We have another good session coming up, session four, on endoscopic treatment of barrett esophagus. So we have moderators, Dr. Reem Sharaya, Dr. Mohinke Shah, and Dr. Pratik Sharma. And we are first going to Chicago, to Northwestern University, where Dr. Sreenath Komanduri will be presenting a multiband ligation EMR. Dr. Komanduri, can you hear us? I can hear you great. Can you guys hear me? Yes, you can. You are live on. You can go ahead. Fantastic. So this is a case of a 73-year-old gentleman who has had longstanding barretts over the years, who was referred for multifocal high-grade dysplasia, and actually had repeat biopsies, almost maybe too many biopsies, and I'll show you in a second, that were referred out to Cleveland Clinic for confirmation. And so I'm going to start just by walking you through. You guys have heard a lot about a high-quality exam. And so I'm going to start by showing you a couple of things here. And before I do anything, many things we do in a high-quality exam have a few issues around what is actually within a guideline, what is a best practice. And a lot of this is important, and I know Vani is a strong believer and probably hinted on this. Obviously, the use of a high-definition white light endoscopy, we'll demonstrate this area with narrowband imaging in a minute. But even before that, there are some best practices which are critical, in my mind, that are not necessarily within a guideline. But the cap, the use of a cap, and you guys have talked about this as well, the cap really kind of helps us see what we need to see in this area, and open up these folds, lay open things, and see this lesion of interest, which we're going to focus on. The next piece is something I'm a strong proponent of, which is a mucolytic. I use N-acetylcysteine or muco-myst on every case. It really is an amazing sort of change, and I'm instilling that here. Even just a few cc's, and I've kind of cleaned this up already, but it helps do a lot of things. Number one, it gets rid of that mucous layer. Number two, we really want to start appreciating some of the fine patterns here, and what's going on, especially with this sort of area right here on the screen. One of the things that has taken place for this gentleman is that he's had very effective reflux control. So as part of the reason that we're talking about the continuum of reflux to cancer is you've got to be cognizant of that. Reflux control in the setting of Barrett's is not a symptomatic disease, so you have to look at this and say, hey, is this a reflux-related ulcer, a malignant ulcer? What's going on here? And so he's had a lot of workup, and he's been on twice a day PPI therapy. He's not had erosive esophagitis elsewhere. And so this area all was biopsied extensively, like I said, multiple times. I think some of this is just from very recent sampling, but there is a concern, obviously, with this ulcerated area here. And I'm going to start kind of marching you through here. And when you look at this first just with white light after mucolytic, we're going to clean it up. And you can start to appreciate from 6 o'clock through this ulcerated area all the way up to about 12 o'clock, we have areas that have sort of lost their vascular pattern. They're obviously raised. In this case, you can start talking about definitely more than a 2A lesion, a little bit of a 2C concept here. And we're going to do some things to test this out to see what's the safe thing to do. And then when you get on this side, you have more of maybe some reflux-type injury, which might be a little bit of uncontrolled reflux, less of that. This was sequentially biopsied by the external, and sort of that left half of the screen was all nondysplastic barrets. And this right half of the screen was all high-grade dysplasia. I'm going to switch over to NBI, so narrowband imaging, a little bit, a couple of things here to talk about, right, and feel free to comment in the panel. But again, we're obviously going to see some distorted large vessels within this ulcerated area. This gives me more of a concern for malignancy or even advanced neoplasia. Over here, we're seeing some, really, if you look carefully, I'm going to freeze that. Even with that nodular raised area, there's mucosal morphology. I know, Pradeep, you can speak to this from your classification of NBI even better. But this is something that, you know, when I teach people how to use NBI, it's really about, boy, that just looks different than the other. You know, even if you don't understand all the sort of nuances of what we're looking at from patterns, from, again, from this area up to here, we definitely have what we would call a visible lesion or something that needs to be thought about. Hey, Sri, what's, is your plan to do EMR? You know, we've had a whole session on imaging, so we want to teach our audience on therapeutics now. Is the plan to do EMR, or what exactly? We got you. We got you, Mohan. We're going to get there in 20 minutes. So I'm going to go. Absolutely. I'm going to go ahead, and I just wanted to emphasize all that, because I think that's even more critical than what we do therapeutically. I'm going to go ahead, and we are going to do, sort of a cheap man's test here, sort of suctioning up this area, and it comes up really easily. So I think this is a sort of superficial neoplasia still. So the first part of therapy, I'm going to go ahead and mark this just very, I have a pretty good idea, even without marking it, but marking is a great first step here, and I'm just going to use the snare tip from the EMR kit, and I'm just going to give myself a couple of marks here to know where, because once we put that cap on, it's going to be a little bit more tricky to know what we need to do, and I'm going to probably aim for this whole 180 degree area, right? So Sri, I'm going to ask both Pratik and Reem here for this ulcerated lesions. I mean, the teaching is, if you have