Okay, we're going to California next. Back to Dr. Kenneth Chang from University of California Irvine, who will demonstrate a hybrid APC. Dr. Chang, you're live on. Hey, guys. Hey, Ian. Hi, Ian. Welcome back. Thank you. Thank you for having me twice. Yeah. Thank you for bearing with us. So what's going on? Let me present the case. This is a 54-year-old male who has obesity and pretty bad refractory GERD, has a hill grade 3, a 2-centimeter hiatal hernia. He also has Barrett's, C8M8, nondisplastic. His father passed away with metastatic adenocarcinoma of the esophagus with METs to the brain. And he's obviously super concerned that he will follow in his father's footsteps because his GERD is uncontrolled, his BMI is 33, and obviously the family history. So with all of that, we went over his individualized risk for developing cancer with 8 centimeters and the family history. We thought that this would be an exception for treating nondisplastic Barrett's. I'd love to hear what other people think. So in February, we did a Barrett's 360, and we can show you the PowerPoint. So the PowerPoint is showing you his... So May of 2021, a colleague of mine did a 360 ablation, and there was an area that I noted on the left side, this deep pocket, that even after two passes with the balloon, that mucosa was essentially untouched. And we see this in long segment Barrett's, we can get these areas of dilation. And with the balloon, no matter what you do, you can't get the balloon to oppose both sides of the lumen equally because one side is a bit outpouched. So we anticipated that he would need a second ablation. So today we're going to do a hybrid APC on the residual Barrett's, which is actually considerable. Any questions about the presentation? No, sounds good, Ken. So how many sessions of RFA he's had? Only one? Just one. Okay. Yeah. So this is a nondisplastic Barrett's? Correct. Okay. But just because of his family history? His profile, white, 50, BMI 33, family history of metastatic adenocarcinoma. Okay. I think, yeah, I don't think any- I think Mohan's point is good. I mean, just for the audience, I mean, the ASGE, you know, most recent guidelines, you know, in just nondisplastic Barrett's, endoscopic therapy is not recommended. So I think Mohan does bring up a good point, but again, Ken's just going over some of the additional risk factors that this patient may have. So Ken, talk to us about, you know, hybrid APC, how does it work? What do you inject? How much do you inject, et cetera? Yeah. So this is the catheter. It's just a, you know, a seven French catheter that goes through the channel of a regular biopsy scope. We have the distal cap on, which is important for visualization, stabilization, and treatment. And I'll give you some kind of tips on how to maximally use the cap. So the idea is the prior studies looking at APC on its own, it was somewhat effective, but the treatment could be spotty and more concerning is there was a significant perforation rate because of the ability to be able to ablate deeper. So with the, then there were trials looking at what if you did semicosal lift first and then ablated over that, and that seemed to be better. So this combines that concept because there's a very forceful jet that is inside the catheter. And essentially it's a needle free injection under high pressure. And so you can lift obviously without a needle with the same device. And so you can do the semicosal injection and the ablation with the same catheter. All right. So let me show, I did a little bit before coming on camera, cause there's quite a bit there to do, and I couldn't do it all in the 20 minutes that we're allotted, but so let me first show you at the G junctions. So this is the hiatal hernia. This is the pinch of the diaphragm about 39, 40. This is the top of the gastric folds. And this, so you can obviously see there's some residual Barrett's here on the right, and maybe some on the left as well. This looks like obvious residual Barrett's and this may be not. So there's some work to be done here. There's an Island or a patch here. The other areas have neo squamous epithelium, which is nice to see. But that area where the Barrett's 360 could not reach, I already treated that. That's this large area to my left. I just went ahead and treated that because I had a few minutes before going on camera. So I took care of that. But there's still a large patch here on my right, which I left for you guys. So I marked it. So I'm going to show you treatment of the G junction. I'm going to show you the treatment of a small Island, and I'm going to show you treatment of a large patch, which is up here. All right, any questions before I start? No, please get started, Ken. Just while you're doing that, any preference you have in going from proximal to distal or distal to proximal? Yeah, I generally like to treat the G junction, you know, first, because that's the area that's most likely going to repopulate or recur. And then I'll treat proximal and going proximal distal, distal proximal at that point, that doesn't matter much. So here on NBI, what I'm trying to do is figure out exactly where the Barrett's ends and stops. So here, I see a demarcation of the Barrett's here. So if I were to mark it here, it would be somewhere, let's go to marking. So can you just trying to mark the distal point which you want to treat? Do you guys agree that that's where the Barrett's extends and this is not Barrett's here or do you think there's Barrett's here? Now that's part of the hiatal hernia. Okay, so then but then down here the Barrett's extends a little bit lower I think. I think the I'll take I'm going to mark here and this is the one of the nice things about this technique is you can be very very precise. So I'm going to mark here and I'm going to mark here and I'm going to make sure I get just this little cuff here. Okay so then here I'll probably mark right here. You can very nicely shown you know and just for the viewers you know just taking your time as he's doing it don't be in a rush just to get to your injection and ablation which may end up being the easier part but in order to get the best results and that's why you you know people will say that at expert centers you know the results are this but others don't get it well that's also because I mean Ken you know not just being a great endoscopist but also spends time and is clearly you know showing how much he wants to ablate because that's also the zone of recurrence. And I think your point is as well like just seeing the other modalities for treatment we've seen that marking is really important also in band EMR as well and you're getting all the lesions you're not getting any skip lesions and you're right so I've I've marked my distal perimeter it's not it's not even it's a little bit lopsided up and down but at least I know my distal extent. So now I'm going to go to injection and first