garbage decision. So simple things like a distal attachment, a sedated patient, and then cleaning. So before I'm even looking at this, guys, in my foot pump here, I've got a combination of amastylcysteine, which is a mucolytic, but then I've also got something called bubble breaker. It's basically just getting rid of this surface sort of crud and mucus. So once that's all off, then I can, that's when I can start to have a look and start making an educated guess as to what I'm seeing is normal or abnormal. So now I've got a nice clean esophagus. So then I'm going to go to simple things like insufflation and desufflation. I know this sounds really straightforward. So at the moment, I've got my finger, my index finger on my left hand is not inflating the esophagus, right? So everything is nice and compressed. So as soon as you then start to inflate the esophagus, you begin to get so much more information. I'm pushing these folds away. And then you can really begin to see the mucosal patterns. And you can begin to see these sort of areas that may or may not be abnormal. So simple things like that will give you a lot of information. So Rehan, excellent showing, you know, the Barrett's part. Since you're at it, do you want to just go into the stomach and show us how you measure the hiatus? And the patient obviously has a hiatal hernia and the top of the gastric folds. I think you're absolutely right. The basics are extremely important. Yeah, so Prateek, I try not to spend too much time in the stomach. I find it quite overwhelming, but I will just because you've asked me to. So I believe this is the proximal stomach. But you're very right. This is an important part. You know, 80% of these patients will have hiatal hernias, and this will inform our decision making in terms of how we treat them. So this here, Prateek, is the diaphragmatic hiatus. Just here, you can see, which lies at about 40 centimeters from the incisor. I'm going to pull back very slowly. And there are two things that will define where the top of the gastric folds are. First is, you will begin to see this transition. You can see here on the, I'm just going to freeze my picture there, the transition in those sort of palisade vessels. So this guy's got about a two centimeter hernia. With this magnification scope, what I'm going to do here is actually start to magnify, and you can see here these crypts. Can you see those, Prateek? Yeah, very nice. And you can see the transition from the sort of gastric pits to the columnar pits. Beautiful patterns, yeah. This is a bit of, you know, I call this, I wouldn't tell you what I call it, but it's very, I find this very, very exciting. And you can see here with a bit of magnification, as I pull back the endoscope, and this is just with a bit of enhanced imaging with surface enhancement, which is a post-processing imaging. And what I'm going to do now, Prateek, is I'm going to switch to what we call eye scan optical enhancement, which is the Pentax mode here. So you can see here, I've got a little bit of magnification. You can really begin to see the columnar lined pits, which is all normal. And this is really, you know, we're very blessed to have this sort of imaging. So this is just very simple chromoendoscopy. So that's the start of my Barrett segment. And it's really important before you, you know, you did this with Bing, Prateek, is unless you know what normal looks like, and Vinny's next to me, you won't know what abnormal looks like. That's normal. That's brain matter. That's columnar metaplastic Barretts. So now I've got eye scan optical enhancement, guys, which is a combination of a bit of pre-processing and then post-processing. And then all of a sudden, things here just begin to look a little bit ugly, a little bit disorganized. So what I'm going to do is I'm going to do a bit of magnification here, okay? And then I'm just going to get you guys to have a look at these areas in the middle here, just drop a bit of magnification. All of a sudden, those pit patterns, Vinny, what do you think here? Normal or abnormal? You can see you've got a bit of disorganized micro mucosa. Can you see that Prateek? Yeah, yeah. Yeah, we can see it really well. That's dysplasia. What I'm going to do now, I'm going to flood my cap with water, okay? And I'm going to go even further down and a little bit of suction, a bit of underwater endoscopy. And once you get your focal length right, then you can really begin to see the sort of microstructures here that will inform your decision-making as to what's normal and what's abnormal. There's a good example, Prateek, Wani. Yeah, yeah. If you can freeze that image, Rehan, so that's a great example of if you go to the extreme left around the nine o'clock, looks a little bit regular. And as you start moving to the rest of the image, extremely abnormal, just as it's seen here. So it's a great demonstration, Rehan. Yeah, so you see, you don't need all of this clever AI stuff, guys. You just need to go back to basics, but you know, Vinny, what do you think of this? This is a guy who's been referred with a biopsy showing dysplasia. Where do we think the lesion is? What are we going to do here with this guy? Let me come off the clever stuff and just back to a bit of white light, high definition endoscopy. Where's the lesion, Vinny? Help me. So it was really interesting, Rehan. You said that. But even before you turned your magnification on, there was some sort of