an ulcerated lesion, it's a deep cancer, so you leave it alone. Pratik, I'll start with you first. Yeah. So Sri, very nicely done an examination. I was going to ask you about what happened previously. It appears that multiple biopsies were taken from this area before, and how recent were they? They were about a week ago, and they were actually jumbo biopsies in that area. So that was, you know, looking at this, that was one of my sort of just thoughts, that is this truly like a 2C, you know, depressed lesion, or is this just the residual effect that we are seeing from multiple biopsies being taken? So you know, again, I think Mohan is absolutely spot on as always, which is that, you know, when you see, I mean, definitely if it's an ulcerated lesion, which is not what this is, but it's a little bit depressed, you wouldn't want to do it. But if this, if these are just biopsies, Sri, then I think you're probably good in doing a resection. And if you're sure that that one week ago biopsy, because it takes about three to four weeks for the biopsy sites to heal, right? I mean, and so if you're within that time window, and you think that those are just the biopsy remnants, is that the thought process you're having Sri? Yeah. There were jumbo forceps. Obviously, we do these cases sometimes, and we don't know what we'll run into a week later. And I agree. And I think that sort of cheap man's test of immediately on suction that mucosa comes up into my cat. And we're going to test that again. We definitely have areas here. Now, we could talk about EUS. I think that's a different question. We know that EUS is very poor in this situation. So much so that it's part of a guideline not to do EUS. In these situations, I still believe in staging resection. We can also in the panel, maybe talk about would you have considered ESD? I think that would be even more difficult in this situation. Any value for injection to see if it lifts, or it's ulcerated from the biopsy, it's not going to lift anyways? Yeah, I think it already suctions into the cat pretty nicely. So I think it would lift. I just, I hate using injection at all in esophageal mucosal resection. I think it's just something that splays everything out and makes everything much more difficult. So I'm going to go down. Let me get to Reem. Reem, any thoughts on that? Do you want to comment on the view that we've seen so far? So first off, if we can also see the endoscopic view, because we can just see now the side. Oh, sorry. We're coming. We're coming. But yeah, my question was about the biopsies and then typically what the wait time is. And I think we answered that sort of saying that at least typically we should wait two to three weeks before doing anything. I like the idea of suctioning into the cap as a sort of a poor man's test of seeing if there's any underlying submucosal involvement or sort of what we were thinking of cancer, if it's really a truly a 2C lesion. I would probably opt for an injecting, but then, you know, there's two thoughts about injecting an EMR or not doing injecting, just doing the cap EMR, and I'm happy to hear other thoughts here. No. So Reem, you're right. I mean, I think when you see a lesion, which appears a little bit more advanced, I mean, you would want to do or a much more extensive lesion. And if you want to do an EMR, you go with the cap EMR setting and doing it. But let's go back to Sri and the endo view. And Sri, can you tell us what you've done so far and what your plan is? Yeah. So just to kind of move things along, I was showing you, this is a sort of captivator EMR system. Some critical things, you're seeing the straps on the side there. I think the key piece here is to make sure you don't see the bands. We're suctioning up the area. We want to be thoughtful about how we do this because we're going to need to make sure there's no skip areas. So this is going to be a multiple area resection. As you saw, this came up very nicely, and this actually includes the backside of that ulcerated area. I'm going to go ahead and pass the snare through, and we're going to resect below the band as a starting point. And then we're going to see where we are in terms of what more we're going to do. The key to mucosal resection in the esophagus is wide margin resection. So we've kind of gotten more and more comfortable with going more than a hundred, sometimes even 270 degrees, just like you would with ESD, and you'll manage those strictures. But the worst thing you can do is partial resection and end up with any kind of buried neoplasia. Go ahead and open the snare. What current settings will you be using, Sri? It's a great question. So we typically use the same, it's ERBI, it's EndoCut for EMR that we would do for any other EMR. There is some debate on whether or not you want to use, sorry, let me just get positioned here. Cut current or coag. It'd be interesting to see what everybody uses here. If you guys use coagulation or cut current, anybody on that? And I think most of us would be using blended currents. Yeah, exactly. Let me start closing. So what I'm trying to do here is push the cap in and make sure I have a nice capture of this below the band, as you can see here. We're going to give it the same kind of a shake. We're going to go ahead and cut through this. One, two, three. So that's a shake a lot of people use to sort of make sure you're not grabbing any muscle. I've used it for the colon as well, but that's a really nice protection. So then what I'm going to do, I'm going to stay in this plane and I'm going to keep going distally because it's still part of my resection bed. We actually got the ulcer pretty nicely, so I'm going to keep going here. And then I'm going to kind of go to my lateral margins, which we think are nodular as well. Shri, can you teach us more about this Captivator EMR device you're using? What's special about it? Anything different from other devices? Yeah, so the