pass so Jay is going to put me on first pass. Okay so now I'm going to inject I'm going to put my catheter up against him because I'm going to hit the underwater jet pedal. What's the pressure set at there? I've got it at 50 I started at 35 and I inched up. And so the advantages with the Irby is that you can you can change it depending on how successful or unsuccessful the injection is which is good to know. And while Ken's doing that ream also good point I mean sometimes what happens is that especially in patients who've been previously treated and if there's some scar tissue from that you end up needing a lot more pressure to get the submucosal lift whereas if you have a naive case it's sometimes very easy just with a lower pressure. And can does this have to be saline or can it be more viscous? This has to be saline in order to fit so I've got some nice circumferential injection around the area that I'm going to treat so now. And your goal is to ablate until you see blue color which means you reach the submucosal? So in terms of depth it's it's a quality of the of the appearance of the mucosa I want to get down to the superficial submucosa and I want to see this tannish brownish color not necessarily a black color so I'll demonstrate that for you so now using my cap to stabilize I'm going to put my catheter now if I'm going to treat the left side hemisphere I'm going to keep the device about two millimeters inside the cap when I go to the right side of the cap I'm going to put my probe a little bit out so right now I'm working from inside the window so to speak and and I know where my distal mark is which is here. And just again note that Ken has his catheter in a very short position and you know when you're doing these focal techniques I think it's very good to just work very close to the tip of your scope and the same thing for this ablation. You notice the precision right I could get right to the area and target it now you know typically these these folds are difficult but with the cap you can you can park your yourself right in in that little fold and open it up and treat even that little tiny spot there we got so now I'm going to come over on this side so I'm looking at my distal mark here and I'm going to aim for that and I'm staying still inside my cap still short Here we are. So the cap both stabilizes, it retracts and acts as a shield. So anything behind me is not treated because the cap is kind of protecting it. Is there a typical size area that you would do in a single session or do you just do everything that you're able to do? Yeah, we've done, you know, we've done like C5, M5. C8, M8 is a lot. This is not a full CM. So this is like a C2, M8 kind of. So this is quite a bit. But it's safe. And it doesn't necessarily take more time than the traditional RF. So Ken, with the cryo on RFA, because that's what we compare this to, right? You can delineate the areas that are treated very well and make sure there are no skip areas. Here, it seems a little messy. Is that an issue? Not really, because look, this is treated. And if I go to zoom in, you can actually see those little nubbins. And that's well-treated Barrett's. I can actually diagnose Barrett's better after ablation. In the center, that's a little bit of Barrett's. Over to the right of it is not Barrett's. So I can actually see Barrett's pretty well, you know, and I know I got it. And Ken, can you tell us your power settings for the first pass versus the second treatment phase? Yeah, so the first pass is 60 watts. It's a pulse APC at a rate of 0.8 liters per minute. So here, I'm going to do just a little bit of touch-up right here. You see how the color changed? Yeah, very nice, Ken. Yeah, that's an ablated Barrett's. Those of us who have done RFA forever, you know, I did have a little bit to do with the RFA catheter. We know when, you know, when the spaghetti is well-cooked. It's kind of your shammy color that you want to get. Yeah, the same shammy color. Is that an issue with strictures for circumferential ablations or maybe less stricture rate with this? Yeah, it's about the same. So Thomas Roche and the European group published 154 patients just came out in the American Journal of Gastro, and they showed a 4% stricture rate, which is, I think, you know, in line with other modalities. We don't have a head-to-head. Do you do anything post-treatment to prevent stricturing? Carfate for the first four weeks and double-dose PPI. Very similar to what we do with our RFA patients. So, Ken, actually their head-to-head trial was just, you know, they presented it at the European meeting. So that just came out and they did show significantly lower stricture rate in that head-to-head trial. And that was part of the reason, Ken, you remember our U.S. trial got stopped is because they already had completed a German trial on the head-to-head comparison. I was so bummed with that, Prateek. You were going to lead the charge and we were all wrapped up to go. Yeah, yeah. Well, the Europeans beat us to the study and they had already completed it. So actually that trial, you know, does show a significant difference in strictures, but the efficacy was very similar. So here you can see the Baris is all well treated. That's well done spaghetti. And then so the G-junction is essentially treated maybe a little bit down here. And then from here, I'm going to go to the island. And when would you bring this patient back? Same, about three months. And so Ken, now in your practice, what's your criteria to bring the patient for hybrid APC versus RFA? Yeah, good one. Now you're putting me on the spot. Long segment. I love the 360. Super long segment. You know, around five centimeters or so, I'll start with RF, but then on the follow-ups, I typically on the follow-ups will go to this. I just love the precision and you know, the control that we get. I'm just going to clean the cap off a little bit. So Ken, we're going to move to the Q&A. Hopefully you can join us once you're done and we can actually, but the one question is, can you use this for a strictured segments within Baris? Yes. Yeah. So you can navigate around strictures. You know, if you have Baris right on the stricture, I would lean towards cryo because there's some evidence that cryo actually helps with, you know, with strictures. I don't know if everyone believes that, but yeah. Okay, perfect. So what's your plan right now before we move to the Q&A? Yeah, so I'm just going to do those islands and then clean. So I'll do the first pass. I'll remove the coagulum and then I can do a little bit more of injection if I need to and really just ablate the areas where on visual inspection, I think needs a little bit more. Again, we're just going for that nice tan color. Once we reach that, there's no need to go deeper or harder.

hybrid APC procedure

refractory GERD

Barrett's esophagus

argon plasma coagulation

nondisplastic Barrett's