superficial contact bleeding, which already raised the suspicion for me that this was harboring something nasty. And your magnification has merely just confirmed your initial suspicion. I don't know if you agree with that, Rehan. Yeah, contact bleeding, guys. You can see that there. It's a really subtle sign. So that's a good sign for the guys and the fellows watching and the non-medical endoscopist. That sort of stuff will really begin to just point your eye towards an area that is abnormal. So I don't think this is a cancer. This is probably high-grade dysplasia. And I think the lesion here, you always got to worry about these squamous islands, Wani. What do you think about these? These are PPI related or you get worried about those? Yeah, this is something, you know, I think with biopsies and PPI and everything, sometimes we get squamous regeneration, but it could still harbor, you know, some disease underneath. So I look carefully in those areas. I also want to go back to basics and talk a little bit more about that cap. You showed us a beautiful underwater examination with magnification, but can you just tell us how the cap helps you just even with your basic examination at the gastric folds and looking, you know, and inspecting the mucosa, and do you use it on all your caps, on all your cases? I love that question. You know, it's just simple things that we sometimes overlook in diagnostic endoscopy is, so, you know, distal attachments come in different shapes and sizes, and I would encourage everyone to spend a bit of time getting to know them between, you know, the length, the flexibility. This is a hard cap. This is made by, it's an SB hood. I quite like these for endorasection. I quite like them for Zed poem, but what this does, it does two things. First is it allows me just with the use of my left hand to be able to angle into areas of the tubular esophagus and really be able to focus an area and isolate it so that I can then use all my fancy imaging and to look at that. The other thing it does is, especially around here at the top of the gastric folds where sometimes, you know, when you, if I just collapse this esophagus here, it can be very difficult sometimes to just look between the folds. You can use your cap and just a bit of gentle up and down movement to really spread these folds out and have a look in between just to make sure you're not missing anything. And then the third thing, Wally, is actually, you know, it allows you just to get a, you know, we use cuffs in colonoscopy withdrawal. This is the equivalent here, Pratik showed really nicely. You know, if you look, look, look, you'll find more, it just pushes the esophagus away from me. So it just gives me this sort of 360 cylindrical view and you can really see it here. You can really see the lesion at the three o'clock position. So, you know, I would encourage you to look at the cap that you've got on your back bench and, you know, spend a bit of time getting to know them because they'll really inform your... So, Rehan, this lesion, can you show us the extent? I mean, it seems to me it's right at the gastroesophageal junction in the three o'clock, four o'clock position, where in the right quadrant, I mean, again, this follows that principle that quite a few of the lesions occur at the three o'clock to five o'clock position. So I think this follows that principle. So how extensive is that lesion based on your imaging, because that will help determine how much resection you want to do today probably. So what I'm going to do is I'm going to freeze the image here and I'm going to throw in a bit of computer-aided diagnostics here just to ask you to answer that question. So we've got a system by Odin Vision, who we've been collaborating with at CADU, which is our AI equivalent. And I'm going to just freeze the image here and just ask CADU to... There you go. So you saw, I just pressed the pedal there, Pradeep, the fatigue. And so Freudian slip there, I'm really sorry. And so my computer-aided system has just told you what you wanted to hear. I haven't told you the ground truth was obviously the experts, but CADU here, our AI system has beautifully told me that's the high risk lesion. That's the highest grade of neoplasia in this esophagus, where that red dot is. And you can see where I need to start thinking about my endo-resection marks. What are your thoughts about what I've just shown you, Pradeep? What's the green and what's the blue dots? Green is the center of the lesion. And the blue is just, it's a 75% interval. So you know that the highest grade of dysplasia is green, blue is slightly outside, and the green arrows are the extent of the dysplasia. And this AI system is for dysplasia rather than just parrots. So look, I'll show you an area of normal esophagus here and see if it actually... So what I'm going to do is just, sorry, I'm just going to get you a nice sort of normal area of parrots here. And it's doing this on still images, correct? So it's like you select the image and it'll do it on a still image, not the moving image, correct? So you can see here, if you've got a bit of esophagitis, it does get a bit confused, but it is still images. So your endoscopist still needs to make the call. Right. Now, and Rehan, that was a good example of maybe, because of inflammation, subtle false positives, right? Totally. If you look up here, you've got a bit of erosive esophagitis. Exactly. Right. So what we're going