Captivator, there's the Duet, there's Olympus sort of, so Olympus is more the non-band ligation, since we're talking about band ligation. The main difference, both are very, very useful and fine. I think the main difference here is you see the longer nose of the cap, close there. And also the bands are behind us visually, so they don't get in the way of our visualization of what's going on. So again, we're going to cut through this. One, two, three. So this one also has a irrigation channel, right? You can irrigate through it. That's correct. And also it can take a biopsy forceps. So it just allows a bigger channel and it has a bigger channel in it. So you can actually put an injection needle through it. So we're getting there. So I'm going to go laterally now and I'm going to take this up. I'm trying to be very thoughtful about making sure we don't get an island. And then you can see here how your marks really help you make sure that you don't skip any lesions as well. It's a little challenging. And one of the technical pros is how do you get the snare under the band with such a long nosed cap? So you got to be thoughtful about not putting out too much snare on these. And I'm going to keep the plastic almost within the cap itself open. And then I'm going to drive the scope because you really want to get under the band. You don't want to do this above the band or you're going to have a lot of extra tissue. So here it's a little challenging, but I'm going to now slide the snare out and close. Make sure I get what I need. And what were you saying when you use a blended current? I mean, Endocut Q, which is a blended. Yeah. Is that the one you use? Yes. Okay, good. Yeah. What about you, Prateek? Yeah, no, it's the same thing. I mean, I think initially when I started off, you know, at that time, you know, you don't want to see any bleeding at all, right? Until you recognize that bleeding is okay and you can control it. I started with COAG, you know, and did it that way. I got one post EMR bleed a couple of days later and I switched to Endocut too. So I think it's been good since. Prateek, how come when we do EMR for the entire GI tract, we inject and in the esophagus, we don't inject? What's special about the esophagus? I don't think that we don't inject. So, you know, it's, I think the technique, which is the band. So the band is in a way your injection, right? Because when you suction it, you're just suctioning the mucosa above the submucosa. And that's what injection does is just separates that layer out. So that's, I think the only reason to do that. Having said that, I know, for example, Ken Wang at the Mayo Clinic, I mean, he uses injection even prior to his band ligations, you know, unlike what Sri is showing us and what all of us are used to. So there are different ways of doing it, but typically I would say the majority of the endoscopists don't inject prior to band ligation. This is really coming along really nicely despite the ulceration, Sri. And you're making sure that you're not leaving any bridges and that the margins are good. So it's beautifully, beautifully done. So for the sake of time, I think we're pretty much done. As you can see, we got you through it pretty quickly. I'm just going to show one final thing, which is we have some oozing. I think this is probably within normal, but one of the tricks, as you know, is we can use the snare tip for soft coagulation just as people do with ESD. But just to make sure, and somebody, he's on a blood thinner as well, and I always want to make sure that there's nothing sort of left over here from a bleeding vessel standpoint. Most of our bleeding post-mucosal resection happens at the inferior margin. So for example here, I'm just setting this to soft coagulation current, just like a coag rasper. I'm advancing this out, and I'm just going to give a buzz here just to demonstrate this, and I'm just going to march along and make sure we don't run into trouble when we put this guy back on anticoagulant. But again, just to show you, we can't really see much of our marks anymore. We're almost about 200 degrees resection. We're down pretty nicely into the cardia. There's no more neoplasia apparently in the cardia. And I think we have a complete mucosal resection here for a high-grade dysplasia. Shreed, did you... Go ahead, Dream. I was just going to ask, risk of stricture in something that has more than 200 degrees, do you put them on a budesonide slurry like Michael Burke shows, or what's the post-op care? Yeah, it's a great question. I think I've tried everything. I think we've definitely become more aggressive with like this, where I'm pretty comfortable. I can pretty much take care of his disease in almost one session. And he may get a stricture, probably it's more than the 5%, 10% chance, and I let them know that. But, and again, I've tried injection budesonide or steroids, and I've tried spray, I've tried them. It really doesn't to me make a huge difference. But I think we got a lot more to learn on that in terms of preventative strategy. I think the key emphasis here is wide margin resection. Do not go into an EMR, take out just a little piece of the nodule without getting some normal tissue, just like we do for colonoscopy, and polyps, because then you're going to come back, ablate something, and we get buried neoplasia, and that's a disaster, and we all see it. This is, again, fairly, very effective, very safe. We did this in Moen's timeframe, and I think it's something that if you're taking on endoscopic eradication therapy in Barrett's, this is how you need to do it. Perfect. Beautiful, Sri, and you're right, I was wrong. So thank you for making that clear. Any final questions from Prateek or Reem before we move on? No, we'll just get at the panel then. So let's get to, I see that, okay Venkat, it's over to you.

Barrett's esophagus

high-grade dysplasia

multiband ligation EMR

wide-margin resection

Captivator device