to do here, we can garbage in, garbage out, Pradeep. You don't need AI to tell you, don't buy into this. Right. So I think it's the same concept that this is going to be a supplementary tool for us because again, I know Pradeep was quite confident that there are no false positives. That obviously is not the case, but this obviously helps us... I don't agree with that, I'm afraid. I have a different view on the systems. You know, you can... But we can nicely see the extent of the lesion based on this imaging that you're showing with the eye scan, Rehan. So Rehan, since this is the imaging section, can you walk us through eye scan 1, 2, 3 while looking at this lesion and tell us what's the difference? Of course. Thanks, Marin. I'm really glad you asked me that. So what I'm going to do is I'm going to start with our default imaging mode, Marin. This is called eye scan 1. Vinny, what are your... Do you want to just tell the guys what eye scan 1 is in terms of the optics? Yes, this is our default imaging mode and this is sort of surface enhancement. We can't hear him well. Can you hear me now? Is that better? A little bit. Can you shout? Okay. How about now? Is that any better? Yeah, yeah. That's good. Great. So eye scan 1 is surface enhancement. And you can see Rehan's toggling with the magnification here. So that's eye scan 1. And if you go to the next mode... So we don't tend to use eye scan 2 as much anymore. That's kind of contrast enhancement. And then eye scan 3 is tone enhancement. And we kind of tend to use that a little bit more. And Rehan was really demonstrating that quite elegantly earlier on. So these are the three modes that we use. We tend to start off our endoscopy in eye scan 1 as opposed to white light endoscopy. And it can really help delineate the surface enhancement and the vascular pattern in a very accurate way, as is being quite elegantly demonstrated here. So with this PENTAX system, you have a combination of the post-processing, which is behind me in the processor, but also you have a filter at source. So that's where you get these images from. It's a combination of both. And you can really see if you get your focal... You can get down to a really handsome level of detail if you just get your focal length right, which for purists like me, this stuff really gets me excited because you can really begin to get into detail that you can't really see with conventional endoscopies. It's really... This scope gives the patient every chance to show you their dysplasia and their cancer. Rehan, while you're doing that, several of our audience members are raising hands and stuff. I just urge them to put their questions in the Q&A section. And we will have a very nice and timely Q&A section with all our experts at the end of all these demonstrations. So please keep those questions coming for us. This is a beautiful demonstration, Dr. Khedri. We will switch rooms in around three minutes. No, thank you very much. Go on. What's your plan here? Are you going to do EMR? Yeah, even I would struggle to find a reason to do an ESD on this, Moin. And I'm very triggered. No, I don't think there's any reason to do an ESD. You're absolutely right, Rehan. I think this is a lesion, small enough, doesn't... Isn't bulky. Paris 2A. I mean, I think it's very much as you're rightfully doing for an EMR. And I think that's a really important point that we haven't discussed. This is called the Hadry sign on the bottom wall, which is trauma, which is something that I've perfected over the years. But it's actually, Prateek, and Riley alluded to this, actually, we've made an endoscopic diagnosis here. You know, it's all about under-treating these patients, isn't it? Your decision as to whether they go to surgery or they go to sub-mucosal resection. But our imaging has told us, guys, that this is probably high-grade dysplasia, maybe an intramucosal cancer. So mucosectomy is enough. It's absolutely enough. And that's, you know, we talk about imaging guiding your decision-making, Vinny. You know, that's the beauty of this. We spent as long looking at this lesion as we will, you know, taking it off. And, Rehan, the other important thing is that, you know, whenever you see that, you want to make sure that there aren't other lesions. So now I see you're examining also with your imaging the other flat area of the parrots, which looks pretty sort of normal and non-neoplastic. So this, to me, would be an ideal case for a resection followed by mucosal ablation. Would you agree with that? Totally. I mean, this will. And, you know, he's a senior gentleman as well. So, you know, I may take a decision here just to think about just getting rid of the cancer or the area of highest dysplasia. And then, you know, sort of having a think about doing nothing after that. So, you know, the resection here will probably be, you know, a couple of bites. And then, you know, do I really want to put a senior gentleman through, you know, a period of advanced, you know, sessional RFA when actually, you know, we've resected the area that's of highest risk. And so, and that's backed on, you know, not forceps biopsy sampling, but is based on high quality imaging. And I think this system really gives us that. Thank you, Rehan. You know, we're going to have a Q&A session at the end. So if you are available, please join us. That was a beautiful demonstration.

Barrett's esophagus

neoplasia

endoscopy

imaging modes

high-grade dysplasia